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Doctor's Consultation  by Dr. Iain Corness


Update July 30, 2016

SuperSight Surgery – Read all about it! Without glasses!

It is a couple of years since I wrote about SuperSight Surgery. This is a revolutionary procedure that has changed the lives of many in Pattaya, and as the news traveled throughout the world, the world traveled to Pattaya to have this life-changing operation. In fact, two of my doctor friends here in Pattaya have had this done, and both are very happy with the end result.

So, are you over 50 and using spectacles to read this article? Do you hate your reading glasses? If so, help is at hand! This is SuperSight Surgery (not to be confused with LASIK).

SuperSight Surgery is in the forefront of ophthalmic procedures. The world leader is Dr. Somchai Trakoolshokesatian and he consults out of the Bangkok Hospital Pattaya. He has been carrying out this procedure for nine years on over 3000 patients and has perfected the technique to ensure good results for each individual patient, with success and satisfaction rates of almost 100 percent.

Unfortunately, the need for reading glasses is a natural progression of aging. The first signs are the fact that you have to hold this newspaper further away to be able to read it, and you also find that you need a good light to be able to see the words clearly. Eventually you succumb and buy reading glasses, to which you become a slave. Eventually you keep one pair at home, another in the car and another in the office. And your nose gets funny indentations either side of the bridge, where the spectacles settle.

As you get older, all the ‘elastic’ tissues in your body become less pliable. Knees, lower back, fingers, neck, the list is endless. However, you have to add to that list, the lens in your eye. The fiddly little lens, supplied at birth as a standard feature, does not have a fixed focus, but under your control you can make it focus close up (to read) and then also focus at a distance. The way you do this is by ‘bending’ the lens to be able to focus on near objects. Unfortunately, as the lens becomes less pliable, the muscles in your eye become unable to bend the stiffening lens enough to produce the near point focus. The near point moves further away, until you have run out of arms, as described previously. We call this condition ‘Presbyopia’.

Unfortunately there is yet another result of aging that occurs in the lens of the eye. This is a gradual cloudiness which lowers the visual acuity, and eventually brings on blindness. This is called a cataract. So not only can you not see well enough to read the magazines, but you also begin to lose your distance vision. Welcome to the wonderful world of white sticks and Labrador dogs. Even the World Health Organization says there are currently between 12 and 15 million people blind from cataracts.

The initial method of treating this was by removal of the now optically inefficient natural lens, and attempting to return some usable vision through the introduction of very thick and heavy spectacles placed before the eye. These glasses looked as if the lenses were made from the bottom of Coca-Cola bottles (registered trade mark and all), and were just as heavy. The patient could see again, but reading required even thicker lenses, or hand-held magnifying glasses. Not all that comfortable, but beats the alternative.

So we come to the latest development in intra-ocular lenses (IOLs), where the hardened lenses are replaced by other, very special lenses. These can be focusable lenses, under the control of the patient’s own intra-ocular muscles, or multi-focal lenses, with the brain picking the necessary focus as required. This is SuperSight Surgery and with these lenses you can read your golf scorecard with your near vision, focus on the ball on the tee with your intermediate vision and then using your distance vision watch it gently arcing into the water hazard. (These new IOLs can improve your sight, but not your golf.)

If you want to know more, go and consult Dr Somchai and reduce your dependence on contact lenses or glasses. You will be amazed.

Update July 23, 2016

Mata Hari, frogs, dogs, horses, toy trains and EKGs (ECGs)

Everyone is familiar these days with the electrocardiogram, known by the acronym ECG or EKG (US style, which comes from the German spelling). This is an invaluable medical test to show the electrical conductivity of the heart, which in turn can give the doctor an idea of the health of the heart muscle itself. Many think of this as one of the newer developments in medical science, but it is not, having a history dating back to the mid 1600s.

In 1664, Jan Swammerdam, a Dutchman, disproved Descartes’ previous mechanical theory of animal motion by removing the heart of a living frog and showing that it was still able to swim. On removing the brain all movement stopped. (This reminded me of the professor who proved that fleas heard through their legs. When he told intact fleas to jump they did – but after he removed the legs they no longer moved, proving they must have previously heard through their legs.)

Almost 200 years later, in 1856, researchers Kolliker and Muller accidentally discovered the electrical activity of the heart when a frog sciatic nerve and leg muscle preparation fell onto an isolated frog heart and both muscles contracted synchronously.

The investigation into the electrical stimulation of muscles continued, with the main stumbling block being the difficulty in measuring such small voltages. However, in 1887, Augustus Waller, working in St Mary’s Medical School, London, published the first human electrocardiogram, having recorded the electrical activity of the heart of a Thomas Goswell, a technician in the laboratory. This required not only wires, but the subject sitting with his hands in glass jars of salt solution. Waller’s electrocardiograph machine consisted of an electrometer fixed to a projector. The trace from the heartbeat was enlarged by projecting it on to a photographic plate which in turn was fixed to a toy train, to produce a graphical, moving record! Unfortunately Waller did not see the clinical application of his EKG at that time.

Two years later, in 1889, Dutch physiologist Willem Einthoven saw Waller demonstrate his technique at the First International Congress of Physiologists in Bale. Waller often demonstrated by using his dog “Jimmy” patiently standing with his paws in glass jars of saline, and began to develop the technique further.

What Einthoven, who was working in Leiden, did was to throw away the toy train and use a different and much more sensitive string galvanometer that he had invented himself in 1901. The different wave formations could be more easily identified, and it was Einthoven who assigned the letters P, Q, R, S and T to the various deflections, and described the electrocardiographic features of a number of cardiovascular disorders, such as atrial fibrillation.

In 1909, Thomas Lewis of University College Hospital, London bought an Einthoven string galvanometer and published a paper in the BMJ detailing his careful clinical and electrocardiographic observations of atrial fibrillation. Lewis identified a fibrillating horse using the string galvanometer’s electrocardiogram recording, and then followed the horse to the slaughterhouse where he could visually confirm the fibrillating atrium.

By 1924, the EKG, in a form close to that we know today was developed by Einthoven, who that year was awarded the Nobel Prize in Medicine for his discoveries.

Since then, the EKG has become even more sophisticated, and the equipment much smaller in size. However, it was not until 1963 that we began to carry out EKGs while making the heart work. This exercise ECG concept was promoted by Robert Bruce to describe their multistage treadmill exercise test later known as the Bruce Protocol. “You would never buy a used car without taking it out for a drive and seeing how the engine performed while it was running, and the same is true for evaluating the function of the heart,” he is rumored to have said. He was quite correct, and the Exercise Stress Test EKGs are important features in modern cardiac diagnosis.

And Mata Hari? Mata (1876-1917) lived in Leiden as a young girl when Einthoven (1860-1927) was doing his experiments there. Who knows, she might have electrically stimulated young Willem as well as her other later exploits which led her to the firing squad!

Update July 16, 2016

Misplaced fingers! What to do

Thailand is infamously known as a culture where certain anatomical bits have been lopped off by unhappy ladies. Following retrieval, re-attachment generally does go well (the Bobbit operation), but much depends on the offending bit being viable.

However, there are other anatomical items that become severed. There are about 10,000 cases of job-related amputations in the United States each year; 94 percent of these involve fingers. Few statistics are available for the outcome of replantations, but with modern surgery the success rate is increasing.

I did come across a report on a series of 208 digital replantations from the frigid zone within the People’s Republic of China. The extremely cold climate (30 degrees below) presents the additional problem of warming the amputated digits prior to replantation. An overall replantation survival rate of 94 percent was reported, and this included 45 cases of multiple digit amputation. Clever people, these Chinese, but you never know, were they ‘copy’ fingers?

Now, to successfully sew the finger(s) back on needs the patient to appear fairly smartly at the hospital, and to also bring the missing digit. Despite some claims to the contrary, we are not yet at the stage of being able to grow new fingers for you.

Recently, an injured person arrived at ER with his nine good fingers, but without the 10th one that had been lopped off. The wound was clean and so the hand surgeon sent the patient’s friends off to find the missing finger, as there was a good chance of successful replantation. They appeared later with a bag of chicken giblets straight from the refrigerator, proclaiming the missing digit was inside. When the surgeon looked, the bag of chicken pieces, which still had the name of the supermarket on it, had not been opened! There was certainly no finger inside with the giblets, and all that could be done was to trim up the traumatic amputation, and hope that the patient was not an accountant.

So, how should you transport missing body parts (people get more than fingers lopped off)? To save the tissue from further damage, keep the amputated bit wrapped in cling film, preferably in a jar or cup with a lid. Do not put it directly in water as this will cause it to shrivel up and become unusable for the surgeon trying to reattach it. Put the container with the finger or whatever inside another large bag with cold water, to keep the amputated part cold. Some authorities say ice water, others say just cold water, and I tend to go along with the ‘cold’ concept.

Be sure to gather up all parts of a severed digit, no matter how small. The body cannot grow a new nail bed, the tissue directly under the nail, so being able to use the original tissue makes a big difference to whether a full reconstruction can take place.

Generally, the tissues will survive for about six hours without cooling, and if the part is cooled, tissue survival time is approximately 12 hours. Fingers, by the way (and not chicken giblets) have the best outcome for transportation survival, since fingers do not have a large percentage of muscle tissue.

The micro-surgery required to successfully replant fingers (and the other bits that were lopped off and offered to the ducks) is very exacting, as nerves, arteries and veins all have to be reconnected. Very often the surgeon has to shorten the finger, so that there is no tension on the sewn up structures. All this takes an enormous amount of time and patience. With one celebrated case in the UK, a woman lost six fingers and it took a team of surgeons working in relays to reattach all six fingers during 17 hours of microsurgery. It is said to be the first time so many fingers have been replanted in one operation.

Many other factors are involved in whether there is a successful outcome. Generally, severe crushing or avulsion (tearing away) injuries to the fingers make replantation difficult. Additionally, older persons may have arteriosclerosis impairing circulation, especially in small vessels.

But if you are unfortunate to cut off a finger, remember to bring it with you, not the chicken giblets!

Update July 9, 2016

AAA – and it’s not your credit rating

I was reminded of this condition when a patient presented with an AAA and he wondered what to do next.

AAA stands for Abdominal Aortic Aneurysm, and as I have often pointed out, we doctors love acronyms. I am sure that the education bodies have decreed that the medical course should contain three years of acronyms, as well as another three years of clinical practice.

So what is an abdominal aortic aneurysm (AAA)? First off, what is the aorta? The aorta is the main artery of the body, directly connected to the heart and taking the vast majority of the blood from that important central pump to the abdominal organs and the legs. This artery is around 2 cm in diameter.

However, a situation can occur, whereby the artery begins to bulge and can grow to four or five times the normal diameter. It is this swelling that is called an ‘aneurysm’. Being of the Abdominal Aorta, then explains the AAA description. An aorta is considered ‘aneurysmal’ when it grows more than 50 percent over its normal size. By the way, aneurysms may occur in any blood vessel in the body, but the most common place is in the abdomen below the renal arteries (the blood vessels that provide the blood to your kidneys). Interestingly, aneurysms are four times more common in men than women and occur most often after 55-60 years of age. Elderly males have yet another aspect to monitor, as well as their prostates!

The danger of the AAA comes from the fact that this can burst, like an over-inflated balloon, and the patient experiences a catastrophic internal hemorrhage. This is generally fatal. Aneurysm rupture affects approximately 15,000 people per year making it the 13th leading cause of death in the US. The incidence of aortic aneurysm increases every decade as the population ages. Fortunately, early detection and diagnosis is increasingly possible as more sophisticated medical screening methods become available.

So why does this aneurysm occur? Aneurysms are caused by a weakening or damage in the wall of a blood vessel. There are many conditions known to contribute to the weakening of the artery wall including atherosclerosis (hardening of the arteries), cigarette smoking, high blood pressure and inflammation or infection.

Atherosclerosis (hardening of the arteries) is the most common cause of abdominal aortic aneurysms. This occurs when substances such as cholesterol, minerals, and blood cells build up in the walls of the artery, and thus damaging it. The muscular wall of the aorta weakens and with the pressure inside the artery, it begins to bulge. High blood pressure may speed up the weakening, but it is not the cause. Aneurysms also tend to run in families, so there is the thought that genetics may play a role in who gets an aneurysm. (When in doubt, blame your parents – for everything!)

There is a strong link between cigarette smoking and the occurrence of aneurysms. Smokers die four times more often from ruptured aneurysms than nonsmokers. Aneurysms in smokers also expand and weaken faster than those in nonsmokers, making this the one hundred and twenty thousandth good reason to give up cigarettes.

Unfortunately, until an AAA bursts, there are generally no symptoms to let you know you have one of these ‘time bombs’ sitting in your belly. The discovery is then usually during an annual physical, where it can be palpated by the doctor, but by far more accurate is an ultrasound, which can give exact dimensions, and thus progressive indication of how rapidly the swelling is growing.

The answer to this is an operation to replace the swollen, weakened artery, with a suitable piece of highly expensive ‘garden hose’ of correct length and diameter. This is a major operation, but once you have had an AAA detected, there is no other way around the problem. There is also some work being done on encasing the aorta to contain the swelling, but this is not the usual method of ‘defusing’ an AAA.

You should be lining up for a routine health check every 12 months, after you reach 40 years of age. When was your last one?

Update July 2, 2016

If you don’t eat your meat – you can’t have any pudding! (Pink Floyd)

What we eat is something that has fascinated us for centuries. We have made rituals and even fetishes out of eating and drinking, and the oldest gourmet group in the world, the Chaine des Rotisseurs, is still going and began in 1248 AD. That’s a long lunch!

These days, with our tentative forays into ‘real’ science, our dietary habits have also been scrutinized plus the many claims made for modifying the kind of food we eat and what we drink. This in turn, has produced legions of people who swear by various foods which will cure everything from falling hair to falling arches (or even falling stock markets)!

Of course, it is very difficult to ‘prove’ that by taking Vietnamese ground nut leaves or similar items, that ‘something’ (usually cancer) does not happen. Even more outrageous are the claims that some herb, poppy or whatnot can actually ‘cure’ cancers. Is it all just poppycock?

To be able to prove these claims needs medical science to look at a large group, or population, and compare its cancer experience with another similar large group or population. Ideally, the two groups are matched for age/sex/ethnicity/working environment, location, etc. You get no worthwhile results comparing Welsh coalminers with sub-Saharan Africans, for example, to go to extremes.

Finally, results of a 15+ year study in Australia were presented at the CSIRO Prospects for Cancer Prevention Symposium. The findings emerged from the Cancer Council’s Melbourne Collaborative Cohort Study, an ongoing research project involving 42,000 Australians who have been monitored since 1990.

Looking at the dietary habits and the cancer connection, Dr Peter Clifton, director of the CSIRO’’s Nutrition Clinic, said there was “zero evidence” that eating fruit and vegetables could protect against cancer. The nutritionists and the healthy eating proponents were shattered. However, this to me is a much more compelling argument than something that comes from folklore, or the lady next door who swears by it.

What the survey did show was that the three prime risk factors as far as predicting cancers were concerned were identified as obesity, drinking too much alcohol and smoking.

More than that, staying within a healthy body weight range was found to be more important than following particular nutritional guidelines. This means a thin person who does not eat enough fruit and vegetables would have a lower risk of developing cancer than someone who is overweight but eats the recommended daily amount of fruit and five colors of vegetables.

Professor Dallas English, of the Cancer Council of Victoria, told the symposium that despite decades of research, there was no convincing evidence on how modifying one’s diet would reduce the risk of cancer.

“The most important thing about diet is limiting energy (kilojoule) intake so people don’t become overweight or obese, because this has emerged as a risk factor for a number of cancers, including breast, prostate, bowel and endometrial (uterus),” he said.

The link between eating red meat and bowel cancer was “weak” and the Cancer Council supported guidelines advising people to eat red meat three or four times a week, Professor English said.

In Australia, the biggest killer is still heart disease, so healthy eating will lower one’s chances of heart disease, even if it does not protect you against cancer.

Both Professor English and Dr. Clifton predict an increase in the incidence of cancer as a result of Australia’s obesity epidemic, but say exercise can play a vital role in cutting cancer rates, potentially halving the risk of some cancers. That I find a rather sweeping claim, but there is no doubt in my mind that moderate exercise is good for you.

And while on exercise, it does not have to be pedaling an exercise bicycle to nowhere, which is mind numbing, the best exercise is half an hour of swimming three times a week.

So there you are – get down to a healthy weight and exercise regularly, drink alcohol in moderation only (be aware, Australians do not know what “moderation” means) and stop smoking. In this way you will lower your chances of heart disease and cancer. Ignore other fanciful claims!

Goodness me, you might even outlive your doctor!

HEADLINES [click on headline to view story]

SuperSight Surgery – Read all about it! Without glasses!

Mata Hari, frogs, dogs, horses, toy trains and EKGs (ECGs)

Misplaced fingers! What to do

AAA – and it’s not your credit rating

If you don’t eat your meat – you can’t have any pudding! (Pink Floyd)