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Doctor's Consultation  by Dr. Iain Corness


Dengue Fever - it’s here again!

We are in the wet season.  There is no doubt about that.  As I write it is bucketing down outside, but being tropical rain, it is warm and all over in a couple of hours.  But there will be many puddles of water left - the ideal environment for the Aedes aegypti mosquito to breed.  Aedes aegypti is not some opera (that’s Aida), but is the name of the main mosquito carrying the Dengue virus.  The other is Aedes albopictus.

We see many westerners with Dengue Fever.  These are not an isolated group that caught it from drinking out of damp glasses in the same bar.  And if you don’t think Dengue is important, there were 70 fatalities last year.  That’s more than died from the SARS epidemic that had people cringing in their homes afraid to go out without a gas mask.

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 figures have now prompted me to repeat my advice on this subject.  This is an important ailment, that can be avoided.

However, first you should understand a little more about Dengue.  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.

Like Malaria, the virus is carried by mosquitoes.  The virus itself 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 standing or 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”.  Interestingly, some patients complain of a metallic taste in the mouth.  (Please don’t ask - I have no idea why!)

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 Serotypes 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 also more susceptible to this than adults.  This also becomes much more of an emergency and might need to be 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 lies 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.  And then remember to use it!

When should you start annual mammograms?

The American College of Obstetricians and Gynecologists now recommends mammograms for women beginning at age 40.

Due to the high incidence of breast cancer in the US and the potential to reduce deaths from it when caught early, The American College of Obstetricians and Gynecologists issued new breast cancer screening guidelines that recommend mammography screening be offered annually to women beginning at age 40. Previous College guidelines recommended mammograms every one to two years starting at age 40 and annually beginning at age 50.

According to the College guidelines, the change in mammography screening is based on three factors: the incidence of breast cancer, the sojourn time for breast cancer growth, and the potential to reduce the number of deaths from it.

(The time period between when a breast cancer may be detected by a mammogram while it is very small and before it grows big enough to become symptomatic is known as the sojourn time.) Although the sojourn time of individual cancers can vary, the greatest predictor is age. Women ages 40-49 have the shortest average sojourn time (2-2.4 years), while women ages 70-74 have the longest average sojourn time (4-4.1 years).

“Although women in their 40s have a lower overall incidence of breast cancer compared with older women, the window to detect tumors before they become symptomatic is shorter, on average,” said Dr. Griffin. The five-year survival rate is 98 percent for women whose breast cancer tumors are discovered at their earliest stage, before they are palpable and when they are small and confined to the breast.

The College continues to recommend annual clinical breast exams (CBE) for women ages 40 and older, and every one to three years for women ages 20-39. Additionally, the College encourages “breast self-awareness” for women ages 20 and older. Enhanced breast cancer screening, such as more frequent CBEs, annual MRI (magnetic resonance imaging), or mammograms before age 40, may be recommended for women at high risk of breast cancer. Breast MRI is not recommended for women at average risk of developing breast cancer.

Breast cancer is the second leading cause of all cancer-related deaths among American women. The incidence of breast cancer in the US declined 2 percent each year between 1999 and 2006, and deaths from breast cancer have also declined steadily over the past two decades. Evidence suggests the breast cancer rate is most likely due to fewer women getting mammograms and therefore not being diagnosed, as well as a significant drop in women using hormone therapy for menopausal symptoms. “The good news is that fewer women are dying from breast cancer because of earlier detection and improved treatments,” said the Vice President for Practice Activities of the College.

The College's breast cancer screening guidelines also address clinical breast exams and breast self-awareness.

Studies on Clinical Breast Exam (CBE) suggest they can help detect breast cancer early, particularly when used along with mammograms. Thus, The College recommends that women ages 40 and older have an annual CBE performed by their physician. Although the benefit of CBEs isn’t clear for those younger than age 40, The College continues to recommend that women ages 20-39 have a CBE every one to three years.

The traditional breast self-exam (BSE) has shifted toward a newer concept called “breast self-awareness.” BSE is performed in a systematic way on a regular basis, typically monthly. Breast self-awareness, on the other hand, is women understanding the normal appearance and feel of their breasts, but without a specific interval or systematic examination technique. The College endorses educating women ages 20 and older regarding breast self-awareness.

“The goal here is for women to be alert to any changes, no matter how small, in their breasts, and report them to their doctor,” said Dr. Griffin. “Although we've moved away from routinely recommending BSEs, some women will want to continue doing them and that's OK.”

According to The College, there is no consensus on the upper age limit for mammograms, although the benefits of screening declines with increasing age compared with the harms of overtreatment. “Women ages 75 and older should discuss with their doctor whether to continue getting mammograms,” said Dr. Griffin.

Ladies, please note these new recommendations.

Check-ups are for women too

There is an unfortunate idea that check-up packages are only for men. After all, men have a higher incidence of heart disease, get cancer of the prostate and lung cancer, so since men die earlier than women, preventive check-ups are more important for the man of the house.

That concept must have been put forward by a man looking for sympathy. The truth of the matter is that serial check-ups don’t keep you alive forever, but they do make a considerable positive difference to the Quality of Life as one gets older. (I use capital Q and capital L on purpose.) Longevity alone, with no Quality, just isn’t worth it in my book. Or yours, most likely, otherwise you would not be reading this column.

The guiding principle behind check-ups is to find deviations from normal health patterns at an early stage. Early enough that the trend can be reversed, before damage has occurred. Examples of this include Blood Pressure (BP), a significant factor in poor health in the future if unchecked now, for both men and women. High BP can affect many organs in the body, not just the heart. But an elevated BP generally gives no warning symptoms.

Another example is blood sugar. Again, it requires sky-high sugar levels before the person begins to feel that something might be wrong. And by then the sugar levels have affected vision, the vascular system and many other systems, all of which can decrease your Quality of Life in the future. Amputation of a limb is a common result of unchecked blood sugar levels. A situation that neither men nor women would wish for themselves, I am sure.

Cardiac conditions and abnormalities, be that in anatomy or function, can also very adversely affect your Quality of Life, but are very easily found during a routine check-up. Various blood tests and an EKG can show just how well the cardiac pump is functioning, and how well it will continue to function in the future. The inability to walk more than 50 meters certainly takes the fun out of mother’s shopping, yet this can be predicted - if you have some serial records!

Another of the silent killers can be discovered in your lipid profile, with Cholesterol and its fractions HDL and LDL, being intimately connected with your cardiac status. Again a situation where detecting abnormalities now can mean that you can get through the deadly 50-60 year age bracket in the future with clear coronary arteries and a clean bill of health.

There are actually so many of the conditions that can affect your enjoyment of the future that can be discovered early. Renal (kidney) function and liver function can be monitored through an annual check-up, as can cervical cancer (pap smear) or breast tumors (by mammogram).

So hopefully I have influenced you enough to begin to think about an annual check-up - especially for your mothers. If Mum is under 40 years of age, and you think your Mother is in good health (non-smoker and moderate drinker) then every two years will be fine. If mother is older than 40, then make it an annual event. It is good ‘insurance’ for the future.

And what degree of check-up should you go for? If mother is in tip-top health and previous check-ups have been normal, then go for the simple screen - however, if she is a smoker, or has some previous results outside of normal, move up a notch to the more comprehensive tests. I would also suggest that if she is over 50, look for the more detailed check-ups.

“Cures” for Diabetes

Late-onset Diabetes Mellitus, sometimes called Type 2 Diabetes, is a disease which is increasing, in line with many sufferers’ increasing waistline. While the tendency to become a diabetic may be familial, it does not necessarily mean you have a 100 percent chance of suffering from the disease yourself. There are some factors you can make work to your benefit.

Recently, the popular press ran the story that if you went on a 600 calorie diet you could reverse your diabetes. This was after Newcastle University researchers found the low calorie diet reduced fat levels in the pancreas and liver, which helped insulin (the sugar balance chemical) production return to normal.

Keith Frayn, professor of human metabolism at the University of Oxford, said the Newcastle study was important. “People who lose large amounts of weight following surgery to alter their stomach size or the plumbing of their intestines often lose their diabetes and no longer need treatment. This study shows that a period of marked weight loss can produce the same reversal of Type 2 diabetes. It offers great hope for many people with diabetes, although it must be said that not everyone will find it possible to stick to the extremely low-calorie diet used in this study.”

Dr Iain Frame, director of research at Diabetes UK, which funded the study, sounded a caution, saying the diet was not an easy fix. “Such a drastic diet should only be undertaken under medical supervision. Despite being a very small trial, we look forward to future results particularly to see whether the reversal would remain in the long term.”

And it certainly was a small trial with only 11 people who had been diagnosed with diabetes in the last four years enrolled. At the end of three months, seven out of the 11 people studied were free of diabetes three months later, say findings published in the journal. I’m sorry, but 11 people is not enough. I will be impressed when they have a sample of 11,000,000.

A few weeks later, and along comes another “cure” for Type 2 Diabetes. Researchers in Australia saying that they had found that a decreased level of Vitamin D in the blood increased the risk of diabetes, and then postulated that by increasing the level of Vitamin D this would be beneficial, and it could lead to ‘at risk’ patients using vitamin D supplements along with diet and exercise to stop their development of the condition.

The research, which tested the blood of 5,200 people (now that’s a better number than 11, but still a little short of my 11,000,000) found every increase of 25 nanomoles of vitamin D per liter of blood (nmol/L) equated to a 24 percent reduced risk of diabetes. A co-author, Zhong Lu, a pathologist at Monash Medical Centre and Melbourne Pathology, said that people with a level of vitamin D in their blood that is less than 50 nmol/L are deficient, although some experts believe the threshold for deficiency should be set higher.

The study’s co-author Ken Sikaris, a pathologist at Melbourne Pathology, said the research could have a big impact in slowing increasing rates of diabetes in Australia. “It’s hard to underestimate how important this might be,” he said.

The study, published in the journal Diabetes Care and presented by Dr Lu at a conference of the Australian and New Zealand College of Anesthetists, retested blood samples taken as part of the major AusDiab study of risk factors for diabetes. Now this was a better study which was made between 1999 and 2005 and is the most recent to widely test for diabetes, revealed 7.4 percent of Australians over 25 had the condition. However, the numbers are not looking so good now, are they, with 92.6 percent not being Vitamin D deficient. “Hard to underestimate”? Hmmmm.

But Professor Peter Ebeling, from the University of Melbourne and Western Health, said that in light of the findings he was conducting a trial to test whether vitamin D supplements could help prevent diabetes.

Professor Ebeling said such research had progressed slowly in the past because it had not attracted funding, particularly from drug companies.
And there’s the nub of it all - attracting funding.