Are you next for a stroke?
Just about everyone knows of someone
who has had a stroke. It is also a very common condition and one of the
major causes of death and disability. It can also be prevented which is why
I made “stroke” the subject of this week’s “consultation”.
A stroke (also called a ‘cerebrovascular accident’ or CVA) occurs when blood
vessels carrying oxygen to a specific part of the brain suddenly burst or
become blocked. When oxygen-rich blood fails to get through to the affected
parts of the brain, the oxygen supply is cut off, and brain cells begin to
Strokes fall into several major categories, based on whether the disrupted
blood supply is caused by a blocked blood vessel (also known as an ischemic
stroke) or by a hemorrhage. Since each type of stroke has a different type
of treatment, it is very important for the physician to determine the cause
of the stroke, as well as the location, as quickly as possible.
Fortunately, it is no longer a case of guesswork, but several diagnostic
studies may be needed to pinpoint the problem area, and to work out whether
the stroke is from blockage or bleed.
Some of the treatment modalities include Computerized Tomography (CT) Scan
which is generally the first diagnostic test done after a patient with a
suspected stroke arrives in the emergency room. It is used to quickly
distinguish between an ischemic or hemorrhagic stroke.
Magnetic Resonance Imaging (MRI) is an advanced diagnostic tool that
provides a high level of anatomical detail for precisely locating the stroke
and determining the extent of damage. Due to its high level of sensitivity,
MRI is considered especially useful when the stroke involves small blood
Magnetic Resonance Angiography (MRA) is another noninvasive technology for
imaging the cerebral blood vessels, which yields valuable information
regarding collateral (alternative) blood vessels in the brain.
Carotid Duplex Scanning is a noninvasive study to diagnose blockage in the
carotid arteries. This technology involves recording sound waves that
reflect the velocity of blood flow.
Transcranial Doppler (TCD) is a newer, noninvasive ultrasound procedure that
allows the assessment of blood flow through the cerebral vessels via a small
probe placed against the skull. TCD is a portable test, which can be
performed frequently at the patient’s bedside to follow the progress of
medical treatment for stroke.
PET Scanning, which measures brain cell metabolism, can determine if brain
tissue is functioning even if blood flow to that area appears to be
Cerebral Angiography (angiogram) is a diagnostic study that requires
injection of a contrast dye through a major artery (usually the femoral
artery in the thigh) for evaluation of blood flow to the brain.
So are you having a stroke? The warning signs of stroke include sudden
weakness, numbness or paralysis of the face, arm or leg (especially on one
side of the body), loss of speech or trouble talking or understanding
language, sudden loss of vision, particularly in only one eye, sudden,
severe headache with no apparent cause, unexplained dizziness, loss of
balance or coordination (especially if associated with any of the above
There are several risk factors, including:
Hypertension - having high blood pressure means the blood vessels are under
more tension, and certain weaknesses (called aneurysms) can rupture.
Smoking - Smokers get more strokes than non-smokers.
Atherosclerosis - Deposits of cholesterol on the inside of the arteries
predispose to blood clots being formed.
Diabetes - Uncontrolled diabetes puts the sufferer into a high risk
Alcohol and drug abuse - neither of these make life ‘better’!
Age - The chance of having a stroke increases with age. Two-thirds of
strokes occur in persons over the age of 65.
Gender - Stroke is 25 percent more common in men than in women.
Race - The incidence of stroke varies among races. African-Americans have a
higher incidence of hypertension than Caucasians, and also a higher rate of
Family or Individual History - A history of cerebrovascular disease in a
family appears to be a contributing factor to stroke.
While you have no control over your family history, you can take steps to
decrease your risk factors with appropriate medical advice.
Is it time to consult a brain specialist?
Dengue Fever - worse than MERS or SARS?
Dengue has become endemic throughout
the world. There are 2.5 billion people living in Dengue endemic areas, and
Thailand is just one of them. Dengue is endemic in at least 100 countries in
Asia, the Pacific, the Americas, Africa, and the Caribbean. The World Health
Organization (WHO) estimates that 50 to 100 million infections occur yearly,
including 500,000 Dengue Hemorrhagic Fever (DHF) cases and 22,000 deaths,
mostly among children.
Dengue Fever was the reason for hospitalization of five percent of the
foreign in-patients recently. That is a lot! In fact, we are getting
increasing inpatient numbers including the dangerous Dengue Hemorrhagic
Dengue Fever is another of those viral illnesses, and we have no direct
answer to the virus. There is no “antibiotic” for the Dengue virus. Like
Malaria, the virus is carried by mosquitoes, this time by one called Aedes
With the monsoon rains we have been having recently, this is one of the
reasons that this disease is on the upsurge in this country - but there is
something we can all do about it.
However, first you should understand a little more about Dengue. The
mosquito Aedes aegypti lays its eggs in standing water (and there is plenty
left each evening after the afternoon showers), 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 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 4
to 7 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
With our ability to treat the viral ailments being very limited, the defense
against the Dengue virus lies in Health and Hygiene initiatives, to stop
getting mosquitoes in the house during the day. For example, do you
regularly change the water in containers the Aedes aegypti mosquito might
call home? Do you have mosquito screens? Does baby sleep under a mosquito
net? If the answer to these questions is “no”, then perhaps it is time to
look critically at your own Dengue prevention plan. Let me assure you, it is
not a disease you want! And the Hemorrhagic form in particular can be
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
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
repellent, check the label - if it has DEET, then get it. And then remember
to use it!
To avoid falling prey to Aedes aegypti, empty free standing water around the
home, use screens and mosquito nets if necessary and apply repellent
containing DEET. Best of luck!
Some news to hand is that Purdue University in the United States claimed
that papaya leaf consists of over 50 active ingredients found to kill fungi,
worms, parasites, bacteria and many forms of cancer cells and sparkle up
your immune system. For dengue fever it is suggested that the juice is
extracted by crushing fresh leaves of papaya. One leaf of papaya gives about
one tablespoon of juice. Two tablespoons of papaya leaf juice are given to
dengue patients three times a day - once every six hours, with miraculous
results. However, before you start crushing and juicing, the results came
from five patients only! I’d stick to DEET if I were you!
Coincidence? Or just a fluke?
There are very many good reasons for
westerners to wish to live in Thailand. Warm weather, cold beer, warm women
and cold beer. That will do for a start.
However, there are also some drawbacks. Aren’t there always! Such things as
a very difficult language for foreigners, being a phonetic one, complete
with a different grammar from English. Then there is the 90 day reporting.
Real estate ownership is another very thorny topic. But let’s not get too
far down that track. There is an olfactory problem as well. And even though
hotels will ban their guests bringing durian into the hotel, there is
something much worse. Much, much worse.
Anyone who has a Thai partner will have come across the sauce called Pla-Ra.
If the name is not familiar to you, the nauseating smell will be. Something
akin to a cross between smelly socks and a dead rodent. I and many other
westerners I know refuse to let it in the house and it is confined to triple
sealed jars in the Thai kitchen out the back. For Westerners who have not
had the pleasure, imagine anchovies with a rotting problem. But more on Pla
Ra in a moment.
Now Thailand prides (deludes?) itself that it is the “hub” of everything
from airports, fashion design and floral arrangements, but whilst these are
all open to debate, there is one area where Thailand is supreme - and this
is in Khon Kaen in Isaan in particular. It is the hub of the Southeast Asian
liver fluke, which is a trematode parasite from the family Opisthorchiidae.
This little charmer called Opisthorchis viverrini gets inside your body,
swims through to the gall bladder region where it reproduces and sucks your
blood. The constant irritation leads to abdominal pain, the blood loss to
anemia and even a special cancer of the gall bladder called a
cholangiocarcinoma. Not a very nice little sucker, is he, our Opisthorchis
How this parasite gets into our bodies is of interest and even more
convoluted than most, coming from the egg stage and then being eaten by
aquatic snails. The eggs then produce a free swimming larval stage, called
cercaria. The cercaria then locate cyprinoid fish, encyst in the fins, skin
and musculature of the fish, and become metacercaria. Places where you are
likely to find this second intermediate host of Opisthorchis viverrini
include freshwater and stagnant or slow-moving waters (ponds, river,
aquaculture, swamps and rice fields).
These fish are netted by Thai fishermen and they prepare fish-based meals
with local herbs, spices, and condiments. The finished dish, called koi-pla
made of raw fish, is a dietary staple of many northeastern Thai villagers
and the common source of infection with Opisthorchis viverrini.
Dishes of raw fish are common in the Isaan cuisine of Thailand, and include
koi-pla, raw fish in spicy salad larb-pla, and salted semi-fermented fish
dishes called Pla-Ra (yes, it’s him again). Infection is acquired when
people ingest raw or undercooked fish dishes containing the live parasite.
Cholangiocarcinoma (CC) is the second most common primary hepatic malignancy
in the world. CC accounts for approximately 10 - 25 percent of all
hepatobiliary malignancies. There are considerable geographic and
demographic variations in the incidence of CC. There are several established
risk factors for CC, including parasitic infections.
Liver fluke infections occur in some Asian countries (read Thailand, and
Khon Kaen in particular) when people eat raw or poorly cooked fish that are
infected with these tiny parasite worms. In humans, these flukes can cause
bile duct cancer. The one most closely related to bile duct cancer risk is
our old friend Opisthorchis viverrini.
Studies from Thailand have found that people with CC were between 5 and 27
times as likely to have antibodies indicating infection with the parasite
Opisthorchis viverrini than anyone else.
To avoid infection, do not eat raw fish, and only eat cooked fish, or fish
that has been stored in the deep freeze for some time to kill the
So now you have another reason to not allow Pla-Ra in the house, as well as
the nauseating smell! By the way, we do have a GI and Liver Center if you’re
Should you take out insurance?
Insurance is such a thorny question
these days that my hospital even has a department just to help you with
advice on your insurance problems.
Unfortunately, for the vast majority of us - we need insurance, just as you
need shoes for your feet.
Everyone seems to be knowledgeable on travel insurance, but remember travel
insurance is to cover the period of travel. Imagine you are in KL and on the
day you are leaving you are hit by a taxi. Head injury and a broken leg. You
are taken to ICU and then graduate to a ward after three days. Your travel
insurance expired three days ago. Where do you stand? (With a broken leg,
not very easily at all!)
It appears that most, but not all, travel insurance companies will continue
to pay for your hospital treatment - but for a limited time only. “Get well
soon” as the sympathy card says!
Now, what about insurance while being at home? If you haven’t upgraded your
cover recently, then you may be in for a nasty surprise. Unfortunately,
everything, be that meds, bread, or baby’s nappies has gone up in price in
the past 12 months. If you haven’t upgraded there could be a shortfall,
which you have to find (or fund), not your insurance company. Remember that
medical bills are all yours - the insurance company just helps you pay them.
I have been very lucky with my choice of careers. Being a medico does have
advantages. If I couldn’t fix my skin rash or whatever, I could always ring
a classmate who could (or should) be able to. Medications and drugs? Again
no worries, just a quick raid of the samples cupboard in my surgery and I
had everything I needed. But that was in the great big sunburned country
And then I came to Thailand. Still I blithely carried on, after all, I was
ten foot tall and bullet proof. Then a friend over here had a stroke and
required hospitalization. Said friend was four years younger than me and I
was forced to review the ten foot bullet proof situation to find I was only
five foot eleven and my anti-kryptonite had expired. Thailand was a
completely new ballgame.
Enquiries as to hospital and medical costs showed that they were
considerably less than the equivalent in Oz, but, and here’s the big but,
there’s no government system or sickness benefits to fall back on. Suddenly
you are walking the tightrope and there’s no safety net to stop you hitting
So I took out medical insurance. Still it was no gold plated cover. But it
was enough to look after me if I needed hospitalization, and that came
sooner than I imagined. I had always subscribed to the “major trauma”
theory, but two days of the galloping gut-rot had me flat on my back with
the IV tube being my only life-line to the world. We are only mortal - even
Do you have medical insurance? Perhaps it is time to chat to a reputable
insurance agent! Yes, reliable insurance agents and reliable insurance
companies do exist, but you need help through the minefield. There are those
who buy directly from the insurance company, but then who is going to bat
for you if there is a disagreement?
You also need help when it comes to filling out the application forms, in my
opinion. And you also need to be 100 percent truthful. Yes, insurance
companies will check on your records, and if it is found that you have been
sparing with the truth over pre-existing conditions, expect a shock at
settling up time at the cashier’s desk.
Remember too, that just because you have an insurance card does not
automatically signify that ‘everything’ is covered. This is why private
hospitals will ask you for a deposit on admission. If the insurance company
later verifies that you are indeed covered for that ailment or condition,
then you’ll get it back, but you have to prove that you are covered, not the
other way round!
And remember to check out your insurance agent, it just makes for an easier
time when things are difficult.