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The Doctor's Consultation

Agony Column

Camera Class by Snapshot

Money Matters

Life in Chiang Mai

Life in the laugh lane

The Doctor's Consultation:  by Dr. Iain Corness

Gallstones - Fat, Fair, Female, Fertile and Forty

I have mentioned gallstones (cholelithiasis) before and used the mnemonic Fat, Fair, Female, Fertile and Forty as being the catchy 5F’s we used as medical students to remind us of the typical gallstone sufferer. Of course, like all catchy mnemonics it isn’t quite true as 10 percent of men can also have gallstone problems, and a fair percentage of the dusky maidens get them and even infants and small children have been known to have the problem.
Being one of those strange organs that lives somewhere within the abdomen, many people are not really quite sure of where it is. Here’s how to find it. Your liver is in the upper right side of the belly, just below the diaphragm tucked under the ribs and the gall bladder, which manufactures the stones, is attached to the underside of your liver and is involved with digestion.
The gallbladder is connected to the liver and the intestine, and its primary role is to store the bile, which is produced by the liver, until the bile is needed to aid in digestion.
Cholecystitis is an inflammation of the gallbladder that causes severe abdominal pain. In 90 percent of cases, acute cholecystitis is caused by gallstones obstructing the duct leading from the gallbladder.
Ninety percent of cholecystitis cases resolve spontaneously; however, complications will develop in 10 percent of cases that will require surgery, antibiotics or other treatments.
So where do these gallstones come from? Well, 80 percent of them are made up of our old friend cholesterol, or cholesterol mixed with pigment, that’s why you can get such pretty colors, though I am yet to see any made into a necklace, but it could catch on I suppose. The cholesterol stays in solution until something happens to slow down the emptying of the gall bladder, or thicken the solution, such as happens during fasting (eating is good for you). This results in what we call biliary “sludge” which then hardens and turns into gallstones. So cholesterol can block more than just your coronary arteries.
Factors which increase the likelihood of developing gallstones include increasing age, obesity, a diet high in animal fats and certain medical conditions such as diabetes. Oh yes, pregnancy also increases the incidence. (With all these problems that can happen with procreation, it is a wonder the human race has got this far!)
The management of gallstones has also changed dramatically over the past 20 years because of three main factors. The first was the development of Ultrasound visualization. At last we had a way of accurately diagnosing gallstones. Not only could we now “see” the gallstones, but we could tell if they were the cause of the pain by being able to pick out inflammation in the gall bladder wall.
The second development was ERCP (you know how we love acronyms in medicine) which stands for Endoscopic Retrograde CholangioPancreatography. At the end of the operating telescope (called the Endoscope) the surgeon can sneak into the bile duct and scoop out stones that are blocking the duct which has been causing jaundice.
The third development was Laparoscopic Cholecystectomy and was pioneered in 1987 by a French surgical team. Instead of practically sawing you in half to get at the gall bladder, hiding under the liver as it does, this is a much less invasive method, where the operating laparoscope is inserted through a small incision in the abdominal wall, and the surgeon does the job under the direct vision. While this results in less trauma, shorter hospitalization and quicker recovery, it is not always successful and the operation may have to be converted to the older “open” method.
It is also important to remember that gallstones can be found incidentally, and if they are causing no problems, the answer is simply to leave them alone. The chances of developing symptoms over 20 years are about 18 percent the good books tell me, so with an 82 percent chance of getting off with nothing, who is going to volunteer for an operation? What “gall” to even suggest it!


Heart to Heart  with Hillary

Dear Hillary,
I find that when I go to a shopping center these days I have become an ogler. I just like to sit in a coffee shop and watch the women go by and try and catch them with my eye. I’m not trying to pick them up or anything like that, I just ogle. I’ve been doing this for a few months and I rotate around the centers so that I’m not in the same one all the time. I’m worried that this might be not normal, and will I go on to something anti-social or something. Should I get help, or will it all pass, or will it get worse?
Dear Ozzie (the ogler),
My Petal, you do have a problem. You “try and catch them with your eye”, and I take it that when you write “try” this means you are unsuccessful? That’s impossible. Your eye contact would have been taken up 1,000 times by now, since you’ve been at it “for a few months” by your own admission. You are not the only one hanging around shopping centers giving people the glad eye, but the others are women trying to pick up men. I think you have to be honest with yourself (and me) and find the reasons why you flit from shopping center to shopping center. Are you afraid of these women? Time you just let nature run its course. Have fun with your eyes and stop worrying about deep and meaningful consequences. You certainly won’t get any deep and meaningful relationships from the benches in a shopping center, that is for sure.

Dear Hillary,
Why do all these middle-aged guys with tattoos want to walk around with no shirts on? I see them every day, if it’s not no shirt then it’s those silly strappy singlets. Do they think it makes them look sexy or what? Do you think it’s sexy, Hillary, and do you have a tattoo in a secret place somewhere?
Dear Tatt,
If I show you mine, will you show me yours? Sorry Tatt, it’s no contest, because my beautiful body is as yet unmarked, or “un-inked”. But getting back to your real question, Petal, the only reason the chaps with the tatts wear those strappy singlets, as you call them, is to display their ink designs. They must think they are sexy, or they wouldn’t do it, just for the same reason we ladies will wear a décolleté to attract the male. It’s terrible primeval, and in Thailand quite unnecessary. Just wear your wallet on a rope around your neck with the contents plainly displayed (large denomination notes are recommended) and you’ll have them hanging off you like flies on one of those sticky paper rolls. By the way, Tatt, if a lady has a tattoo on her breast is that a tatt for tit? Ooh, I am naughty today!

Dear Hillary,
Each week I read your column and do enjoy a laugh, but nobody drives them to do it but themselves. I do want to write about rip-offs though, as every second letter seems to be about some poor sod who get carried away, hands over great chunks of money and of course never sees the end result, especially if this is for houses for Mamma and Pappa or a pig farm up country. There is another side to it all though, and I want you and the readers to hear about my tale. I had been here for about six months and got to know a girl (from the bar) very well. The relationship had gone past the usual “Hello sexy man” and I began to have some serious thoughts about having a more permanent state of affairs. Just after I heard that I had to go back to England, she asked me for 100,000 baht which she wanted to get set up in the small Thai restaurant where we would eat some nights. She promised to pay me back in six months after I came back. I’m not the richest sucker in the world, but I could afford the 1500 pounds at that time, so I shelled out and left. She stayed in touch and when I came back after six months, she paid me back in full, and I had a free dinner in her little restaurant. They’re not all as bad as some people would paint them Hillary.
Bill the Banker
Dear Bill the Banker,
Aren’t you the nicest man, and I am glad you were not let down. However, there are a few pointers for others reading your letter to ponder over. You had not met the girl two weeks before, in fact you had known her for six months (still not a long relationship, but better than two weeks). You had also formed a relationship with her and were even contemplating something more deep and meaningful, so much so that the pair of you kept in touch. You could also afford to lose the money - it wasn’t your life savings, so the risk was quantified. You had seen where the money was going to go. The bemoaning souls who write to me have met the girl during the two week holiday and lose the lot. That was not your situation, Petal. However, Bill, I’d like to buy this small champagne vineyard in France …

Camera Class:  by Harry Flashman

The sky’s the limit

One of the more rewarding photographic subjects is the sky. It appears in almost every outdoors picture and has so many different appearances, from bright blue, to fluffy white clouds, sunsets, overcast and stormy and finally the night sky. Plenty to choose from. And of course there is always the Bangkok sky, noted for its homogenous all over dirty off-white color!
There is not too much you can do about the Bangkok sky, but try using the widest angle lens in the bag and you have a chance of getting a blue sky background. The reason for this is that you are compressing more sky into the 35 mm frame, so if there is any blue up there, you are deepening the color.
However, very often, grey featureless sky cannot be avoided. If this is the case, compose the shot to exclude the dull sky from the picture as much as possible. There is a limit sometimes!
If you have access to a bunch of filters, there are other ways to make the sky more interesting. Generally, you are trying to reduce the contrast between the sky and the foreground, because the camera (film or digital) cannot get both of them accurately exposed. So if the foreground is white or bright you will need to dampen it down a bit, or if the sky is too bright, then you have to deepen in to get closer to the foreground exposure. This is where graduated filters will make life easier. The Cokin style that slides up and down is best, and when you have finished composing the shot, use the preview setting to see exactly what you are going to get.
However, today’s automated cameras handle exposure well, especially when your subject is set against a uniform background of blue sky, green vegetation, or dark water. When your subject is against a background of bright sky or water, the camera often underexposes your subject. Your SLR camera has several ways to overcome this tendency, through use of spot metering or by compensating to adjust exposure. Take the readings from the brighter areas of sky or clouds to get better photographs. If you do not have spot metering, then switch to manual mode under these conditions, and take readings from different areas. Select the one which will compensate for underexposure.
Having mentioned digital, these cameras have many advantages when you are out shooting skies. One of the best features is the instant feedback you get on your technique. You can review your exposure, composition, and sharpness on screen, and shoot again if necessary. Today’s digital SLRs are also fairly quiet. In low light, you can easily use 400 and even 800 ISO settings without the ‘grainy’ look that equivalent films produce.
There is also another very easy way to get your skies exposed correctly, and that is by ‘bracketing’. This is where you take three shots, one at the exposure you (or the camera) thinks it should be, then another one stop more exposure and the third at one stop less exposure. You can do five exposures if you like, though three is generally enough. Some of the newer cameras (and professional ones) will do this automatically.
A few other tips when shooting skies, particularly if the sky is the main subject: one is to hold the camera to give a horizontal horizon, this being one of the most obvious. Drunken horizons will spoil even the greatest sky shots. The other is not to place the horizon slap bang in the middle of the frame, but make it at one third. If the sky is the feature, then make if two thirds sky. Another tip is to take some shots in the vertical (portrait) frame as well as the usual horizontal one.
Finally, when shooting rainbows, make the background a dark color if possible. Dark and stormy clouds in the sky are ideal. The colors of the rainbow stand out better against darker colors, but will blend into light skies.
Remember, the sky’s the limit.

Money Matters:  Paul Gambles MBMG International Ltd.

Will the rally in commodities eventually weigh on the market? Part 2

Chart 7

Chart 8

Chart 9

I believe that one of the factors keeping global rates relatively low has been the weakness of Japan. That weakness has been largely the result of a deflationary problem which is just now showing signs of dissipating. [The threat of Asian deflation after 1998 was one of the factors driving global bond yields to historically low levels].
The relative weakness of Japan (and rates near 1%) has acted as a weight on global yields since then. Today’s announcement that Japan’s GDP was revised up to 3.3% makes its economy potentially stronger than the U.S. or Europe. That increases the odds for higher Japanese bond yields; which in turn increases the odds for higher U.S. bond yields. That suggests to me that Japan may hold one of the keys to the upward revision in global interest rates. Charts 7, 8 & 9 show a similarity between Japanese stocks (Chart 7) and U.S. bond yields (Chart 8). To make the point more graphically, the final Chart (9) overlays the Nikkei 225 (orange line) and the yield on the 10-Year T-Note yield since 1989. It looks to me like the two lines have been closely correlated for the last 20 years. A falling Japan from 1990 to 2003 acted as a depressant on U.S. bond yields. A rising Japan is now having the opposite effect.
T-Bill yields have suddenly slumped (see chart 8)
This is the first big drop from a peak like this since early 2001 (i.e., the early days of the last recession). So what could be causing the current T-Bill yield decline?
1) There was evidence of a distinct flight to safety from the jittery mortgage securities market following the sub-prime meltdown.
2) There is also clear evidence of an impending US business cycle contraction. US Eurodollar libor deposit rates haven’t budged which has caused the Ted spread (Eurodollar yield minus T-Bill yield) to widen dramatically. This is really a measure of credit market distress and therefore should be seen as a warning for junk bond and emerging market debt credit spreads. As usual for wisdom on this Michael Belkin is a good place to look - he believes that a junk bond market dislocation is long overdue.
What does this mean for the US (and by implication global) economy? Well in the real world real indicators are turning negative despite all the CNBC and official/quasi official hype that things are
i) different this time
ii) have never been better
iii) are definitely no cause for alarm (why would they need to keep saying this if they really believed either i) or ii) above)
There may be a further top in the latest market rally although there is clearly now greater volatility and more downside action in the markets, but the stock markets just measure forecasted sentiment; this is ephemeral. Every day living and business conditions are real and the latest consumer sentiment reading (down 5 points from May according to the University of Michigan survey data) reflects the impact on US consumers of higher fuel prices and lower housing value. Here’s a question that isn’t being asked - if house prices gave fallen and this is just temporary why aren’t people rushing into the market? Either they can’t (they’re feeling the squeeze) or they don’t want to (they think that prices are geared further south) or both! Whichever way, it’s bad news for the outlook and it makes sense that Belkin’s extremely statistical analysis is forecasting a deeper deterioration in consumer sentiment going forward.
So, taking all of that on board, how can you reconcile the recent rise in longer-term US interest rates with the decline in T-Bill yields? Belkin draws a comparison with the last recession when the 10Yr/3 month Treasury yield spread went from zero to +350 basis points in 2001 as longer-term interest rates remained static while the Fed forced short-term interest rates lower. This time might not be too different although junk bond and emerging market debt excesses are certainly more extreme now than they were in early 2001. These could be one of the catalysts of a shock to the whole system: junk and emerging bond markets could be the stronger aftershock of the initial sub-prime quake that shook the markets in February.
So all of this is bleak for US consumer confidence, economic growth and corporate earnings (exactly the opposite of the current Wall Street euphoria). In fact in the US indices such as Utilities and Transports seem to have rolled over and commenced a downtrend already. Watch the S&P500 and DJIA Industrials carefully - they could still move higher but any decline over the next few weeks could be signal the end of the innocence for all those who still believe the 3 hypes above.
Globally, it seems clear that UK, Italy, Spain and France are poised to follow although the German picture is more open to short term question (there may be a time delay). Emerging equity markets are in a long term uptrend but don’t be surprised to see a fall of 40-50% short term. Sidelined but poised is a good emerging equity stance right now.
Belkin think that energy stocks performance has boosted the market lately but that “Energy stocks should trade down with the market, when stock indexes finally break down. Energy stock outperformance has been the ‘hook’ that has kept speculation going in the latest rally. When that hook fails, the tent might collapse.”
The time isn’t now but it could be imminent.
Enjoy your day!

The above data and research was compiled from sources believed to be reliable. However, neither MBMG International Ltd nor its officers can accept any liability for any errors or omissions in the above article nor bear any responsibility for any losses achieved as a result of any actions taken or not taken as a consequence of reading the above article. For more information please contact Paul Gambles on [email protected]

Life in Chiang Mai: by Mark Whitman

Unsurprisingly, the best movies in the EU film festival came from the pre-eminent ‘film nations’ in Europe, France and Britain, with one-time contender for third place, Italy, languishing behind with a determinedly ‘cute’ comedy culled from a true story. There was no masterpiece to compete with last years L’Enfant, although there might have been if the Romanian 4 Months, 3 Weeks, 2 Days had made the journey from Bangkok. Just possibly it might get a small release in Thailand given its prizes and rave reviews. Still, given the dearth of good movies in Chiang Mai the 10 day event was most welcome and the higher than previous attendances augur well for the future.
Both Demented from France and the U.K.’s Last King of Scotland, an unsettling work depicting the rise and rise of dictator Idi Amin, reminded us that cinema above all the arts has the power to move and shock us. Each drew on the main strands of cinema, imaginative fantasy and documentary realism, as did the brilliant and disturbing Dallas amongst Us (Hungary) to confirm one’s faith in the medium the French invented well over 100 years ago and have nurtured ever since.
Demented, the only film I saw twice, had its faults including the glaringly redundant shot of the older brother hanging in the barn, but it was not otherwise gratuitously violent or disturbing, thanks to the director’s restrained style, which showed debts to two great masters, Bresson and Rossellini.
The Amin movie had a leavening of black humor and a barnstorming central performance from Forest Whitaker, which possibly left audiences unprepared for the horrors to come. If you missed the film, the DVD is widely on sale in Chiang Mai.
Of the five movies concerning childhood, Demented was closely shadowed by Dallas, a fluent and desperately sad depiction of life on a gypsy encampment. From Luxembourg came the modest and charming Little Secrets, which also depicted a stifling bourgeois family. Here the 12-year-old protagonist used less dramatic means to cope with his bigoted cleric father and acquiescent mother. The Finnish Mother of Mine told a good story of the displaced children sent to neutral Sweden to avoid the war and benefited fro the best performance in the festival films from Maria Lindqvist, as the adoptive mother who grows to love her charge too much. It was miles better than the nostalgia-laden Queen of Shebas’s Pearls, which drove me from the cinema with its relentless kitsch.
Should you be suffering from withdrawal symptoms or a surfeit of low budget angst, then head down to the Major Complex at Airport Plaza and catch the big movie of the Autumn, Michael Clayton. This gripping socio-political thriller is in the John Grisham mould and stars George Clooney as a good-bad guy. Within a memorable cast the English Tilda Swinton is a knockout as front player and lethal executive who condones murder to protect her firm’s interests. A slightly soft ending lets the lovely George off the hook, but hey this is Hollywood and the movie certainly cost twice the budgets of all the EU films. Meanwhile on a more serious note we can observe the Burma/Myanmar tragedy unwinding at a snail’s pace. The generals continue to prevaricate and treat the rest of the world and its emissaries with the contempt we deserve. A few pieces of good news trickle out. A handful of political prisoners are released along with some criminals (to boost the figures) and Aung San Suu Kyi attends a couple of meetings, allowing some foolish optimist to suggest that she might be released from her house arrest.
She in turn has made some very conciliatory comments with no demands suggesting an attempt to ‘open up a dialogue’ towards a democratic solution. This pleases the Asean countries, which can signify their support since this in no way upsets the boat rocking on choppy waters. And the ‘suits’ hold meetings in New York, press releases are issued listing the generals who have taken part in discussions. The top brass are noticeably absent and Brig. Gen Kyaw Hsan demands that Mr Gumbari supports the lifting of sanctions to ‘help Burma’.
This at least suggests that sanctions are hurting and apparently the sales of rubies, which net the generals over 250 million dollars a year are declining, something likely to be affected if the USA – as seems likely – bans the import of stones being sourced from a third country (mainly Thailand). Of course, other countries including Japan will still buy the stones. Meanwhile apologists say that a dramatic change in the situation could de-stabilize the region. Tell that to those who are starving or in forced labor or in prison or the many more fleeing to Thailand in search of medical care or work. It might give them their first (wry) laugh in many a year. And to cap it all the Burmese generals are allowed to announce that they are signing the Asean Charter. Has there ever been such an example of blatant hypocrisy in recent years? I certainly cannot recall one.

Life in the laugh lane: by Scott Jones

The War at Home

In quintessential American fashion, we’re engaged in a pointless war against a small kingdom of migratory natives. Our stern words have escalated to vicious threats; our guns have no effect; our new bombing techniques appear fruitless. Fearless bands of guerrilla forces pillage our food supply daily and poop strategically…on the table, the chairs, the counter, and the floor of the porch and kitchen, all of which are outside. The Chicken War is in full swing with twenty-to-two odds, without the help of Gluai, or Banana in English, our dog that should be named Log, which would match his mental capacity and military ambition. Immobile, as if bolted to the floor, he watches his idiotic humans scamper around with massive Songkram squirt guns and embarrass themselves in front of the neighbors.
My mate has traded her gun for an arsenal of Loi Krathong firecrackers with very impressive names—Mini Matches, The Black, Jumbo C and Dancing Frogs—which she flings in all directions at the sound of the slightest squawk, successfully scaring Log the Dog as well, who exits the porch hastily and is then perhaps not pooped upon by the Poulet Predators as they pilfer his provisions. Last week his orange dog bowl was filled when we left, but upon returning in the afternoon, and I’m not making this up, it was gone: the food and the bowl. A banana on the counter (the fruit, luckily not the dog) had been pecked beyond recognition and was covered with a thousand ants, although they weren’t pooping anything large enough for us to see.
Besides their blatant thievery of our rations and the psychological warfare of incessant cackling and cock-a-doodling at any time of the day or night, but especially way before dawn, one centimeter from our window and one meter from our heads, their apparent goal is to infect us with bird flu by surrounding us with gelatinous black poop, which is then transferred internally through the pores of bare feet stepping onto the porch in the dark. I’m certain this form of biological warfare was outlawed by the Geneva Convention, or maybe at the Swiss Army Knife Convention, which proclaimed that all battles must be fought with corkscrews, small inefficient scissors, plastic toothpicks and tweezers.
The element rendering this war hopeless is the fact that chickens have only five working brain cells, about three fewer than Log the Dog. These five cells control their entire repertoire of bodily functions: 1) walk, 2) squawk, 3) eat, 4) excrete and 5) lay. Hens lay eggs; roosters lay hens. If you’ve never seen a rooster perform its manly skills, it takes about a half second since there’s not much DNA information to transfer. Without an extra brain cell to house a memory bank, they have no remembrance that our general vicinity is a danger zone inhabited by savage maniacs. With typical Thai Loi Krathong enthusiasm, they even seem to like the explosions and I swear their cackling sounds more like gleeful laughter as they sprint undercover into the neighbor’s garden.
It reminds me of a night spent in my bright purple sleeping bag under the full moon on a hill top field at a friend’s farm. They had one cow, which also had a five-cell brain, with one cell controlling each of its five stomachs. I’d wake to hot bovine breath near my head, flail my arms to scare Bessie away and she’d lurch off to one side of the field. Again and again while engrossed in grass rumination, she’d notice me anew and think, “Look! A purple croissant! Maybe it tastes good with grass!” There was no education during that endless night of repetition, just hot breath, flail, lurch, ruminate, hot breath, flail, lurch, etcetera.
Contrary to our current local reputation, we’re not violent killers and are trying to find a humane solution to this dilemma by considering alternative schemes: wear fox costumes 24/7, duct tape chickens to the landlord’s car windshield or launch them into the next province on fire lanterns, perhaps roasted. I tried strewing leftover bones from a barbequed chicken around the porch entrance, but live poultry attacked in a ravenous pack and picked Aunt Henrietta clean. It’s a chicken-eat-chicken world. If this column disappears, you may find me wearing a straight jacket in the Bird Flu Ward, clutching a large squirt gun and Dancing Frogs.