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Update April 2017

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Update by Natrakorn Paewsoongnern

Doctor's Consultation  by Dr. Iain Corness


Update April 23, 2017

Siamese Twins

Conjoined twins are always newsworthy, and these days with the advances in surgical techniques, they have a greater chance of independent survival. Conjoined twins are also known as Siamese twins but did they really come from Siam (the old name for Thailand)? In a way, yes, though the condition is not restricted to Siam.

The incidence in the world is about one in 400,000 births, though it is difficult to get exact figures. Stillborn Siamese twins have been disposed of and the mothers have remained ignorant of their anatomical problems. It is rumored that in Russia there was the case of conjoined twins that were kept in a pediatric institution and the mother told they had died at birth. There is still a lot of superstition surrounding Siamese twins, even in the present day.

I have personal experience of one pair of Siamese twins in Pattaya. These two girls had been separated, having been joined at the lower part of their bodies. Unfortunately, the parents did not have any money and although the operation had apparently been done for free, they were unable, or even perhaps unwilling, to continue follow up surgical care. I managed to find a farang sponsor and the two girls did get some further treatment, but then disappeared as quickly as they had come into view. They would be around 20 years of age today, if they have survived.

The major deciding factor in survival of Siamese twins is where the joining is, and how many common organs are shared. The most common varieties encountered are joined at chest and abdomen (28 percent), joined at chest (18.5 percent), joined at abdomen (10 percent), parasitic twins (10 percent) and joined at the head (6 percent). Of these, about 40 percent were stillborn, and 60 percent live born, although only about 25 percent of those who survived at birth lived long enough to be candidates for surgery.

Conjoined twins can occur in any country, but the most publicized conjoined twins did come from Siam, and gave the condition its original name. They were called Chang and Eng Bunker, born in the Mekong Valley to a Chinese father and a Thai-Chinese mother in 1811. Their surname came later after they had lived in America for some time, as in 1811 Siamese people did not have any family name. A law requiring Thai people to have a surname was not enacted until 1913 by King Vajaravudh, Rama VI.

In 1829, Chang and Eng were discovered in old Siam by a British merchant, Robert Hunter, and exhibited as a curiosity around the world. This was the fate of anyone who had some major deformity in those days, and live adult Siamese twins would have been very rare, with most never making it through childhood.

Chang and Eng were joined at the breast-bone (sternum) by a small piece of cartilaginous tissue. Their livers were fused but independently complete. Unfortunately, 19th century medicine did not have the diagnostic imaging equipment necessary or the surgical know-how to separate them. Modern advances in diagnostic and surgical techniques would have allowed them to be easily separated.

Upon termination of their contract with their discoverer, they successfully went into business for themselves, which is really quite amazing, considering their origin in rural Siam. In 1839, while visiting Wilkesboro, North Carolina, the twins were attracted to the town and settled there, eventually becoming naturalized United States citizens.

They had become wealthy, thanks to Robert Hunter and his world tours, so they settled on a plantation, bought slaves, and adopted the name “Bunker”. They were accepted as respected members of the community. On April 13, 1843, they married two sisters: Chang to Adelaide Yates and Eng to Sarah Anne Yates. Chang and his wife had ten children; Eng and his wife had twelve. The mechanical difficulties in procreation would have been even more of a problem than the mental acceptance of a strange four some in those more straight-laced days.

Unfortunately, the sisters squabbled and eventually two separate households were set up just west of Mount Airy, North Carolina — Chang and Eng would alternate, spending three days at each home. Domestic bliss? Or two women in the kitchen?

Joined in life, they died together in 1874.

Update April 16, 2017

Going round in circles

Ever turned over in bed and the room began to spin? And you were sober? It might have been Benign Paroxysmal Positional Vertigo (BPPV). This is a very distressing condition, and much more common than you imagine. If you have it, after you move in a particular way, you feel that the room spins around you and you cannot stop it. It is like being so drunk that when you lie down on the bed the spinning rotation is so bad you grip the edges of the bed to stop falling off? That is what BPPV is like – but without the hangover the next morning!

The symptoms of BPPV include the dizziness (vertigo), lightheadedness, imbalance, and nausea. Activities that bring on symptoms will vary, but are almost always produced by a rapid change of position of the head. Getting out of bed or turning over in bed are common ‘problem’ motions. Because people with BPPV often feel dizzy and unsteady when they tip their heads back to look up, BPPV is sometimes called ‘top shelf vertigo.’ Women with BPPV may find that having a shampoo can bring on the symptoms. It also tends to be recurrent. So until you read further, don’t look up or get your hair washed!

To understand BPPV, you have to understand the workings of your inner ear. You have three semi-circular canals aligned in different directions, which act like spirit levels (the builders’ type, not the three fingers on the glass barman type) which have cells with fine hairs bathed with fluid as your head moves in different directions. The movement of the fine hairs sends electrical impulses to the brain to tell it (and you) which way is “up”.

However, with BPPV, the natural movement inside the semi-circular canals is disrupted, so the fine hairs send the wrong signals to the brain, and being unable to work out which way is really “up” the sufferer falls over, totally unable to save themselves from hitting the floor. Debilitating and embarrassing! Ask anyone who has had BPPV.

The commonest cause of interruption to the normal ebb and flow in the semi-circular canals is produced by something we have called “ear rocks”. These are made up of crystals of calcium carbonate, and we medicos call these ear rocks “otoconia”. Imagine these rocks to be like sugar crystals in the bottom of your coffee cup. These now swish around every time you move your cup, and likewise your “ear rocks” swish around every time you move your head.

However, it is not all that simple (it never is, is it?) as the commonest cause of BPPV in people under 50 is head injury. In older people, the most common cause is degeneration in the semi-circular canals of the inner ear. BPPV becomes much more common with advancing age, but in 50 percent of all cases, BPPV is called ‘idiopathic’, which is a fancy word we use when we don’t know!

Viruses can be accused too, such as those causing vestibular neuritis, minor strokes such as those involving anterior inferior cerebellar artery (AICA) syndrome, and Meniere’s disease are significant but unusual causes. Occasionally BPPV follows surgery, where the cause is felt to be from a prolonged period of lying on the back with the chin raised (for the anaesthetic tubes to slip down your throat), or ear trauma when the surgery is to the inner ear. The simple situation is that we can make the diagnosis, but it can be harder for us to exactly pinpoint the cause. To make it even harder, an intermittent pattern is common. Your BPPV may be present for a few weeks, then stop, but then come back again.

Is there any treatment? Yes there is, if ear rocks are the cause. Treatment usually consists of a series of maneuvers you are put through which are designed to move the ‘ear rocks’ around till they no longer cause problems. These are demonstrated by the Ear, Nose and Throat (ENT) specialists and usually result in around a 90 percent cure rate. The most common is called the Epley maneuver or the particle repositioning or canalith repositioning procedure, but have your ENT specialist show you how to do this.

Update April 9, 2017

Cancer – when time is of the essence

What are your chances of surviving cancer? According to some authors, better shift to Taiwan.

The differences in five year survival rates between the UK and Taiwan was put down to the fact that your cancer diagnosis was done more quickly in Taiwan than it was in the UK.

If my late mother’s experience of the UK National Health System is anything to go by, you will be lucky to live long enough for the diagnosis to be made, by the time you actually get your specialist’s appointment and then wait for the test results and then see the specialist again. But, I suppose, if nothing else, it does help cut down the waiting lists!

However, there is a message for us all in this. Timely cancer diagnosis does improve your chances of survival. This is not really rocket science or some new breakthrough. If you leave battery acid on your shirt long enough, it will eat a hole in the fabric. If you leave cancer cells in your body long enough, they can eat so many good cells your life and living is compromised.

Unfortunately, the diagnosis of cancer is generally not made (or the diagnostic procedure even started) until the cancer produces some abnormal symptoms. Those abnormal symptoms are also not made by the cancer itself, but by the organs that have been attacked, or by the sheer physical size of the cancer causing physical problems. Cancer of the lung is a good example of the first case, and cancer of the bowel is often an example of the second type.

We are actually very lucky in Thailand, as there are several centers of excellence in the capital and in the provinces, one being such as my own hospital, the Bangkok Hospital Pattaya.

Now when I say “centers of excellence” I am referring to the speed of diagnosis that is possible, not just the treatments that are available. There are many factors that can influence that speed (the following table has been extracted from Jiwa et al, BMC Family Practice 2007 8:27):

1. Need to travel to clinics in the capital may have financial and logistical implications for the patient and therefore lead to procrastination.

2. Health professional, different gender of GP may deter some patients from presenting with embarrassing symptoms that require intimate examination for diagnosis.

3. Equivocal tests necessitate repeat visits to clinic.

4. Lack of coordination for individual patients’ needs may result in inconvenient scheduling of appointments.

5. Limited scope to obtain second opinions.

6. Access to specialists limited by distance from capital.

As you can see from the table, we are very lucky in the metropolitan areas of Thailand, as the centers of excellence can easily cover the six factors. What is also not expressed in the six point table, is the speed of test result returns. Where we enjoy a 60 minute turnaround for blood tests, patients in the UK receive their results in days, not minutes. Similarly, appointments for CT scans and MRI’s here are usually ‘same day’ with results usually the same speedy service.

So, timely diagnosis is very possible in this country, but unfortunately there are still instances of late diagnosis, but in the majority of cases this has occurred through ignoring the symptoms or ignorance of the importance of the symptoms. The simple advice is to never ignore any deviation from ‘normal’ in your body – after all, you know your body better than anyone else.

There is also a somewhat mistaken idea that your annual check-up will uncover all cancers, so you don’t have to do anything until next year. Certainly there are some cancers that are detected in this way, but whilst the annual check-up can discover many endocrine problems, blood problems and cardiac abnormalities, it is not going to uncover cancer in the brain, bones or skin, unless they are very advanced.

Timely diagnosis does come back to your ability to inform your doctor of changes. Do not feel embarrassed that it “might be nothing”. Let me assure you that all doctors enjoy informing people that they have not got a problem after diagnostic testing, rather than the other way round!

Update April 2, 2017

La Maladie des griffes du chat

Ever tried to import the family cat from your home country? Difficulty level 9. Well, one of the difficulties relates to “La Maladie des griffes du chat” known in English as Cat Scratch Disease.

Now most people know that dogs and bats carry diseases, including the deadly rabies, but the other domestic pet, the cat, carries its fair share as well. However, almost every household has at least one cat, and often more and cats get the run of the house. Cats are affectionate, warm pets that will sit on your lap for hours, purring away, while it licks your hands. During that time, it may even be giving you more than love. It may be giving you a little present called Bartonella henselae, AKA Cat Scratch Disease! Yes, your cat is a walking, purring receptacle of illness.

Tell me more, you say, while wondering if you should strangle the cat now or later! But first a little history. A little over 50 years ago, the clinical signs of Cat Scratch Disease were described, and despite 50 years in between, it is still in the feline population.

Cat Scratch Disease affects between 2-10 people per 100,000 head of population in America, so whilst it isn’t an everyday diagnosis, most doctors will come across a few cases in their medical lifetime.

The presenting symptom is a regional swelling of the lymph nodes, generally in a young person or a child, and the usual scenario involves a panicking parent who is sure the child has lymphatic cancer.

What actually happens is that the cat is carrying the organism known as Bartonella henselae, which is found all over the world, and which it inoculates into the human system. This bug in turn is trapped by the lymph glands, within which one almighty fight takes place, with the end result being that the glands swell dramatically and can even burst through the skin as a suppurating discharge. Other signs and symptoms include a fever, sore throat and headache.

Now there are many causes for swollen glands, fever, headache and sore throat, so how do we pick on the family pussy cat? Quite simply, there will be a history of having been bitten or scratched by the family moggy, and the inoculation site will drain into the affected lymph glands.

So just how does the cat give you a “shot” of bugs? Well, firstly somewhere between 20-40 percent of cats are carrying the organism, and it lives in the cat’s saliva as well as in its blood. While licking its claws, pussy cat leaves a collection of the organism there, which in turn becomes yours when the cat scratches you. Deliberately or accidentally.

Cat Scratch Disease, although generally localized can even end up infecting internal organs such as the liver, spleen heart and brain, though this is very rare. For most people who contract the illness they quietly recover, though it can sometimes take some months. However, for people with compromised immune systems, spontaneous recovery is not the norm. Children get the disease more than adults, because children tend to spend more time with pets, and pull more than the occasional tail.

There is treatment, with one of the most appropriate antibiotics being Doxycycline, while the most usually available penicillins are fairly ineffective. There are tests which can be done in the laboratory to prove or disprove infection by Bartonella henselae, so what we call a “Definitive” diagnosis can be made. Again you can see the dangers in self medication. If you do indeed have Cat Scratch Disease from the cat bite, the penicillin you bought is useless!

So should we all go out and take our cats down to the vet and consign them to the great veterinary hospital in the sky? The simple answer is no, but the moral to this tale is that we should be on our guard. Cat scratches and bites should not be taken lightly. Immediately after any injuries you should wash the wounds with soap and water and after a thorough cleansing only then apply your favorite antiseptic, and at the first sign of problem, pop into my hospital and get it checked. But just leave the cat at home!

Update March 25, 2017

Can hookworm hook you?

“Worms” are everywhere. Probably the commonest infestation of mankind. All children go through harboring worms at some stage, but usually the tiny thread worms.

Of course, when you talk about ‘worms’, most people only think of threadworms that all children seem to get. The answer is always “a good worming”. Yes, we’ve all been down to the chemist shop and bought a packet of ‘worming’ tablets.

However, you should not imagine that ‘worms’ stops there. I can assure you that there are far more dangerous wrigglers in the community. And the sandy beaches are the habitat for some of them.

My friends laugh at me when they see me walking along the beach. Instead of letting the cool sand squish between my toes, I wear closed shoes. Does this mean I am a pedantic pedestrian? Or a member of a weird anti-sandal sect? Fortunately it is neither. I am just a trifle afraid of Ancylostoma duodenale. And so should you!

Ancylostoma duodenale is one of the two hookworms that can get their hooks into you (and me if I let them). The other is called Necator americanus. These little chaps are roundworms between 7 to 13 mm long and are far from rare. Approximately one-quarter of the world's population is infected with Hookworm.

So how do you get infected? Easy, the hookworm eggs are passed in feces (or poop if you prefer) and infection results when you come in contact with the eggs from the contaminated soil. The larvae enter through the skin and travel to the lungs through the blood. They ascend the lungs through the bronchi and trachea and are then swallowed. As the larvae pass into the digestive tract, they attach themselves to the wall of the small intestine. Here they mature into adult worms, mate and feed on the blood of the host. And adult hookworms may live up to ten years. A not so Happy Birthday!

Unfortunately many hookworm infestations do not produce symptoms; however, there may be local irritation of the skin where the worm penetrated or even an itchy rash. While going through the lungs, there may be asthma-like symptoms or even pneumonia. The most common symptoms of hookworm infection, however, are from their taking up residence in the intestine. Hookworm here can lead to abdominal pain, diarrhea, weight loss, loss of appetite and excessive gas.

With long-standing infections, the intestine’s owner may become anemic as the worms feed on the individual's blood. This in turn leads to the usual anemic symptoms including pale complexion, tiredness and weakness.

Diagnosis is done by looking for hookworm eggs in the stool (by using a microscope). Blood tests will show the amount of blood loss and can be used as a pointer towards the seriousness of the infestation.

Fortunately hookworm is treatable, generally with the drug mebendazole. This drug cures more than 99 percent of all cases of hookworm if given twice per day for three days. It kills both the worms and the eggs, but is contraindicated during pregnancy (your pregnancy, not its pregnancy!). If anemia has become a problem, then iron supplements can be given as well. Once treated, the symptoms settle quickly in a few weeks at most.

So what can you do to avoid hookworms? Well since hookworm infection comes from non-hygienic practices and fecal contact in the soil, my shoes sound like a great idea, don’t you think? Never mind the problems with hypodermic needles found in the sand in many countries these days!

Hookworm infections should be dealt quickly and stringently. Known symptomatic infections should be treated rapidly and treatment given to asymptomatic family members or neighbors. Strict attention to cleanliness and sanitary practices is needed when a hookworm infection is detected to prevent its spread. This means hygienic disposal of human waste, limiting skin contact with soil and even water, where there is untreated sewage.

Hookworm can be a very serious illness so it is essential to be aware of any change in one's health status. Any difficulty breathing, rapid heartbeat, chest or abdominal pain, bloody diarrhea, blood with coughing, asthma-like symptoms, skin rashes, abdominal swelling or bloating, lightheadedness or weight loss should be brought to your doctor's attention.

Me? I’ll just keep wearing shoes!

Update March 18, 2017

Why you should stay in touch with the family

We all have much to thank our family for. Just letting us grow up for starters. As an aside, if your young children are demanding attention with terrible two year old tantrums, they do grow out of them. My young son was lucky to reach his third birthday, but his mother shielded him from paternal wrath and he has grown up to be a nice young 11 year old.

However, the family heredity is one of the ‘clues’ to your health in the future, and what you can do to enjoy a long, lively and healthy one. This is where ‘thanks Mum and Dad’ comes in.

One problem of being an orphan is that it leaves the person with no idea as to what hereditary ailments are going to befall them. Dad might have legged it (an Olympic sport in Thailand) or ‘fled the scene’, but did he live to tell the tale when he was 60 when he suffered from heart disease?

With the increasing research into genetics, we are able to map out our likely futures and can predict such ailments as diabetes, epilepsy and other neurological problems like Huntington’s Chorea and Alzheimer’s Disease, some cancers such as breast, ovarian, lower bowel, prostate, skin and testicular, heart attacks, blood pressure problems, certain blood diseases like Sickle Cell anemia and so the list goes on.

However, you do not need to have multi-million baht examinations done on your DNA to see where you are headed, all you need to do is to start asking the older family members about your inheritance. Not the money - your genetic inheritance in the health stakes.

Have you ever wondered why the questionnaire for life insurance asks whether any close member of your family has ever suffered from diabetes, epilepsy and other ailments and then also asks you to write down how old your parents or brothers and sisters were when they died, and what they died from? All that they, the insurance companies, are doing is finding out the relative likelihood (or ‘risk’) of your succumbing early to an easily identifiable hereditary condition. This does not need a postgraduate Masters degree in rocket science. It only needs a cursory application of family history.

If either of your parents had diabetes, your elder brother has diabetes, your younger brother has diabetes and your cousin has diabetes, what are the odds on your getting (or already having) diabetes? Again this is not rocket science. The answer is pretty damn high! And yet, I see families like this, where the individual members are totally surprised and amazed when they fall ill, go to hospital, and diabetes is diagnosed.

It does not really take very much time over a family lunch to begin to enquire about one’s forebears. After five minutes it will be obvious if there is some kind of common medical thread running through your family. That thread may not necessarily be life threatening, but could be something like arthritis for example.

Look at it this way - your future is being displayed by your family’s past. This could be considered frightening, when your father, his brother and your grandfather all died very early from heart attacks. Or, this could be considered as life saving, if it pushes you towards looking at you own cardiac health and overcoming an apparently disastrous medical history.

This is the advantage that you get provided you are not an orphan. You know what to look for before it becomes a problem. Going back to the family with diabetes, what should the younger members do? Well, if it were me, I would be having my blood sugar checked at least once a year from the age of 20. Any time I had reason to visit the doctor in between, I would also ask to have the level checked. We are talking about a very inexpensive test that could literally save you millions of baht in the future, as well as giving you a better quality of life, and a longer one.

Ask around the dinner table today and plan to check your medical future tomorrow. It’s called a ‘Check-up’!

Update March 11, 2017

Genghis Khan and your children

Some medical facts: Bruises on a child’s body are often considered proof that a baby has been battered. A visible bruise on the buttocks, the shape of a hand and five fingers is almost ‘undeniable’ proof. In fact, there was a very celebrated instance of a GP in the UK having discovered that so many of the Asian babies in the practice were showing signs of being ‘battered’ that the children’s welfare people were called in and an enormous number of children taken away. However, the highly observant GP was wrong!

In Thailand, and the rest of Asia, a new-born baby with the ‘handprint’ bruise is very common, while child abuse is not common at all. The problem, or rather the condition, relates back to Genghis Khan and the Mongol hordes. It is a wonderful piece of folklore and also a fine example of applied genetics.

Let’s look at the folklore first, and you are going to have to dig very deep to get this tale anywhere else! A Mongolian baby, called Tanujin, was born just over 1,000 years ago, but did not breathe. His father, in desperation, held his new-born son upside down and smacked him severely over the bottom, so much so that the baby drew breath and lived, but carried the life giving bruise for the rest of his days. That baby later became Genghis Khan, (which means King of the Earth), and by the time he died in 1227 he was the ruler of a large chunk of it, including the area which later became known as Thailand.

History has chronicled that the Mongol hordes raped, pillaged and annexed countries from China to Persia. His highly mobile troops traveled the difficult terrain of Siberia. Famous cities were captured and looted such as Tashkent, Baghdad (still a good place to stay away from, thanks George) and Bokhara. Cities that surrendered were spared but those that resisted were razed and the people slaughtered. The Mongols conquered northern India and Afghanistan. In 1222, they defeated the Russian and Bulgarian armies. At the time of Genghis Khan’s death, his empire stretched from China’s Yellow River to the Dnieper, in Russia.

And now back to some interesting folklore. The descendants of Genghis Khan also showed the hand-shaped bruise on the buttocks, beginning with his four sons Ogdai, Jagatai, Juji and Tule, who were given one quarter of the empire each after their father died. They in turn passed on this ‘trademark’ and so this continues till today. If your “Luk Krung” children have the sign of Genghis Khan, called Mongolian Blue Spot, you can claim descent from the warrior king. However, there is quite a number of you, so I think there won’t be much left in Genghis’ estate by today.

Now Mongolian Blue Spot, as a clinical condition, is well documented, and I came across figures suggesting that at least one Mongolian spot is present on over 90 percent of Native Americans and people of African descent, over 80 percent of Asians, over 70 percent of Hispanics, and just under 10 percent of fair-skinned infants (Clinical Pediatric Dermatology, 1993).

Medically we describe Mongolian Blue Spot as flat bluish to bluish gray skin markings that commonly appear at birth (or shortly thereafter) and scientifically they are called congenital dermal melanocytosis. They are flat, pigmented lesions with nebulous borders and irregular shape. They appear commonly at the base of the spine, on the buttocks and back, but also can appear as high as the shoulders and elsewhere. The medical text books also warn that occasionally Mongolian Blue Spots are mistaken for bruises and questions about child abuse arise. Obviously a text book that the UK GP did not read! Mongolian Blue Spots are birthmarks, not bruises.

So, for all of you with children with a peculiar blue birthmark on their bottoms, or for those interested in checking friends and neighbors (or the young ladies dancing in the chrome pole palaces), it seems fairly positive that the lineage is verified. You really have found descendants of the man who conquered more of the world than Alexander the Great. And guess what – my children have it too!

Update March 4, 2017

Biting on a bullet!

Surgeons can be the ‘prima donnas’ of medicine, if you like. It is the surgeons who get the headlines in the newspapers. It is the surgeons who are the stars in movies and TV. Who can remember the irascible surgeon Sir Lancelot Spratt (Dr. In The House, 1954) or the young surgeon Dr. Kildare (1961)? Slightly more recent, the American surgeons in M*A*S*H?

However, surgeons have been around for many centuries and have their own Royal College. The origins of the first Royal College of Surgeons go back to the fourteenth century with the foundation of the 'Guild of Surgeons Within the City of London'. There was dispute between the surgeons and barber surgeons until an agreement was signed between them in 1493, giving the fellowship of surgeons the power of incorporation. In 1745 the surgeons broke away from the barbers to form the Company of Surgeons. In 1800 the Company was granted a Royal Charter to become the Royal College of Surgeons in London. A further charter in 1843 granted it the present title of the Royal College of Surgeons of England (of which I proudly say I am a member).

We marvel at the surgical advances in the past century, but while I take my hat off to the surgeons, the real praise goes to the anesthetists. Without the advances in anesthetics, brawny assistants would still be holding patients down while surgeons attacked with scalpels and saws and the patient lay there biting on a bullet.

The first anesthetic agent was ether, dribbled on to a mask to knock the patient out and allow the surgeon to take his time and become meticulous in his approach. The first public demonstration of ether anesthesia took place on 16 October 1846, at Massachusetts General Hospital in Boston. The anesthetist was William Morton and the surgeon was John Warren; and the operation was the removal of a lump under the jaw of a Gilbert Abbott.

While there have been enormous advances since then, I can remember being a medical student and assisting at an operation in outback Australia in 1964. The anesthetic was ether, dribbled on to the patient’s gauze mask by the matron of the public hospital, and it was a Caesarian section for twins. There was no air-conditioning and it was 43 degrees in the theatre, where the fumes were making us all woozy. Amazingly everyone survived the ordeal, mother, twin sons, the local doctor, the matron and me.

Despite outback Australia, anesthesia progressed in the rest of the world. Chloroform was introduced by James Simpson, the Professor of Obstetrics in Edinburgh, in November 1847. This was a more potent agent but it had more severe side effects, including sudden death. However, it worked well and was easier to use than ether and so, despite its drawbacks, became very popular.

The next major advance was the introduction of local anesthesia – cocaine – in 1877. Things definitely did go better with ‘coke’! Then came local infiltration, nerve blocks and then spinal and epidural anesthesia, which in the 1900s allowed surgery in a relaxed abdomen, and is still used today, especially in obstetric anesthesia, where the mother can be anaesthetized without the baby being affected as well.

The next important innovation was the control of the airways with the use of tubes placed into the trachea. This permitted control of breathing and techniques introduced in the 1910s were perfected in the late 1920s and early 1930s. Then came the introduction of intravenous induction agents. These were barbiturates which enabled the patient to go off to sleep quickly, smoothly and pleasantly and therefore avoided any unpleasant inhalational agents. Then in the 1940s and early 1950s, there came the introduction of muscle relaxants, firstly with curare (the South American Indian poison, but not administered by native blowpipe) and then agents less dangerous.

Anesthesia is now very safe, with mortality of less than 1 in 250,000 directly related to anesthesia. Nevertheless, with today’s sophisticated monitoring systems and a greater understanding of bodily functions, the anesthetic profession will continue to strive for improvement over the next 150 years.

On behalf of all patients requiring surgery in the future I thank the anesthetists. No longer do they have to bite on this bullet!

Update February 25, 2017

The diced carrot syndrome

For many of my childhood years I wondered why every time I vomited, it looked as if the vomitus contained diced carrot. True? You have found the same. Even when you haven’t eaten diced carrot for several months.

I also thought that my stomach was like a tray with compartments, with one for potatoes, another for cabbage, etc. How did the food know which compartment to dive into? My young mind worked that one out as well – it was the uvula (the clapper thingy at the back of the throat) that kicked the potatoes in the correct direction. No wonder I ended up studying medicine at university.

However, minds greater than mine (who actually know about the uvula) have announced to the world that a dinosaur-like animal that looked like a dolphin and swam like a fish can add another string to its bow – it was frequently as sick as a parrot.

Scientists have discovered the oldest fossilized vomit of ichthyosaurs, (an ancient marine reptile that lived 160 million years ago) which delighted in feeding off squid-like prey which had indigestible shells. For those who are worried, you are not likely to accidentally step on fresh ichthyosaur vomit as it is fossilized vomit that has the researchers all excited.

The scientists unearthed the regurgitated stomach contents of ichthyosaurs in a clay quarry near Peterborough, north of London, which has provided the researchers with a fascinating insight into the feeding habits of these long-extinct creatures.

“We believe that this is the first time the existence of fossil vomit on a grand scale has been proven beyond reasonable doubt,” said Peter Doyle, professor of geoscience from the University of Greenwich.

“It seems that ichthyosaurs regularly regurgitated the harder elements of its meal, rather like an owl coughs up a pellet of indigestible bones and fur after digesting its prey.  (I knew there was a reason I have never trusted owls.)

“The vomitus, known as “splat” contains the distinctive shells of belemnites, the nutritious shellfish on which the ichthyosaurs fed, which 160 million years later have been partly only digested by the reptile's gastric juices.

“The Peterborough belemnite shells, viewed under a powerful electron microscope, have revealed acid-etching marks caused by the digestive fluids from the gut of the marine reptile,” Professor Doyle said.

“This proves that the belemnites had been eaten by a predator. The fact that most of these belemnites were juveniles, reinforces our view that the belemnites did not die of old age,” he said. The plot thickens. (Or is that the splat thickens?)

It seems that Ichthyosaurs were to ancient reptiles what dolphins and whales are to mammals today, an animal perfectly adapted to a fully marine life which evolved from a terrestrial ancestor, and not the other way around as popular comic book ‘science’ would have you believe.

Professor Doyle, who made the discovery with Jason Wood of the Open University, said the fossil vomit clears up a long-standing mystery of what happened to the shells of its belemnite diet.

“It is highly unlikely that these shells passed through the ichthyosaur's intestines and were excreted as droppings, as they would have damaged the soft tissue of the reptile's internal organs,” Professor Doyle said.

“The only scientific alternative is that the shells were vomited out, in much the same way that modern-day sperm whales regurgitate the indigestible beaks of squid they have eaten,” he said.

As an adjunct to the ichthyosaur story, it has been postulated that the ichthyosaurs and plesiosaurs co-existed, and the ichthyosaurs were preyed upon by the much larger plesiosaurs, thus causing the smaller animal to ingest prehistoric squid.

And to bring the item right up to date, Angela Milner, associate keeper of paleontology at the Natural History Museum in London, says this idea (of having stones in the plesiosaur’s stomach) makes sense. “I don't think it has been suggested before that (gastroliths) might have acted as a gastric mill, but there is no real reason why not,” she said.  All that just to eat the belemnites.

And to throw the Xenosmilus (prehistoric cats) amongst the pterodactyls, the Loch Ness Monster was a plesiosaur.

Update February 18, 2017

Fractured collar bones

Fracture is the medical term for a crack or a break in the structure of a bone. There are many different types of fractures including:

Open or compound fracture, where the fracture site is open to air because one end of the bone has broken through the skin.

Closed fracture: neither end of the bone has broken through the skin.

Complete fracture: the broken bone is completely separated at the break.

Incomplete fracture: the broken bone is not completely separated at the break.

Transverse fracture: a straight break across the bone.

Spiral fracture or oblique fracture: usually caused by sudden, violent, rotating movements, such as twisting the leg during a fall.

Comminuted fracture: there are more than two fragments of bone at the fracture site.

Compression fracture: the break occurs because of extreme pressure on the bone.

Impacted fracture: the broken ends are driven into each other.

Avulsion fracture: the breaking force has been applied in such a way that the muscle pulls a portion of the bone away from the site where it is normally attached.

Pathological fracture: the fracture occurs in a bone that is weakened or damaged by disease.

Torus fracture or a greenstick or ripple fracture: on one side of the bone. Always a children’s fracture and very common.

Stress fracture: microscopic fractures caused by repeated jarring and overuse of a bone. This is typically seen in athletes.

Fractures can be displaced or not displaced. A displaced fracture means the bone has shifted its position relative to the bone on the other side of the fracture.

What is a Fracture of the Clavicle (“Collar Bone”)? Your clavicle bone or “collar bone” connects the scapula bone in your shoulder to your sternum in your chest. Its function is to hold the shoulder upward and backward.

Clavicle fractures are among the most common bone injuries. A break in the clavicle bone is usually always a closed fracture that normally takes about 6 weeks to heal in an adult, 4 weeks in a child.

Surgery is rarely needed.

Causes of a Fracture of the Clavicle?

At the time of birth, the clavicle may fracture during passage through the birth canal. The fracture is frequently not diagnosed until the healing bone callus is noticed as a hard lump. At this time it needs no treatment and the lump will disappear as the baby grows.

Accidents such as falls against the shoulder or on an outstretched hand are the most common cause of fractures of the clavicle.

Sometimes, a blow from a blunt object or a collision of some sort can cause the clavicle to break.

Symptoms of a Fracture of the Clavicle are the same for almost all fractures.




Deformity or “bump” at the site of the fracture

Internal bleeding

If asked to lift their arm, patients with a broken clavicle cannot do so without extreme pain.

Treatment of a Fracture of the Clavicle:

The goal of treating broken bones is to set them, making them whole again.

A broken clavicle usually requires a simple arm sling to be worn for about six weeks. Children with broken clavicles are often equipped with a figure of 8 clavicle strap that keeps their clavicle immobilized until it heals, which is usually three to four weeks. Most adults with the fracture will also use a figure of 8 splint or strap and will probably sleep in a chair or in bed with extra pillows because the fracture takes a week or two to get the healing process going and it is important not to roll onto the bone while sleeping.

Your doctor will examine the fracture site for neurovascular damage and take x-rays of the injured area, including the joints above and below the primary injury site. He or she will ask for details about how the injury occurred, and will need to know about any previous accidents resulting in a fractured bone.

Healing is considered complete when there is no motion at the fracture site and x-rays reveal complete bone union.

Patients with broken clavicles will usually be able to exercise their shoulders after three weeks of immobilization.

Golfers can expect to miss the walk behind the ball for up to 12 weeks.

Update February 11, 2017

Prostate Cancer in the news again

Every week some male asks me about the PSA test, and even knowing exactly what their PSA numbers have been for the past 10 years. You think I joke? I do not.

The male child is born with a subconscious fascination for the anatomy he finds in his nappy. Watch an infant learning this. As the boy turns into man, what goes on in his underpants becomes a major pre-occupation. As the man turns older, fear of cancer in the underpants is an even greater pre-occupation.

Unfortunately prostate problems are extremely common, a situation we men have to live with. Like all things, there is a downside as well as the fun side. In fact this year in the United States, almost 180,000 men will be told that they have prostate cancer.

With all our older friends getting prostate problems, does this mean there is a rise in the incidence? Are our underpants too tight? One reason for the ‘apparent’ increase is the fact that prostate cancer is a disease of aging, and we are all living longer. The statistics show that by age 50, almost 50 percent of American men will have microscopic signs of prostate cancer. By age 75, almost 75 percent of men will have some cancerous changes in their prostate glands. Do the maths. By 100 we’ve all got it!

So does this mean that life really ends at around 76? Fortunately no. Most of these cancers stay within the prostate, producing no signs or symptoms, or are so slow-growing, that they never become a serious threat to health. The good news is you die of something else before the prostate gets you! You die with it, rather than from it.

The real situation is that a much smaller number of men will actually be treated for prostate cancer. About 16 percent of American men will be diagnosed with prostate cancer during their lives; 8 percent will develop significant symptoms; but only 3 percent will die of the disease. Put another much more positive way, 97 percent won’t die from prostate cancer.

While prostate cancer can be ‘aggressive’, breaking out from the prostate gland itself and attacking other tissues, including brain and bone, fortunately this is the minority scenario. The great majority of prostate cancers are slow growing, and it can be decades between the early diagnosis and the cancer growing large enough to produce symptoms.

So let’s look at diagnosis and get the “blood test” out of the way first. The blood test is called Prostate Specific Antigen, or PSA for short (we medico’s love acronyms). Up till then we had another test called DRE (digital rectal examination), which, quite frankly, was not all that popular. So when news came through about a “blood test”, millions of men began rejoicing and the sale of rubber gloves plummeted. Unfortunately, PSA is not a go/no-go test. A normal range test doesn’t guarantee you haven’t got it, and an elevated result doesn’t automatically mean that you are about to claim early on your life insurance (or your dependents, anyway).

However, there is good news. We are becoming smarter with the PSA test. Serial PSA examinations can show the rate of growth. This gives us ‘Staging’ with four main grades. Stage I cannot be felt and is diagnosed through pathological testing. Stage II can be felt, but it is confined to the prostate. Stage III is coming out of the gland and Stage IV has grown into nearby tissues.

There is also the biopsy to contend with. Sticking a needle into the prostate isn’t fun either, and in my opinion is a bit hit and miss, but now there is the application of the MRI to try to avoid biopsy.

This is where you need to discuss your options with your doctor. If you are a young man with stage IV, then you have to make up your mind quickly. But if you are 75 with stage I or II, then you have more time, as you will most likely die of other causes rather than prostate cancer. “Watch and Wait” has much going for it, but you must be prepared to get to know your urologist. Pick a young one!

Update February 4, 2017

Living Wills – make one before you need it!

One medical situation that appears not to be well understood, is the making of Living Wills. I am repeatedly asked about whether a Living Will is legal in this country, and how do you enforce the provisions. Read on, all will be made clear.

A couple of years ago, there was a small paragraph in one of the Bangkok English language daily papers, reporting on the fact that Living Wills were now accepted as being legal in Thailand. I cheered as I read it. It was ‘about time’, in my opinion.

However, there is confusion in the minds of many people, as to what a “Living Will” actually is and what it covers. First off, it is not euthanasia. Borrowing from the Mayo Clinic in the US, it states on their website: “This written, legal document spells out the types of medical treatments and life-sustaining measures you do and don’t want, such as mechanical breathing (respiration and ventilation), tube feeding or resuscitation.” The important words to note are “life sustaining” and “resuscitation”. Neither of these concepts imply medically assisted suicide.

Once again from the Mayo Clinic, “Injury, illness and death aren’t easy subjects to talk about, but by planning ahead you can ensure that you receive the type of medical care you want, to take the burden off your family of trying to guess at what you’d want done.”

Remember that we are talking about terminal situations here. Not situations from which it would be reasonably expected that you will recover and still have a good quality of life. A fractured hip when you are 90 is a serious situation, but provided you are healthy otherwise, then it would be expected that you would recover. You might need a stick for a while, but you would still be able to have a beer with your mates or whatever your pursuits were before the incident. In other words, the expectancy of a reasonable quality of life is there.

However, if you are in the terminal phase of metastatic cancer, which has progressed despite treatment, the future quality of life is not there. Artificially prolonging life under that situation is then covered by the Living Will.

As an example, note the following:

The Living Will is made while in sound mind. It is not something you scribble out while lying in God’s waiting room. An example of a Living Will. “Being of sound mind and understanding all the implications, I ask that this document be brought to the attention of any medical facility in whose care I happen to be, and to any person who may become responsible for my affairs.

“This is my ‘Living Will’ stating my wishes in that my life should not be artificially prolonged, if this sacrifices my Quality of Life.

“If, for any reason, I am diagnosed as being in a terminal condition, I wish that my treatment be designed to keep me comfortable and to relieve pain, and allow me to die as naturally as possible, with as much dignity as can be maintained under the circumstances.

“As well as the situation in which I have been diagnosed as being in a terminal condition, these instructions will apply to situations of permanently unconscious states and irreversible brain damage.

“In the case of a life-threatening condition, in which I am unconscious or otherwise unable to express my wishes, I hereby advise that I do not want to be kept alive on a life support system, and I do not want resuscitation, nor do I authorize, or give my consent to procedures being carried out which would compromise any Quality of Life that I might expect in the future.

“I ask that you are sensitive to and respectful of my wishes; and use the most appropriate measures that are consistent with my choices and encompass alleviation of pain and other physical symptoms; without attempting to prolong life.

Now those are only examples. The Bangkok Hospital Pattaya has a pro forma Living Will, which is also repeated in the Pattaya City Expats website, I believe.

The message is that a Living Will is not euthanasia, and that you must lodge it, before you need it!

Update January 28, 2017

A Wayside Inn of Ill Repute

My anatomy teacher, Professor Max Hickey, had a wicked sense of humor. An anatomical out pocket on the bowel is called a diverticulum, which comes from the Latin meaning “a small diversion from the normal path”; however, Max taught us that it was Latin for “a wayside inn of ill repute”. I certainly like Max’s definition better, and his words have stayed with me for many years!

Inflammation of these anatomical out pockets is called Diverticulitis, and the little pockets are called ‘diverticulae’ (Latin plural of diverticulum). So, the condition of having diverticulae is called Diverticulosis, and if they become inflamed (from any reason) this is called Diverticulitis.

Diverticulae are more common in industrialized countries than in third world countries. The reason given for this is the lack of bulk present in the diet of industrialized countries allowing muscle contractions to create localized areas of high pressure allowing diverticulae to form, popping through the lining of the bowel.

The prevalence of diverticulae clearly increases with age. While fairly uncommon during the first four decades of life they reach a frequency of 50 percent in people older than 65. And welcome to the wonderful life of a retiree.

It must be remembered that Diverticulosis has no symptoms, but Diverticulitis does when they can rupture into the abdominal cavity, cause localized irritation and inflammation or produce an abscess. This is called acute diverticulitis.

Patients who have diverticulitis can present with a rather sudden onset of pain located in the lower left part of the abdomen over the sigmoid colon. It frequently is exquisitely tender and is associated with fever and a high white blood cell count.

Secondly, they can painlessly start to have significant amounts of rectal bleeding. When diverticulae bleed it is usually rather large amounts 500 ml or more. This happens without any inflammation whatsoever. The cause is a weakening of the blood vessel adjacent to the diverticulum.

Acute diverticulitis can be diagnosed by a typical history and a physical exam showing tenderness over the sigmoid colon which is located in the left lower part of the abdomen. If fever and a high white blood cell count are present this is confirmatory. A CAT scan or ultrasound of the lower abdomen can be very helpful in showing an inflammatory mass over the sigmoid colon.

Diverticular bleeding can be a bit more difficult to diagnose and is frequently a "diagnosis of exclusion". Fortunately this is not common. Less than 5 percent of people with diverticular disease of the colon will bleed.

Acute diverticulitis is treated with antibiotics for 7-10 days. These antibiotics frequently have to be given intravenously. Diet is often severely limited during the first few days of treatment. Most patients will recover completely, but occasionally surgery is necessary in order to drain all the infected material and completely empty an abscess cavity. At times this can require the creation of a colostomy to remove the feces from the infected area. After this has healed (usually about 6 weeks) the colostomy is removed and the colon is restored to its original state with removal of the diseased portion of the colon.

Bleeding diverticulosis is managed initially by monitoring the patient closely regarding his rate of blood loss and giving blood transfusions if necessary. Fortunately the bleeding normally stops. If not, the part of the colon containing the bleeding diverticulum needs to be surgically removed.

There is much written but little proof that anything can be done to prevent a recurrence of bleeding diverticular disease of the colon or acute diverticulitis short of a surgical resection. Of those that have bled about 15 percent will have a second bleed. If a second bleed occurs, the risks increase to 50 percent they will have a third. About 25 percent of those patients with acute diverticulitis will have a relapse and many of these will need a surgical resection. The use of a high fiber diet or use of stool softeners has been advocated to prevent recurrences of this disease by some researchers. The theory is that bulk in the colon in the form of a high fiber diet will help prevent recurrences by preventing localize high pressures from occurring. I remain unconvinced.

Update January 21, 2017

Dengue Fever - now we have a vaccine!

Many people were under the impression that Dengue is a mild illness, caused by a mosquito bite. However, with the Thai TV actor ending up in intensive care with Dengue Hemorrhagic Fever, this has brought home the realities of this disease.

The female Aedes aegypti mosquito, which carries the Dengue virus, is the culprit. Dengue fever is endemic locally and the change in the weather is partly to blame (not to be confused with “climate change”, by the way).

Since the beginning of this year, dengue fever is reported to have been seen in 14,000 people. The Disease Control Department says the rainy season each year is usually the breeding period for the dengue virus, and it has certainly rained recently.

So, despite my previous pleas (and those of the Public Health Department), Dengue Fever and its potentially fatal variant, Dengue Hemorrhagic Fever (DHF) is still with us. The latest information has now prompted me to repeat my advice on this subject. If you remember reading about it before, I apologize, but the subject matter is very important. This is an important ailment, which can be avoided.

However, first you should understand a little more about Dengue and its history. It was first described in 1780 by a Benjamin Rush in Philadelphia (so it didn’t start here) when the name Break Bone Fever was applied, with the symptoms of pain in the bones and rise in temperature. The name “Dengue” came in 1828 during an epidemic in Cuba. The new name was a Spanish attempt at a Swahili phrase “ki denga pepo” which describes a sudden cramping seizure caused by an evil spirit! Let me assure you that the local brand of Dengue Fever owes nothing to spirits, evil, bottled or otherwise.

The dengue virus is related to Japanese encephalitis, Murray Valley encephalitis and Yellow fever, and there are four “serotypes” or subgroups of it.

The mosquito lays its eggs in water containers, preferring the clean water found in water tanks and pots, in the saucers under pot plants and even under the pet’s food dish. Inside discarded car tyres is another favorite spot. These mosquitoes are not of the adventurous type and feed during the day and spend their time within 200 meters of their hatchery. Consequently, the eradication of any local breeding areas becomes very important towards maintaining your own health, as you can see. Keep your home free from lying water for a radius of 200 meters and you’re looking good!

Simple Dengue (if you can call it that) has an incubation period of around four to seven days and then the full blown symptoms of high fever and headache begin. The headache is usually behind the eyes and is made worse by eye movement. From there the pains progress to the limbs with acute muscle pains, which gave it the old name “Break Bone Fever”.

On the other hand, Dengue Hemorrhagic Fever (DHF) can certainly be fatal! It appears that Serotype 2 may be the culprit here, but does not usually produce DHF unless you have been previously bitten by types 1, 3 or 4. In addition to the symptoms of Classical Dengue the skin begins to bruise very easily as the blood hemorrhages into the skin. Children are generally more susceptible to this than adults. This also becomes much more of an emergency and is best treated in the Intensive Care Unit (ICU) of your favorite hospital.

With our ability to treat the viral ailments being very limited, the defense against the Dengue virus used to lie in the preventive measures. The other precautions are to wear long trousers and long sleeved shirts, especially at sun up and sun down, when the mosquito is at its most ravenous. The other factor to remember is “D” for Dengue and “D” for DEET. DEET is the magic ingredient in mosquito repellents, so when you go to buy some, check the label – if it has DEET, then get it. However, there is also now a vaccine against Dengue (ages 9-45), available at the Bangkok Hospital Pattaya till February 28. B. 9,600 for three injections. Looks worthwhile to me.

Update January 14, 2017

Good Exercise. Does that include sexercise?

The new check-up programs are out in my hospital with all the discounted items so you can chart your health (or otherwise) and star remedial action.

Probably the commonest advice a doctor gives to patients who have just done a check-up is to lose weight and get some exercise. Does that ring a bell in your memory? Was that part of the advice after your annual physical check-up?

Unfortunately, there seems to be very little real understanding of what exercise should consist of, how often, what type, how long and what about sex? For example, I was reading an article on exercise the other day and it said authoritatively that one should wear comfortable clothing and socks with the correct size of non-slippery, shock-absorbing shoes. If this includes sexercise, there are some strange shoe fetishes out there that I haven’t heard of yet!

However, getting a little serious, exercise will be good for you, provided that you pick a form of exercise that is not harmful for you! Now I know that looks as if I have put my money on every horse in the race, but take that sentence at its face value.

Enough research has been done to show that regular exercise is beneficial for everybody, in both the physical and psychological aspects, but, and it is a big ‘but’, all forms of exercise have relative bodily risks, and this has to be taken into account before you buy a pair of expensive jogging shoes and tackle a 10 km trot up Pratamnak Hill in the middle of the day.

True stories – a medical colleague in Australia took up playing squash when he turned 50 to improve his fitness and dropped dead on the court of a heart attack, and another acquaintance of mine turned 40, decided he wasn’t fit, bought a bicycle to ride to work each day and was run over by a bus.

The same article that advised non-slippery shoes, did have some wise words, however. These included to choose appropriate exercise according to your ability. Never exceed your limit. Remember that it is not the harder the better. If you have acute medical problems (such as fever, or pain), stop exercising. If you have chronic medical conditions (such as hypertension, diabetes, ischemic heart disease and arthritis), seek advice from your doctor or physiotherapist beforehand.

All of these I agree with. Remember that if you are happy to take your body to your medical advisor when it is sick, take it back to your doctor for advice on how to keep it fit as well.

The other words of wisdom in the article suggested that for prolonged exercise such as hiking, continually drink water to supplement the loss of body fluid due to sweating. Do not wait until you are thirsty. Take appropriate breaks during exercise. Do not over-exert yourself. Forget about “powering through the pain barrier”. Leave that for Tour de France cyclists and their “special” hormones.

As well as the form of exercise, there is the frequency. At least three times per week is recommended and 20-30 minutes (or more) is necessary each time, to derive the maximum benefit. And always remember, if there is dizziness, fainting, shortness of breath, chest pain, vomiting, nausea or severe pain during exercise, stop exercising immediately and seek medical advice as soon as possible.

Now I did mention at the start of this week’s article, the word “sexercise”, and some of you have been impatiently reading, while nervously fiddling with your expensive packet of Viagras, Kanagras, Cialis, Sidegra and other lead-in-your-pencil medications (I draw the line at tiger willy). OK, what about sex? The advisability of this form of exercise when you have some chronic complaint (such as hypertension, diabetes, ischemic heart disease, etc.), should be part of the advice you get from your doctor beforehand. The danger of over the counter willy stiffeners is that you don’t get advice with them and the strain of sexual activity may not be the best for you.

Finally, the learned article did say “Exercise with friends. Company provides enjoyment, mutual encouragement and support.” That goes for sexercise too I would imagine, but take the joggers off first!

Update January 8, 2017

The Seven Deadly Sins!

Heart disease is still one of the greatest killers of mankind, ranking a strong second after the Songkran road toll – OK, I exaggerated that a little, but I still maintain that any celebration in which 500 people get killed is a blight on the face of our community.

Interestingly, if you look at the major causes of death by development of the countries, in the high income countries death toll comes from heart disease, stroke and lung cancer, middle income countries have stroke, heart disease and lung disease and for the low income countries it is heart disease, respiratory infections and then HIV/AIDS.

There are many reasons for the differences, including dietary, socio-economic, educational, development of health services and tobacco and alcohol abuse. However, this week I am only going to address heart disease, and the seven deadly ‘sins’ that can predict your likelihood of getting (and suffering from) heart disease.

1. High Blood Pressure: 20 percent of elderly people suffer from this condition. Imagine trying to blow through a long tube. If the tube becomes constricted for any reason, you will have to blow harder, increasing the pressure. Blood pressure is the same – if the arteries are constricted or less pliable, it takes a greater pressure to force the blood around. The heart has to work harder to produce the increased pressure, and eventually the heart gets tired and fails.

2. High cholesterol: High cholesterol foods such as egg yolk, offal, animal brain, animal fats, dairy products, seafood, oyster, squid, etc., leave deposits in the blood vessel walls. As a result, the fat “plaque” on the vessel walls obstructs the blood flow and this will eventually cause heart disease, as per the first deadly sin above.

3. Smoking: Smoking is a primary factor in the causation of coronary artery disease. Smokers are at a much higher risk, even two times more than non-smokers. Smoking increases adrenaline, which causes an increased heart rate, increased blood pressure and lowers the amount of oxygen carried by the blood.

4. Diabetes: Diabetic people have twice the risk of congestive heart failure than people with normal blood sugar levels, due to their increased weight (see number 5) and high cholesterol levels produced in the blood.

5. Obesity: People who are fatter than average have to face a 30-40 percent increase in risk of heart disease compared to thin people. In just carting around the extra weight, the heart has to work harder (and the knee and hip joints wear out). Try walking around with 10 kg extra on your back and tell me how you feel at the end of a week. Tired? Of course. And your heart is tired too.

6. Stress: Stress is not totally bad for us, as it keeps you going, and in an appropriate level actually stimulates our curiosity and motivation; however, by getting over-stressed, adrenaline levels are increased and this may lead to abnormal heart function. Though stress is not the main cause of heart disease, it can make the artery walls less flexible, which is the beginning of heart disease.

7. Lack of exercise: Exercise is the best way to increase high density lipoprotein (HDL) – “good” cholesterol that prevents the arteries becoming abnormal. By exercising, blood pressure, body weight, and the possibility of thrombosis will be reduced.

So you can see just how these seven risk factors all are inter-related. Keep the arteries clean, watch the diet and ensure you have a reasonable level of exercise. Check the Blood Pressure and stop smoking.

Remember too, that as you get older, the chances (and risks) of heart disease are higher. (Young males are more likely to die from Songkran effects than heart failure.) Statistically, men aged over 40 years as well as the postmenopausal women have a higher risk than adolescents.

Despite our knowledge, we still cannot predict exactly when the demise will come, but looking at the big picture, we do know that smoking, overweight, unfit diabetics with high blood pressure and high cholesterol do not live as long as non-smoking, fit, lean people with normal blood pressure, and normal blood sugar and cholesterol levels.

Do you know your levels? A brief medical check-up will tell you.

Update December 30, 2016

A PET scan is not an X-Ray of your dog

There is only December 30 and 31 left in which to pay to get the discounted Check-up Packages in my hospital. However, as long as you have paid before December 31, you have till February 28 to actually have the physical examination.

The usual request is “I want everything.” And by that they mean blood testing. If I told them that sitting on my desk is the “Manual of Use and Interpretation of Pathology Tests” which is almost 400 pages and there are about five tests per page. Imagine the bill for all that lot! But I doubt if many of you need Basement Membrane Antibodies to be done for any reason.

There is also, in the collective subconscious, interest in a “whole body scan” which is thought of as some magical device that you can walk into in one end and out the other and a print-out will tell you (and us) exactly how you are inside and out. Every organ! Even Willy the Wonder Wand! Unfortunately, this is stretching the truth somewhat. Machines like that are only seen in Star Trek movies.

However, there is the PET scan, which is a specialized form of whole body scanner, that can give an indication of what is going on inside.

PET stands for Positron Emission Tomography and is a type of nuclear medicine imaging. Nuclear medicine is a subspecialty within the field of radiology that uses very small amounts of radioactive material to diagnose or treat disease and other abnormalities within the body.

Nuclear medicine imaging procedures are noninvasive and usually painless medical tests that help physicians diagnose medical conditions. To be able to produce the images in a PET scan, you have to have radioactive materials, called a radiopharmaceutical or radiotracer, and these are injected into your veins. The radioactive material has a very short life and is usable for only about two hours, though it will take a day before you have excreted it all.

The radioactive energy is detected by a device called a gamma camera, a (positron emission tomography) PET scanner. These radiology devices work together with a computer to measure the amount of radiotracer absorbed by your body and to produce special pictures offering details on both the structure and function of organs and other internal body parts.

The PET scanner is most usually used in cancer medicine and can demonstrate a ‘hot spot’ to show up the primary cancer, stage a cancer, show any metastases (spread), and even show whether cancer treatment modalities are working. For example, the PET scan can show the difference between scar tissue and active cancer tissue.

The benefits provided by PET scans are primarily because the information provided by nuclear medicine examinations is unique and often unattainable using other imaging procedures.

For many diseases, nuclear medicine scans yield the most useful information needed to make a diagnosis or to determine appropriate treatment, if any.

Nuclear medicine is much less traumatic than exploratory surgery.

By identifying changes in the body at the cellular level, PET imaging may detect the early onset of disease before it is evident on other imaging tests such as CT or MRI.

The risks are very low. Because the doses of radiotracer administered are small, diagnostic nuclear medicine procedures result in minimal radiation exposure. Thus, the radiation risk is very low compared with the potential benefits.

Nuclear medicine has been used for more than five decades, and there are no known long-term adverse effects from such low-dose exposure.

Allergic reactions to radiopharmaceuticals may occur but are extremely rare.

Injection of the radiotracer may cause slight pain and redness which should rapidly resolve.

Women should always inform their physician or radiology technologist if there is any possibility that they are pregnant or if they are breastfeeding their baby.

Can you get this kind of scan here? Yes, at Wattanosoth Hospital in Bangkok, and it costs around 60,000 baht last time I asked. However, if you purchase a Chivawattana personal health insurance card (available at Bangkok Hospital Pattaya) it has a discount for the PET scan (as well as many other benefits). Well worthwhile looking into if a PET is on the agenda.

Update December 24, 2016

Christmas Disease – it’s not Happy Holiday disease!

Christmas Disease has nothing to do with Happy Holidays, Christianity, or Santa, mangers, three wise men and a bottle of myrrh. But it has everything to do with Stephen. And not St. Stephen but Stephen Christmas, that is.

Stephen, a young British lad, was the first patient with a bleeding tendency recognized to have a different form from “classical” hemophilia (or haemophilia if you come from the right hand side of the Atlantic Ocean).

His condition was studied by researchers Biggs, Douglas, and Macfarlane in 1952, who discovered that young Stephen was missing a different coagulation factor than the more usual one (which is known as Factor VIII). They named Stephen’s missing factor as Factor IX, and his condition became known as Christmas Disease.

Just to confuse the issue, we also call Christmas Disease by other names, including Factor IX deficiency, hemophilia II, hemophilia B, hemophiloid state C, hereditary plasma thromboplastin component deficiency, plasma thromboplastin component deficiency, and plasma thromboplastin factor-B deficiency. There’s probably more, but Christmas Disease has a much nicer “ring” to it. (Probably “Jingle Bells” at this time of year!)

From the diagnostic viewpoint, it is very difficult to differentiate between classical hemophilia (my editor comes from the left hand side of the Atlantic, so it is spelled with “e”) and Christmas Disease. The symptoms are the same, with excessive bleeding seen by recurrent nosebleeds, bruising, spontaneous bleeding, bleeding into joints and associated pain and swelling, gastrointestinal tract and urinary tract hemorrhage producing blood in the urine or stool, prolonged bleeding from cuts, tooth extraction, and surgery and excessive bleeding following circumcision.

Christmas Disease covers around one in seven cases of the total hemophilia incidence and is around 1/30,000 in the general population. This disease is also male dominated, being called a sex-linked recessive trait passed on by female carriers. This means the bleeding disorder is carried on the X chromosome. Males being of XY make-up will have the disease if the X they inherit has the gene. Females, who have XX chromosomes, are only carriers if either X has the bleeding gene.

Hemophilia has been noted in history for many years, and Jewish texts of the second century A.D. refer to boys who bled to death after circumcision, and the Arab physician Albucasis (1013-1106) also described males in one family dying after minor injuries.

In more recent history, royal watchers know that Queen Victoria of Britain’s son Leopold had hemophilia, and that two of her daughters, Alice and Beatrice, were carriers of the gene. Through them, hemophilia was passed to the royal families in Spain and Russia, leading to one of the most famous young men with the disease, Tsar Nicholas II’s only son Alexei.

In the 1800’s physicians thought that the bleeding occurred because of a structural problem in blood vessels. In 1937 a substance was found in normal blood that would make hemophilic blood clot, which was named “anti-hemophilic globulin.”

In 1944 researchers found in one case that when the blood from two different hemophiliacs was mixed, both were able to clot. Nobody could explain this until 1952, when the researchers in England realized there were two types of hemophilia. They called his version hemophilia B, or “Christmas disease,” and the more prevalent kind hemophilia A, or “classic hemophilia.”

With the discovery of A and B types came the realization that there must be different types of “anti-hemophilic globulin” involved in the clotting process. Names were assigned to these various “coagulation factors” by an international committee in 1962. Hemophilia A is a deficiency of Factor VIII, and hemophilia B is a deficiency of Factor IX.

Once it became clear that hemophilia was caused by a deficiency of a coagulation factor, replacement of the missing factor became the method of treatment. In the early 1950’s animal plasma was used. By the 1970’s, coagulation factor concentrates made from human plasma were available, and by the 1980’s we could guarantee that it was HIV free. It has been a long road since Stephen Christmas.

Last minute reminder!

The discount check-up packages at Bangkok Hospital Pattaya have to be paid for by December 31, but you can delay having the test up till 28 February 2017.

Update December 17, 2016

Where’s my readers?

I don’t need these any more!

By “readers” I don’t mean those kind souls who read my columns, but I am referring to reading glasses. I just opened my top drawer at work and there were eight pairs of readers! No, it wasn’t a “Buy 1 and get 7 free!” These were the result of wear and tear, broken side pieces, lenses missing, broken frames, unsuccessful repairs with Super Glue or Araldite (the Greek Goddess of stickiness) and the list goes on. I did, however, manage to successfully glue my finger to one lens with Super Glue. It did neither the lens, or my finger, any good at all.

A little history here, which will probably remind you of your time of decreasing visual acuity.

26 years ago I was ready to admit that my near vision was gone. Reading a map was just not possible, even holding the map in front of the headlights. A visit to the optometrist saw me leaving with suitable contact lenses which introduced a whole new world to my life. I could read the destination signs on busses and street signs ditto.

Unfortunately this Utopia was not to last. Stronger prescriptions for the contact lenses did help, but were not the answer. Remembering to remove the contacts every night was a bit hit and miss, but I always knew in the morning as the lenses were stuck to my eyeballs and everything was blurred.

I did try and remember to use a sterile technique putting the lenses in, but that too would fail regularly and I would have to do without, which suggested to me that a white stick and a Labrador was next. Of course there were also the dropped lenses with me on all fours looking for the errant bit of soft plastic.

I struggled on, but then found that my distance vision was not as good as it used to be. Recognizing faces across the street was difficult. By now I had arrived at a situation where driving at night was taking my life in my hands.

It was at this point that I discussed my vision with Dr. Somchai Trakool Choke-satian in the SuperSight surgery department at the Bangkok Hospital Pattaya.

It was at that initial consultation that I discovered that SuperSight was not just changing the lens in the eye, but a thorough eye examination to ensure that the eye itself is healthy, other than the cataracts and hardening of the natural lens. This examination takes about one hour, so it’s not a case of “Read the bottom line,” and it’s all over style exam.

Dr Somchai advised me that my eyes were suitable for the SuperSight lenses and then went on to discuss all the pros and cons of the surgery and the final results that could be expected, and then told me to go and think about it.

I did that by speaking to all the people I knew who had SuperSight surgery done before. To a man the answers were the same, “Wish I’d done it years ago”.

So a convenient date was selected for Dr. Somchai and myself and the stage was set. No turning back.

I am asked by others whether the operation was painful and I can honestly say it was not. It is a weird sensation having someone ‘inside’ your eyeball, but not painful. Under local anesthetic I found I could relax and keep my eye still as Dr. Somchai did his magic. And the results are magical. And the freedom from the glasses is wonderful.

Now two months after the operation, I still pat my pocket for the readers as I sit down in front of the computer and then realize I don’t need them. And as a funny ending, I can now wear T-shirts without a pocket for the glasses. My wardrobe has doubled! And I can finally read the numbers on the remote for the TV.

For more information contact the SuperSight surgery department at the hospital, they are nice people. Telephone 1719.

Update December 10, 2016

Do you have “sugar”

Diabetes is a serious ailment, which can arise for many reasons, and can affect many systems in the human body. Diabetes, often called “sugar” by patients, is diagnosed and monitored mainly through a simple blood test – the Blood Glucose level.

Glucose is a type of sugar found in fruits and many other foods (this includes lactose and fructose). It is the main source of energy used by the body. Most of the carbohydrates that people eat are also turned into glucose, which can be used for energy or stored in the liver and kidneys as glycogen.

To stop the sugar levels just increasing daily, a balance is achieved through a hormone called Insulin which helps the body use and control the amount of glucose in the blood. Insulin is produced in areas of the pancreas called ‘islets’ and released into the blood when the level of glucose in the blood rises. In simple terms, people who do not produce enough insulin develop diabetes. People can also develop diabetes if they do not respond normally to the insulin their bodies produce. This occurs most commonly when a person is overweight, and since obesity is on the rise, so are various types of diabetes.

Normally, blood glucose levels increase slightly after a person eats a meal. This increase causes the pancreas to release insulin so that blood glucose levels do not get too high. Blood glucose levels that remain high over time can cause damage to the eyes, kidneys, nerves, and blood vessels, which explains why good glucose control is important.

There are many ways to carry out blood glucose tests, including fasting blood sugar (FBS). This is a measurement of blood glucose after fasting for 12 to 14 hours. For an accurate fasting blood sugar test, do not eat or drink for 12 to 14 hours before the blood sample is taken. However, water can be freely taken, as otherwise hemoconcentration occurs to give a falsely high reading. This is often the first test done to detect diabetes, and explains why fasting blood tests are usually done when having a medical check-up.

The other common test is called the random blood sugar (RBS). A random blood sugar measurement may also be called a casual blood glucose test. This is a measurement of blood glucose that is taken regardless of when the person last ate a meal. Sometimes several random measurements are taken throughout a day. Random testing is useful because glucose levels in healthy people do not vary widely throughout the day, so wild swings may indicate a metabolic problem.

Glucose tolerance testing can also be done, usually to confirm a condition known as gestational diabetes, which can occur during pregnancy. An oral glucose tolerance test is simply a series of blood glucose measurements taken after a person drinks a liquid containing a specific amount of glucose; however, this test is not used to diagnose diabetes.

To monitor the treatment of diabetes, there are another couple of tests which can be carried out. The commonest is Glycated Hemoglobin, otherwise referred to as HbA1c. This test actually is an indicator of the average glucose concentration over the life of the red blood cells (which is taken as over the previous three months).

Another is the Serum C-Peptide which is used to investigate low blood sugar levels, done by measuring the C-Peptide which is produced by the Beta cells in the pancreas.

“Normal” levels may vary from lab to lab, but generally the range taken for FBS is that the level should be less than 110 milligrams per deciliter (mg/dL).

Diagnosis of diabetes needs a fasting blood glucose level higher than 125 mg/dL on two separate days.

A fasting glucose level below 40 mg/dL in women or below 50 mg/dL in men that is accompanied by symptoms of hypoglycemia (low blood sugar) may indicate an insulinoma, a tumor that produces abnormally high amounts of insulin. Lower than expected glucose levels can also indicate Addison’s disease, an underactive thyroid gland or pituitary gland, liver disease (such as cirrhosis), malnutrition, or a problem that prevents the intestines from absorbing the nutrients in food.

So you can see “sugar” is important which is why we have specialist endocrinologists at my hospital.

Update December 3, 2016

Bernardino Ramazzini where are you now?

Bernardino Ramazzini (1633 – 1714) was an Italian physician who is considered to be the founding father a rather different medical specialty called Occupational Medicine. One of the lesser known medical specialties, this is the study of worker health, how the workplace affects health, the man-machine interface, industrial exposure to contaminants and many other occupational hazards. (This is not something very well known in SE Asia.)

There are many medical conditions caused by work, right the way from Housemaid’s Knee and another example of occupationally induced conditions is ‘Vibration White Fingers’ and comes under the general umbrella of an interesting set of conditions known as Raynaud’s phenomenon.

Since doctors like to have conditions named after them, Raynaud’s phenomenon comes from Dr. Maurice Raynaud, a French physician who published a report in 1862 of a young woman whose fingertips changed colors when she was cold or under stress. He is credited with the discovery of the condition.

Raynaud’s phenomenon, sometimes called Raynaud’s syndrome or disease, is a disorder of blood circulation in the fingers. This condition is usually produced by exposure to cold which reduces blood circulation causing the fingers to become pale, waxy-white or purple. This condition is sometimes called “white finger,” “wax finger” or “dead finger”. These attacks occur when the hands or the whole body get cold either at work or at home. Household or leisure activities resulting in cold exposure can include washing a car, holding a cold steering wheel, or the cold handlebars of a bicycle. Attacks of white finger can also occur when a person is outdoors watching sports, or while gardening, fishing or golfing in cold weather.

Typical attacks occur with tingling and slight loss of feeling or numbness in the fingers, blanching or whitening of the fingers, usually without affecting the thumb, and pain, sometimes with redness, which accompanies the return of blood circulation generally after 30 minutes to two hours.

Many cases of Raynaud’s phenomenon are such that we cannot identify the cause. To escape the embarrassment of admitting that we just don’t know, we call this “primary Raynaud’s phenomenon” or even “constitutional” white finger. However, when we do know the occupational cause of Raynaud’s phenomenon we call it “secondary Raynaud’s phenomenon”!

In the occupational sphere, there are many causes of this secondary condition. It is most commonly associated with hand-arm vibration syndrome but it is also involved in other occupational diseases. Awareness of the condition can help prevent the disorder from occurring or progressing, as if not detected in the early stages, the disorder can permanently impair blood circulation in the fingers.

Although Raynaud’s phenomenon is not life threatening, severe cases cause disability and may force workers to leave their jobs and workman’s compensation issues may end up in courts of law. Although rare, severe cases can lead to breakdown of the skin and gangrene. Less severely affected workers sometimes have to change their social activities and work habits to avoid attacks of white finger.

The underlying cause relates to the physiology of maintaining an even body temperature. Usually, the body conserves heat by reducing blood circulation to the extremities, particularly the hands and feet. This response uses a complex system of nerves and muscles to control blood flow through the smallest blood vessels in the skin. In people with Raynaud’s phenomenon, this control system becomes too sensitive to cold and greatly reduces blood flow in the fingers.

Exposure to vibration from power tools is by far the greatest concern in secondary Raynauds. Hand-held power tools such as chain saws, jackhammers and pneumatic rock drillers and chippers can cause “hand-arm vibration syndrome”. This disorder is the “vibration white finger”, “hand-arm vibration syndrome (HAVS)”, or “secondary Raynaud’s phenomenon of occupational origin.” How many times have you seen Thai construction workers with the flip-flop “safety” footwear blasting away on concrete floors? Many times I am sure.

Another occupationally induced Raynaud’s phenomenon occurred in the early years, before the cancer-causing effects of vinyl chloride monomer were known. Workers exposed to high levels of this chemical also experienced Raynaud’s phenomenon.

So that is the story of Raynaud’s phenomenon. Fortunately, in our warm tropical climate it is not seen too often, other than the occupational secondary variety.

HEADLINES [click on headline to view story]


Siamese Twins

Going round in circles

Cancer – when time is of the essence

La Maladie des griffes du chat

Can hookworm hook you?

Why you should stay in touch with the family

Genghis Khan and your children

Biting on a bullet!

The diced carrot syndrome

Fractured collar bones

Prostate Cancer in the news again

Living Wills – make one before you need it!

A Wayside Inn of Ill Repute

Dengue Fever - now we have a vaccine!

Good Exercise. Does that include sexercise?

The Seven Deadly Sins!

A PET scan is not an X-Ray of your dog

Christmas Disease – it’s not Happy Holiday disease!

Where’s my readers?

Do you have “sugar”

Bernardino Ramazzini where are you now?



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