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Doctor's Consultation  by Dr. Iain Corness


Update April 25, 2015

Bargains in medication?

How many pharmacies in your street? I can count five over 500 meters. This must mean we are all very sick and needing constant medication - or, like beauty salons and massage parlors, the collective imagination is lacking somewhat.

But back to the pharmacies, with so many of them, the only way they can compete with each other is on price. A box of Enalapril looks the same as any other box of Enalapril. So where do they get cheaper drugs in the first place?

The big money spinners are the drugs which can keep you in a state of perpetual priapism, a continuing (and painful) male erection and the term was coined after the Greek god Priapus who is shown in paintings to have a central member like a third leg.

Cheap pills for Erectile Dysfunction (ED) that seem too good to be true, are usually just that - too good to be true! The chances are very high that they are counterfeit.

One of the patients showed me a box purporting to be genuine brand name Cialis tablets, which were not having the desired effect. I was immediately suspicious as the box was not all that well printed. I was quite sure they were counterfeit when I read the Patient Information slip. The English grammar was incorrect, and there were spelling mistakes. Eli Lilly, the ‘real’ manufacturer does not send out mis-spelled literature with their product.

Eli Lilly’s website on Cialis confirms that there is fake Cialis in the marketplace. The website suggests you ask yourself these questions; any “yes” answers could mean that the Cialis being sold may be fake:
Is the price so much lower than the price at the hospital pharmacy that it seems too good to be true?

Does the pharmacy offer “soft tab” or “fast dissolve” Cialis? (Cialis only comes in tablets. There is no such thing as “soft tab” or “fast dissolve” Cialis.)

Does your local pharmacy offer “generic Cialis” or a drug with a name that is similar to Cialis? (Such products have not have been evaluated by the FDA for safety and effectiveness - they could be harmful.)

The World Health Organization puts the annual amount of counterfeit drugs sales at something like $35-40 billion per year. No wonder I (and you) get so many offers of drugs through the internet. That’s a very large pie.

The World Health Organization also estimates that one in three drugs on the worldwide market today is counterfeit. Sometimes the fake drugs contain toxic substances from which you can die.

Pfizer’s laboratories analyze the fakes and a representative stated, “We’ve seen boric acid, we’ve seen heavy metals, we’ve seen road paint, we’ve also seen floor wax to coat the pills and give them a shine. Obviously, they are detrimental to anyone’s health.”

It is not just Eli Lilly that is targeted. Pharmaceutical giant Pfizer (yes chaps, the makers of the blue diamonds of happiness) estimates its annual losses to counterfeit drug sales at $2 billion.

However, this is actually a serious situation. If specific drugs are only available through pharmacies, on the prescription of a doctor, is it safe to just buy over the counter (or the internet), without any doctor’s advice?

The American Food and Drug Administration (FDA) says, “Patients who buy prescription drugs from websites operating outside the law are at increased risk of suffering life-threatening adverse events, such as side effects from inappropriately prescribed medications, dangerous drug interactions, contaminated drugs, and impure or unknown ingredients found in unapproved drugs.”

According to WHO, drugs commonly counterfeited include antibiotics, antimalarials, hormones and steroids. Increasingly, anticancer and antiviral drugs are also fake. And you can add to that, the ‘blue diamonds’. Never forget the phrase “Caveat emptor” (Let the buyer beware).

If you receive a spam e-mail from someone who you don’t know, offering you specific pharmaceuticals at a cheap price, that should be enough for you to go no further. If your local pharmacies will offer you ‘name brand’ medication that is supposedly prescription only at a very cheap price, that should ring alarm bells in your head too.

Get your medications on a doctor’s prescription from a pharmacy you can trust. Or suffer the consequences.

Update April 16, 2015

Mammograms and BSE. Worthwhile?

The opening of our new Breast Center the other day made me think once more about breast cancer. Screening for breast cancer is still a subject that seems to be controversial, though honestly, I do not know why. The sensationalist press feeds on fear, and by instilling fear into women about detection of breast cancer will always sell a few more papers. Despite mammograms and suchlike, there were cases that escaped detection until it was too late and other such negative predictions. Was it all then a waste of resources and money?

No it is not, says the American Cancer Society’s director of cancer screening, Robert Smith, PhD, who says there is plenty of evidence that mammograms save lives, even for younger women.

“The American Cancer Society and other organizations have endorsed mammography screening for women in their 40s because direct and inferential evidence supports its value in reducing morbidity (injuries) and mortality (deaths) from breast cancer, the second leading cause of cancer death in women,” he says.

Other groups that recommend mammograms every one or two years for women in their 40’s include the US Preventive Services Task Force and the American College of Obstetricians and Gynecologists.

The American College of Physicians guideline says mammograms can reduce breast cancer deaths by about 15 percent among women in their 40’s, but Dr. Smith says newer studies indicate the benefit is much greater - 40 percent or more.

Unfortunately, the cancer detection story is one that suffers from a problem which can be associated with an inexact science. Since we can put men on the moon, clone sheep (and even rabbits in Chonburi) and other incredible facts, we should then be able to diagnose human conditions with pin-point accuracy. Unfortunately no!

Diagnosis and detection are “real time” arts, not sciences. 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, that doesn’t mean to say it wasn’t there. The telescope was facing the wrong way, the object was behind not in front.

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

Again I ask you to look at the “real time” situation. So today cancer was found. 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. The slow growing variety can be picked up years ahead. Unfortunately mammography cannot be a 100 percent indicator - we are not that good - yet. But it 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, studies from the American National Cancer Institute show that 96 percent of women whose breast cancer is detected early live 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 it were a 10 percent figure - in other words, after five years only 10 percent of the people were still alive, then I would probably also feel that predictive testing was not all that worthwhile. But it is not that bleak an outcome - 96 percent are still alive and many go on for many, many years.

With new 3D screening tests such as digital mammograms with tomosynthesis, breast cancer can be detected even earlier.

Update April 10, 2015

Counting sheep - on the bosses time!

I attended a lecture the other day and someone asked if falling asleep on the job was enough reason to give an employee the sack. This was apparently a recurring problem with this employee, but I did caution that this daytime napping might be a medical problem, and not a late night karaoke problem.

The medical condition is an interesting one, and it is called Sleep Apnea. (I actually wrote this article on the World Sleep Day, which is why it jogged my memory.)

Put very simply, Sleep Apnea is when people stop breathing for some seconds while asleep. They are usually not aware of this fact, but bed partners are! People with Sleep Apnea stop breathing repeatedly during the night, sometimes hundreds of times and often for a minute or longer.

It is a worrisome situation when the person lying next to you just seems to have stopped breathing. Was that last breath really their last breath? Should you start CPR?

“Apnea” comes from the Greek and literally means “without breath”, so it is an apt word for the condition where people stop breathing when asleep.

Like so many conditions in medicine, it is not quite cut and dried simple, as there are three types of Sleep Apnea. These are called Obstructive, Central and Mixed, with Obstructive being the most common.

Obstructive Sleep Apnea (OSA) is caused by an obstruction producing a blockage of the airway, usually caused by the soft tissue in the rear of the throat collapses and closes during sleep.

In Central Sleep Apnea, the airway is not blocked but the brain fails to signal the muscles to breathe. Normally as the oxygen level drops, a reflex in the brain tells the body to breathe, to increase the oxygen saturation. This reflex is normally very powerful. For example, try holding your breath, and you will find that you breathe again involuntarily. You cannot over-ride your brain.

Mixed Apnea, as the name suggests, is a combination of the two. With each apnea event, the brain briefly arouses people with sleep apnea in order for them to resume breathing, but consequently sleep is extremely fragmented and of poor quality.

Sleep Apnea is much more common than you would have thought, being as common as adult diabetes, and affects more than twelve million Americans, according to the National Institutes of Health.

Risk factors include being overweight, and over the age of forty, but sleep apnea can strike anyone at any age, even children. Males suffer from this more than females, yet still because of the lack of awareness by the public and healthcare professionals, the vast majority remain undiagnosed and therefore untreated, despite the fact that this serious disorder can have significant consequences.

Untreated, Sleep Apnea can cause high blood pressure and other cardiovascular diseases, memory problems, weight gain, impotency, and headaches. And I think I don’t want any of them. It is also stated that untreated sleep apnea may be responsible for job impairment and motor vehicle crashes.

The symptoms of Sleep Apnea include frequent silences during sleep due to breaks in breathing, choking or gasping during sleep to get air into the lungs, loud snoring, sudden awakenings to restart breathing or waking up in a sweat and feeling un-refreshed by a night’s sleep, including falling asleep at inappropriate times during the day. While snoring can accompany Sleep Apnea, snoring is not in itself harmful (other than keeping your bed partner awake).

Fortunately, these days, Sleep Apnea can be diagnosed and treated in our Sleep Lab, where the respirations, oxygen saturation and other parameters can be measured.

Several treatment options exist, and research into additional options continues. For mild cases, lose weight. Stop using alcohol, tobacco, and sedatives, or anything that relaxes the muscles of the throat and encourages snoring. Sleep on your side. Elevate the head of your bed 150 mm. Use a nasal dilator, ‘breathe right’ strips or saline nasal spray to help open nasal passages. Surgery may be needed to open the throat.

However, the main route for treatment is the CPAP (Continuous Positive Airway Pressure) machine which forces air into the lungs through tubes feeding a face mask. It is cumbersome, but may be necessary, when all else has failed.

Update April 4, 2015

Should you worry about being a little bit overweight?

Is a little bit overweight dangerous? In a word - YES!
The western world has an epidemic of obesity, and guess what, the Asian world is rapidly following. Thirty years ago, it was rare to see an overweight Thai. Not any longer. What has happened?

Quite simply, our diets are far from healthy, and that includes both food and drink, especially the kinds of drinks that come in dark green or brown bottles. I am sure you know the types.

The problem here is the fact that being overweight puts a strain on the cardiovascular system, which sends the blood pressure up. That in turn affects all the organs and systems, and everything goes pear-shaped from there on, as well as your body shape.

You are entering the world of Syndrome X. Unfortunately Syndrome X, which is otherwise known as the Metabolic Syndrome, is a classic example of what we medicos call ‘co-morbidity’. This is the situation where one disease process or ailment affects, or “X”aggerates, another disease process you may have. In these situations, the combined effects can be life threatening. It is also a syndrome possessed by around 40 percent of adults over 40.

Now there can be many occasions when you have more than one ailment at one time. You can have a sore throat and a broken leg all at the same time, and these conditions have no real bearing on each other. The broken leg will get better and the sore throat ditto.

However, the combination of diabetes and obesity can be disaster waiting. The combination of diabetes, smoking, obesity, hypertension and high triglycerides (blood fats) is cardiac dynamite. Your conclusive heart attack is a matter of ‘when’ not ‘if’. The risk factors stemming from all those conditions become not a case of simple addition, but are multiplied.

The problem from your point of view is that most of these factors come on very slowly, and become part of your daily living. You’ve smoked for years and never had a smoker’s cough, so why stop now? Every time you get some trousers made the waistband has to be that little larger. Your belt has been let out two more holes over the past two years. Your doctor said you had a “Little bit of blood pressure” three years ago, but you haven’t been back to check, as you feel quite OK in yourself. Your ‘triglycerides’? “My what?” Your blood sugar? “It was OK last time it was checked five years ago!”

The big problem is that the “Little bit of blood pressure”, even say 150/100, can produce a very dangerous situation when the person with that BP has elevated blood sugar as well. Or smokes. It is the multiplication effect again. Whereas you can (almost) ignore mild elevations like 150/100, if you have nothing else wrong, ignoring it when there are other conditions co-existing brings up that co-morbidity problem again. And the likelihood of a cardiac calamity.

Likewise, a “little bit of extra weight” that we all excuse ourselves for carrying, may (just ‘may’) be fine for someone with no other medical conditions, but represents an enormous risk factor for someone with the Metabolic Syndrome.

For those who like figures with their information, here are some chilling ones. Between 87-100 percent of people with fatal coronary heart disease, or a non-fatal heart attack had at least one of the following risk factors - smoking, diabetes, increased blood fats and high blood pressure. Syndrome X, or the Metabolic Syndrome, is characterized by having Diabetes, increased blood pressure, and raised blood fats. Can you now see the importance of doing something about weight, blood fats and blood pressure? I for one would not like to be sitting with a condition that gives me between 87-100 percent chance of a cardiac problem.

So what is this week’s message? Quite simply, if you have diabetes, do something about the other risk factors. Stop smoking and get your BP and blood fats checked. If you don’t even know what your blood sugar level is, then get a check-up and find about all of it!

In the meantime, take 100 mg of aspirin each morning. It is cardio-protective. I do!

HEADLINES [click on headline to view story]

Bargains in medication?

Mammograms and BSE. Worthwhile?

Counting sheep - on the bosses time!

Should you worry about being a little bit overweight?