Make Chiangmai Mail | your Homepage | Bookmark

Chiangmai 's First English Language Newspaper

Pattaya Blatt | Pattaya Mail | Pattaya Mail TV

 
 

Doctor's Consultation  by Dr. Iain Corness

 

Update March 27, 2015

Just in Time

It stands to reason. Early diagnosis improves the prognosis. A news item a couple of years ago claimed that if you lived in Taiwan you had a better chance of cancer survival, than if you lived in the UK. This was put down to the fact that your cancer diagnosis was done more quickly in Taiwan than it was in the UK.

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

The message is simple - 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. The cough from cancer of the lung is a good example of the first case, and constipation from cancer of the bowel is 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, and I include my own hospital, the Bangkok Hospital Pattaya in this.

Now when I say “centers of excellence” I am referring to the speed of diagnosis that is possible, not 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 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 one hour turnaround for blood tests, patients in the UK receive their results in days, not minutes. Similarly, our appointments for CT scans and MRI’s can be ‘same day’ with results usually the same.

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 hidden or early 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 and causing symptoms.

Timely diagnosis does come back to your ability to inform your doctor of changes. Do not feel embarrassed that it “might be nothing”. All doctors prefer telling people that they do not have a problem after diagnostic testing, rather than the other way around!


Update March 21, 2015

Good Medical Practice, as opposed to Bad Medical Practice

Is orthodox medicine really that bad? It has always been the case that people seem to like to throwing stones at conventional clinical medicine. Claims of over-servicing, over-prescribing and downright fraudulent practices are thrown about, citing someone whose uncle/friend/mother (delete that which is inappropriate) suffered at the hands of “bad” doctors, who missed the diagnosis and treated the wrong bit.

Now, there are certainly some “bad” doctors out there, just as there are “bad” lawyers, “bad” Real Estate agents, “bad” mechanics and just about any profession you would like to think of. But they’re not all “bad”.

How do you become a “doctor”? Take me for example, I am a conventionally trained British/Australian style medical practitioner who has spent a lifetime practicing EBM, otherwise known as Evidence Based Medicine. Practices that have been proven to work. Call it “good” medicine, if you like.

I am proud of my training. Six years at an Australian university that had a good name, and still does, despite undergraduates like me. I am also proud of passing the exams in the Royal Colleges of Physicians and Surgeons in London. I have the honor to have my name listed in the ‘great book’ with luminaries such as Hunter, Jenner and Lister. I am also indebted to my tutors during the 12 months of ‘pre-registration’, where you apply your knowledge under the supervision of accredited specialists. An arduous road, but one that is a safeguard for you, the general public.

The ‘powers that be’ are also ensuring that we keep up to date with a process called Continuous Medical Education (CME). That medical education continues, with CME lectures being attended by my hospital’s doctors (and myself). Fortunately for me, the slides are in English, even though sometimes the lecture is not.

Those ‘powers that be’ also try to ensure that we prescribe drugs that are efficacious, that have been tested, and the evidence points to this. It is not anecdotal evidence, but true scientific evidence shown by research in many countries, with hundreds of thousands of patients. It is following that type of evidence that I can recommend with all good faith, that 100 mg of aspirin a day is “good” medicine. I also know that if you are prescribed a ‘statin’ drug it will lower your cholesterol levels. They have been tested. And these days, very rigorously indeed.

I am also the first to admit that we have sometimes managed to get it wrong. The Thalidomide story still has living examples of this. However, the medical world-wide network is cohesive enough to ensure that this drug was withdrawn. It is the checks and balances system that has kept western medicine afloat. This is not to be equated with the checks and balances system that have been incorrectly applied in the banking industry that sees those institutions on the brink of sinking!

I am often asked my opinion on “alternative” medicine, and all its diverse areas of ‘specialization’. I try to avoid direct confrontation over this. If devotees have found that they can diagnose tumors by looking at patient’s auras through their third eye in the middle of their foreheads, then I am genuinely pleased, in fact delighted, provided that they have subjected the method to scientific scrutiny.

If various groups can actually cure cancer, epilepsy, halitosis or lock-jaw by inserting dandelions into a fundamental orifice, then again I am delighted. This is a medical break-through, but as such, must be subjected to medical scrutiny. If the method stands true scientific examination (not to be confused with anecdotal ‘evidence’) then it will be adopted by everyone, complete with thanks to those clever people who picked the dandelions in the first place. After all, penicillin was tripped over, not designed. But it has had a very rigorous scientific scrutiny since.

As far as the majority of ‘folk’ remedies is concerned, I work on the principle that if you ‘think’ it is doing you good, then it probably is. But don’t ask me to endorse something that has not been scientifically tested.

When the ‘alternative’ group spends more time proving their methods, instead of complaining about non-acceptance, EBM practitioners will give them more credence.


Update March 14, 2015

Quality of Life

A bit “deep” this week, but for many, an important message. So you have been told you have terminal cancer. What can you do? The first thing is to sit down and take stock of your circumstances. All of us know that that piece of string called “life” eventually comes to an end, but we don’t know when. The only difference with you, is that your doctor has actually told you when your piece of “life” string is due to run out.

Now whilst the immediate thought is “How do I beat this?” there are many factors you have to consider in the time ahead, and one of the main ones is called ‘The Quality of Life’.

Now is the time to talk with family, friends and health care team. It is natural for a person with advanced cancer to feel many emotions including anger, fear, and sadness. Just as you may need time to adjust to this new phase of your illness, your family and friends may also need time. If you are having trouble talking with family and friends, ask your nurse, doctor, or counselor to gather everyone together to talk.

This talking phase should also include your getting to understand your cancer. This you do by talking with your treating doctors, and also from information from reliable internet sites. Note I say “reliable” sites. There are always plenty of sites ready to sell you snake oil.

Now is the time to manage your symptoms. Your quality of life is better if your symptoms are under control. Talk to your health care team about the best way for you and your caregivers to manage your symptoms.

Do not be afraid to ask your doctors about any proposed modalities of treatment. Getting an extra two months of life, but at the cost of the quality of life, may not be worth having. Always keep that in mind. Quality of (the remaining) life is everything.

Be as active as you can. When an illness progresses, it may be harder to do the things you have always done. Talk to your health care team about what, if any, limitations you may have. If your physical health allows, continue to exercise in some enjoyable way. Or, if you find it is too much for you, take up a new hobby or find things that you can still do and enjoy, such as reading, writing, creating a photo album, or making a video for family and friends.

Let friends and family know what they can do to help. What can you do for yourself? What is important to you? What can friends and family do for you? What can all of you do together? Where do you turn if you need extra help or care? If you are not up to being social, let people know this as well.

Make your wishes known. Making the decision to stop active cancer treatments can be a hard choice for a person with cancer and their family. These are personal choices. If you are faced with making these decisions, talk with your family and health care team about your wishes and explore all of your options. You are still able to make decisions about your life to the extent that you desire.

Maybe you want to give someone else some of the responsibilities or share decisions about what to do. You may want to create a health care proxy and/or power of attorney. This allows someone who you choose to make health care or other decisions for you. Whatever you choose, you are in control of your life and you know what will work best for you.

You should consider creating a ‘Living Will’ giving specific instructions on what your wishes are as the cancer progresses. This process makes your end-of-life wishes and desires known, and your health care team and can help ensure that your wishes are honored. These wishes may include funeral arrangements or decisions about hospice care. Discuss with your family, friends, and health care team your wishes regarding resuscitation.

Sorry if the column this week was a trifle dark, but it can give assistance to those who feel as if all their options have gone.


Update March 7, 2015

Elixir of Youth next week!

There was an article in the Pattaya Mail a couple of weeks back about my extra-curricular activities on the motor racing circuits. I said that it was race driving that keeps me young, or put another way - growing old disgracefully.

I have a book on my desk called ‘Geriatric Medicine’ and what a depressing start to the day that can be! Gloom, doom and disaster! However, the picture is not really as bad as all that, so I thought that this week I would go through the aging process, and then what we can do about it. The recipe for the elixir of youth is not enclosed as I am still trying to perfect it, but instead, I will give you some ways you can stay feeling ‘young’ while waiting till next week!

Let’s begin with the depressing news that you have actually been going downhill since the age of 14 (mentally) and from the age of around 30 (physically). That bar-room ditty that relates to what you used to do all night, now taking all night to do, can be too close to the mark for some of us. But don’t despair, help is at hand (no pun intended).

The book suggested that the aging of our individual organs is influenced by diet, environment, personal habits and genetic factors. Read that again - did you notice that three of them (diet, environment, personal habits) are actually under our control, so the angle of the slippery slide can be changed. Good News number one.

The physiological changes associated with aging do include an increase in body fat, a difficulty in reading (called presbyopia) and a clouding of the optic lens (called a cataract). Glucose metabolism goes a little awry as well, as we get older. In the lungs, the elasticity goes out of the lung tissue, meaning that the lungs don’t absorb the oxygen as well as they should.

It doesn’t end there. This elasticity thing gets increasingly important. The arteries become less elastic too, so the heart has to pump harder to force the blood around, increasing blood pressure and enlarging the heart.

Then the liver doesn’t cope as well with the toxic chemicals we meet as it used to, and the bowel gets a little lazy as well, leading to constipation. For men, the prostate slowly enlarges and makes it difficult for the bladder to empty properly, so you have to get up to pee a few times a night. The awful statistics are that 50 percent of all men will have some degree of enlargement by the time they are 50 years old, 60 percent by 60, 70 percent by 70, and you don’t have to be Albert Einstein to do the math for the time you are 100.

Finally, the brain shrinks and you begin to forget things, “I’ll never forget what’s-her-name” being a real problem! You lose the recent memory first, and then the long term memory second.

So what to do? The main thing is to make sure your organs get enough oxygen to work properly. Oxygen gets into the blood via the lungs. Clogged air sacs in the lungs is a big problem. Answer? Stop smoking - immediately, and get some exercise every day, so that you start to use the lungs, and their capacity, again.

Now we have some oxygen back in the blood we have to circulate the magic red fluid. Cholesterol build-up in the arteries produces blockages. Reverse it by lowering cholesterol in your diet. You do this by decreasing animal fats and increasing vegetables. That’s not too difficult either, is it?

Now the sugar problems. Another one with an easy fix - cut out all the ‘extra’ sugar in your diet. You don’t have to use sugar in your coffee, and chocolates should be a very occasional indulgence only.

The liver? The main toxic substance it has to deal with is ethanol, otherwise known as alcohol. Give the liver one day a week to recover. That’s your AFD (alcohol free day).

So look at the three items again under your control - diet, environment, habits. The answer to counter aging is there. Begin with fags, fat, booze and fancy foods. It’s the right start.


Update March 1, 2015

WHO targeting 17 tropical diseases

The World Health Organization (WHO) urges affected countries to scale up their investment in tackling 17 neglected tropical diseases in order to improve the health and well-being of more than 1.5 billion people.

This investment would represent as little as 0.1 percent of current domestic expenditure on health in affected low and middle income countries for the period 2015-2030.

Neglected tropical diseases cause blindness, disfigurement, permanent disability and death, particularly among the poor. WHO’s new report, “Investing to Overcome the Impact of Neglected Tropical Diseases”, outlines an investment case and essential package of interventions for these diseases.

“Increased investments by national governments can alleviate human misery, distribute economic gains more evenly and free masses of people long trapped in poverty,” says WHO Director-General Dr Margaret Chan.

Unfortunately, with the current “epidemic” of terrorist activity amongst the poorer nations in Sub-Saharan Africa, for example, this concept of forward thinking does not have much chance of being implemented. Boko Haram is not renowned for worrying about social welfare.

Listed below is a short description of the 17 neglected tropical diseases, also accessible at http://www.who.int/neglected_diseases/diseases/summary/en/
Dengue: A mosquito-borne infection causing flu-like illness that may develop into severe dengue and cause lethal complications.

Rabies: A preventable viral disease transmitted to humans through the bites of infected dogs that is invariably fatal once symptoms develop.

Trachoma: A chlamydial infection transmitted through direct contact with infectious eye or nasal discharge, or through indirect contact with unsafe living conditions and hygiene practices, which left untreated causes irreversible corneal opacities and blindness.

Buruli ulcer: A debilitating mycobacterial skin infection causing severe destruction of the skin, bone and soft tissue.

Yaws: A chronic bacterial infection affecting mainly the skin and bone.
Leprosy: A complex disease caused by infection mainly of the skin, peripheral nerves, mucosa of the upper respiratory tract and eyes.

Chagas disease: A life-threatening illness transmitted to humans through contact with vector insects (triatomine bugs), ingestion of contaminated food, infected blood transfusions, congenital transmission, organ transplantation or laboratory accidents.

Human African trypanosomiasis (sleeping sickness): A parasitic infection spread by the bites of tsetse flies that is almost 100 percent fatal without prompt diagnosis and treatment to prevent the parasites invading the central nervous system.

Leishmaniases: Disease transmitted through the bites of infected female sandflies that in its most severe (visceral) form attacks the internal organs and in its most prevalent (cutaneous) form causes facial ulcers, disfiguring scars and disability.

Taeniasis and neurocysticercosis: An infection caused by adult tapeworms in human intestines. Cysticercosis results when humans ingest tapeworm eggs that develop as larvae in tissues.

Dracunculiasis (guinea-worm disease): A nematode infection transmitted exclusively by drinking-water contaminated with parasite-infected water fleas.

Echinococcosis: Infection caused by the larval stages of tapeworms forming pathogenic cysts in humans and transmitted when ingesting eggs most commonly shed in feces of dogs and wild animals.

Foodborne trematodiases: Infection acquired by consuming fish, vegetables and crustaceans contaminated with larval parasites. Clonorchiasis, opisthorchiasis and fascioliasis are the main diseases.

Lymphatic filariasis: Infection transmitted by mosquitoes causing abnormal enlargement of limbs and genitals from adult worms inhabiting and reproducing in the lymphatic system.

Onchocerciasis (river blindness): Infection transmitted by the bite of infected black flies causing severe itching and eye lesions as the adult worm produces larvae and leading to visual impairment and permanent blindness.

Schistosomiasis: Trematode infections transmitted when larval forms released by freshwater snails penetrate human skin during contact with infested water.

Soil-transmitted helminthiases: Nematode infections transmitted through soil contaminated by human feces causing anemia, vitamin A deficiency, stunted growth, malnutrition, intestinal obstruction and impaired development.

In 2013, Colombia became the first country where WHO verified the elimination of river blindness (onchocerciasis), followed by Ecuador in 2014.

Bangladesh and Nepal are poised to eliminate visceral leishmaniasis as a public-health problem by the end of 2015.
And Dengue and Rabies can be found in Thailand!

The number of new cases of sleeping sickness (human African trypanosomiasis) has dropped to fewer than 10,000 annually and this for the first time in 30 years with 6 314 cases reported in 2013.

In 2009 approximately 30 percent of children in need of preventive treatment for soil-transmitted helminthiases were receiving it. Reaching 50 percent of children with this treatment by end 2015 is achievable.


HEADLINES [click on headline to view story]

Just in Time

Good Medical Practice, as opposed to Bad Medical Practice

Quality of Life

Elixir of Youth next week!

WHO targeting 17 tropical diseases