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Doctor's Consultation  by Dr. Iain Corness


Pinktober and Breast Cancer screening

We are still in October, and this is Breast Cancer Awareness month, and in Thailand, the Hard Rock Hotel and Hard Rock Cafe help promote this through their “Pinktober” programs.

Breast cancer is an emotive subject, and unfortunately it then becomes a very popular subject for the ‘pulp’ press.  The stories generally run as the “I got breast cancer the day after my mammogram” shockers, or the “I had my breasts cut off because my family has the cancer genes.”  All these are guaranteed to panic the female half of the population and send readership numbers up, which is the name of the game.  Nothing even vaguely related to dissemination of the truth.  This article is hopefully going to redress the situation.  And sorry Mr. Editor, it won’t boost the circulation figures this week either.

Ladies, let me assure you that breast cancer is well understood, and the results are not as the pulp papers would have you believe.  Unfortunately, the cancer detection story is one that suffers from the problems of being an inexact science.  Since we can put men on the moon, clone sheep (and even cattle in Korat) and other incredible facts, we should then be able to diagnose human conditions with pin-point accuracy.  Wrong!  The state of development in Medicine is not so cut and dried.

Diagnosis and detection are “real time” arts, not sciences, even though we would like them to be.  Sure, we use “science” as a tool, but that is all it is.  A tool to help us see the problem.  Just like we can use a telescope to see things at a distance - even if we can’t see the object with unaided vision, that doesn’t mean to say it isn’t there.

There has been a bit of that thinking with Mammograms of late.  A lady has three annual clear Mammograms and then finds she has advanced breast cancer during year number four.  Was the testing useless?  Should we just drop mammograms altogether?

I ask you to look at the "real time" situation.  So today cancer was found.  The most important question is when did it start to grow?  This week, this month, this year?  The answer depends upon the type of the cancer.  Some fast growing cancers would be impossible to pick up, even if the person had monthly mammograms.  However, the slow growing variety can be picked up years ahead.  Unfortunately mammography cannot be a 100 percent indicator either - medical science is not that good - yet.  But repeated mammograms is still one of the best diagnostic procedures we have.  And it is better than nothing.

Likewise, Breast Self Examination (BSE) has its detractors as well as its proponents.  Sure, a lot depends upon how well the woman carries out this self testing, but again, surely it is better to look than to carry on in blissful innocence?

I do not believe the doomsayers who would tell you that the outcome is just the same.  Breast cancer is like all cancers - the sooner you find it, the sooner you can deal with it and the earlier treatment is administered, the better the outcome.  In fact, did you know that studies from the American National Cancer Institute show that 96 percent of women whose breast cancer is detected are still alive five or more years after treatment?  This is called a 96 percent five year survival rate, one of the ways we measure the severity of life threatening cancers.  If the five year survival rate was only 10 percent - in other words, after five years only 10 percent were still alive, then I would also probably feel that predictive testing was not all that worthwhile.  But it is not that bleak an outcome in this case - 96 percent are still alive and many go on for many, many years.

Finally, just because there is the “cancer gene” in your family, this does not mean that you are going to get breast cancer.  It just means there is a “tendency” for the women in that family to develop breast cancer.

Ladies, talk with your doctor regarding breast screening, and ignore sensationalism in the popular press!

White sticks and Labradors

Our vision is something we just take for granted.  You open your eyes in the morning and as the fog clears, you can see your toes.  Yes, the full complement of 10 are all there.  But remember, toes falling off in the night is a fairly rare occurrence.

Vision, as one of our senses, is very interesting.  Even though you may be looking at the same picture as the person next to you, you may not actually be experiencing the same view.

Take color vision.  What is the color of your shirt?  This knowledge is something you learned from your mother, who would point out articles to you and say, “This is red.”  Eventually you came to know that the particular shade or hue was called “red”.  That does not mean that the person next to you “sees” the same “red” as you do, but just that his mother also told him that the shade he sees is also called “red”.

Now, what is the similarity between high blood pressure leading to a stroke and the eye condition called “Glaucoma” which can lead to blindness?  The answer is simple - both of these conditions are “silent” in the fact they do not produce symptoms on their own till very late in the piece, and secondly, both of these conditions can be detected by simple testing, and both respond well to treatment.

So what exactly is glaucoma?  In simple terms it is a build up of pressure inside the eye, which eventually pressurizes the optic nerve and causes it to malfunction.  The optic nerve is a bundle of more than 1 million nerve fibers that connect the retina, the light sensitive membrane in the back of your eye with the visual centers in the brain.  If this pathway degenerates, so does your vision.  Glaucoma is the cause of 10 percent of blindness in the USA.

The fluid pressure build-up in the eye comes from poor function in the ‘drain’ which is a mesh of tissue where the iris (the colored part) and the cornea meet.  If the ‘drain’ blocks for any reason, then the pressure can build, until it becomes so high it produces pressure symptoms on the functioning of the optic nerve.

There are various types of glaucoma, but the commonest by far is called Open Angle Glaucoma and covers about 80 percent of all cases of glaucoma.  The condition affects both eyes and comes on very gradually, with little or no symptoms initially.

Narrow Angle Glaucoma accounts for around 10 percent of the cases, and Asians have the greatest incidence, especially those of Chinese origin, with the Asian “short” eyeball.  This generally comes on much quicker and often will only affect one eye.  This condition is an ocular emergency.

The final 10 percent of cases comes from a condition we call Secondary Glaucoma.  This happens after another condition, such as diabetes, tumors or infection can block up the ‘drain’ hole.  Some cases arise when steroid eye drops are used, which shows again the dangers of ‘self-prescribing’.

In the majority of cases, and after a long period of time, the patient begins to notice that the edges of the visual fields are going, until it is like looking through a tube or tunnel.  The deterioration continues from there and next up is the white stick and the Labrador.

Detection of the condition is the most important factor.  The testing for the increased pressure in glaucoma is called tonometry and is painless and easily carried out by the eye specialist.  Those at risk should have the test done every year after the age of 40, and for the rest of us, we can probably leave it till we get to 60 - but the choice is yours if you want to commence testing earlier.

The treatment includes special eye drops and surgery is also an option, to open up the ‘drain’ hole using a laser.  However, the eye drops generally have to be continued as well.

So now you should add tonometry testing for glaucoma to your annual check-up list which includes blood pressure testing and cholesterol levels, mammograms (for the ladies) and prostate checks for the men.

Cholelithiasis (AKA Gallstones)

Cholelithiasis, or ‘gallstones’, affect around 10 percent of the population.  That’s a fair whack of people.  When I was a student, we were given the mnemonic Fat, Fair, Female, Fertile and Forty as being the catchy 5F’s to remind us of the ‘typical’ gallstone sufferer.  Of course, like all catchy mnemonics it isn’t quite true as 10 percent of men also have gallstone problems.

Unsure where your gall bladder is hiding?  It is found under your lower ribs on the right side of your body and is attached to the underside of your liver and is involved with digestion.  In its natural healthy state it is like a hollow sausage attached by a tube (the bile duct) to your “stomach”.  It is when it gets gallstones inside it that you begin to get a problem.

So where do these gallstones come from?  Well, 80 percent of them are made of our old friend Cholesterol, or Cholesterol mixed with pigment, that’s why you can get gallstones in such pretty colors, though I am yet to see any made into a necklace, but it could catch on, I suppose.

The Cholesterol stays in solution until something happens to slow down the emptying of the gall bladder, or thicken the solution, such as happens during fasting or dehydration.  This results in what we call biliary “sludge” which then hardens and turns into gallstones.  Another good reason to drink more water.  Beer is not the same as water, sorry.

Factors which increase the likelihood of developing gallstones include increasing age, obesity, a diet high in animal fats and certain medical conditions such as diabetes.  Oh yes, pregnancy also increases the incidence.  (With all these problems that can happen with procreation, it is a wonder the human race has got this far!)

The management of gallstones has also changed dramatically over the past 20 years because of three main factors.  The first was the development of Ultrasound visualization.  At last we had a way of diagnosing gallstones by actually seeing them in situ.  Not only could we now “see” the gallstones, but we could tell if they really were the cause of the pain by being able to pick out the inflammation in the gall bladder wall.

The second development was ERCP (you know how we love acronyms in medicine) which stands for Endoscopic Retrograde Cholangio-Pancreatography.  At the end of the operating telescope (the Endoscope) the surgeon can sneak into the bile duct and scoop out stones that are blocking the duct which have been causing jaundice.  This is one of the common causes of jaundice - but not the only cause.

The third development was Laparoscopic Cholecystectomy and was pioneered in 1987 by a French surgical team.  Instead of practically sawing you in half to get at the gall bladder, hiding under the liver, this is a much less invasive method, where the operating laparoscope is inserted through a small incision in the abdominal wall, and the surgeon does the job under the direct vision.  While this results in less trauma, shorter hospitalization and quicker recovery, it is not always successful, as if there has been much recurrent inflammation, the gall bladder can be very difficult to extract and the operation may have to be converted to the older “open” method.

The principal presenting symptom in cholelithiasis is pain, but some people with cholelithiasis have no symptoms at all, while others may have severe abdominal pain, nausea and vomiting, and complete blockage that may pose the risk of infection.  Cholelithiasis can lead to cholecystitis, which is inflammation of the gallbladder.  Acute gallstone attacks may be managed with intravenous medications, but chronic (long-standing) cholelithiasis is best treated by surgical removal of the gallbladder.

It is also important to remember that gallstones can be found incidentally, and if they are causing no problems, the answer is simply to leave them alone.  The chances of developing symptoms over 20 years are about 18 percent the good books tell me, so with an 82 percent chance of getting off with nothing, who is going to volunteer for an operation?  What “gall” to even suggest it!

Just grief or depression?

My Mother died two weeks ago.  She was 94 years of age, and other than the physical frailties that nine decades brings, she was in quite reasonable health.  She lived in the north of Scotland and looked forward to my telephone calls, catching up on the family happenings.  Her passing was quick and gentle.  Took to her bed on the Saturday and slid out of this life on the Sunday morning.

My sister and I shared the familial grief by phone.  With Mother at 94 we knew in advance that she had to have turned the corner into the home straight, but even so, our grief was one of copious tears followed by an unwilling acceptance that our Mother had “gone”.

Two weeks later I can still get teary-eyed.  Is this still grief, or is it now depression?

Well, if you are a western male, even if it is ‘depression’, you will almost automatically repress the emotion.  You were taught to do this by your father.  You probably even picked up your crying toddler son after a tumble and said, “There, there.  Big boys don’t cry.  You’re OK.”  We are all guilty of promoting this stereotype.

“Men tend to be action-oriented, so they mistrust feelings and tend to regard emotions as a sign of weakness,” says Dr Michael Dudley, a psychiatrist and chairman of Suicide Prevention Australia.  “For men, mental illness is seen as a moral failing, so they bury pain and don’t talk to people about it.  But depression is an illness, not a weakness.”

However, what has to be understood is that just “feeling down” on its own is not a symptom of mental illness.  We all feel down from time to time, generally when something has happened to precipitate it, such as the passing on of my Mother.  We all feel sad from time to time, but depression is an ongoing sadness that lasts for two weeks or more, with a complete loss of pleasure in things that were once enjoyed.  With that description, I can honestly say I am still grieving, but I am not depressed.

Since men have been raised not to have public displays of depression, many adopt strategies to cover the problem, with the common ways being to become workaholics, risk taking to produce ‘highs’, alcohol and illegal drugs.

The incidence in the community is frightening.  The Australian National Survey of Mental Health and Wellbeing found that one in four women and one in six men suffered from depression.  In 20 years it is predicted that depression will be second only to heart disease as Australia’s biggest health problem.

While the causes of depression are multiple, and men try to mask their problem, the sad part is that depression can be treated.  Modern pharmaceutical medication is not ‘mind altering’ but restores the chemical balance in the brain to allow ‘normal’ thought processes to return.

So here are 10 tips to help beat depression:

1. Stay active - go gardening, take a brisk walk or go swimming.

2. Healthiness is happiness - don’t neglect your health when you’re feeling low.  Eating and sleeping well will have a positive impact.

3. Don’t drown your sorrows - alcohol is a depressant that will make things worse both in the short and long term.

4. Knowledge is power - think it through and systematically pinpoint the things that make you feel depressed in the first place.

5. Don’t isolate yourself - surround yourself with family and friends, they are a fantastic support mechanism.

6. Keep it simple - evaluate the aspects of your lifestyle that put added pressure onto you and try to cut them out.

7. Rationalize your worries - writing them down can help get them out of your head.

8. Feelings are fleeting - the world around us is not depressing, only our own perception of it, which can just as easily turn around in an instant.

9. Altruism enhances moods - a kind gesture here and there will do wonders for your wellbeing.

10. Take responsibility - things will only change when you realize you are the number 1 change factor.

And if you are male, it is very important you recognize your own moods and not be afraid to ask for professional help.