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Doctor's Consultation  by Dr. Iain Corness


Update September 30, 2016

Another WHO-driven epidemic

According to the World Health Organization (WHO), a total of 8,098 people worldwide became sick with SARS during the 2003 outbreak. Of these, 774 died.

Yes, 774 in the entire world and the travel industry was hit so hard it is only just recovering. Thailand can kill more than that in two holiday weekends.

However, the WHO has uncovered another epidemic, which almost brought the Rio Olympics undone, and stopped many top athletes competing, as they were worried about the medical implications of this new WHO epidemic. Its name? Zika!

Zika fever (also known as Zika virus disease) is an illness caused by the Zika virus. Most cases have no symptoms, but when present they are usually mild and can resemble dengue fever. Symptoms may include fever, red eyes, joint pain, headache, and a rash. Symptoms generally last less than seven days. It has not caused any reported deaths during the initial infection.

So what is so fearful about Zika? According to WHO, infection during pregnancy causes microcephaly and other brain malformations in some babies.

You will be interested to know that the Zika virus (ZIKV) is not new and was first discovered in 1947, but has now emerged as a global public health threat over the last decade, with the accelerated geographic spread of the virus noted during the last 5 years.

The World Health Organization (WHO) predicts that millions of cases of ZIKV are likely to occur in the Americas during the next 12 months. These projections, in conjunction with suspected Zika-associated increase in newborn microcephaly cases, prompted WHO to declare public health emergency of international concern. ZIKV-associated illness is characterized by an incubation period of 3-12 days. Most patients remain asymptomatic (i.e., ~80%) after contracting the virus. When symptomatic, clinical presentation is usually mild and consists of a self-limiting febrile illness that lasts approximately 2-7 days.

Hospitalization and complication rates are low, with fatalities being extremely rare. Newborn microcephaly, the most devastating and insidious complication associated with the ZIKV, has been described in the offspring of women who became infected while pregnant. Much remains to be elucidated about the timing of ZIKV infection in the context of the progression of pregnancy, the corresponding in utero fetal development stage(s), and the risk of microcephaly.

Without further knowledge of the pathophysiology involved, the true risk of ZIKV to the unborn remains difficult to quantify or suggest remedies. Accurate, portable, and inexpensive point-of-care testing is required to better identify cases and manage the current and future outbreaks of ZIKV, including optimization of preventive approaches and the identification of more effective risk reduction strategies.

If we use other viral problems in the womb as examples, the first three months are the ‘danger’ times, and to be quite honest, I would be very surprised if ZIKV were any different.

Another complicating factor for the WHO statisticians is the fact that microcephaly can arise without ZIKV infection.

Helping the WHO case is the global distribution of the most cited carrier of ZIKV which is A. aegypti (yes the same one as Dengue), and is expanding due to global trade and travel. A. aegypti distribution is now the most extensive ever recorded – across all continents including North America and even the European periphery (Madeira, the Netherlands, and the northeastern Black Sea coast). A mosquito population capable of carrying Zika has been found in a Capitol Hill neighborhood of Washington, D. C., and genetic evidence suggests they survived at least four consecutive winters in the region. The study authors conclude that mosquitos are adapting for persistence in a northern climate.

If one accepts the fact that there is a potential ‘risk’ for pregnant ladies who pick up ZIKV, the WHO has more bad news. It’s in the bedroom! In March 2016, the CDC updated its recommendations about length of precautions for couples, and advised that heterosexual couples with men who have confirmed Zika fever or symptoms of Zika should consider using condoms for at least 6 months after symptoms begin. Couples with men who live in an area with Zika, but have not developed symptoms, might consider using condoms or not having sex while there is active Zika transmission in the area, they are saying.

Scare tactics over an unproven threat!

Update September 24, 2016

Another ‘breakthrough’ or more false hopes?

Cancer “breakthroughs” are always hot news in the media. Hardly a week goes by without another treatment being claimed as the “cure” for cancer. For example, “A drug made from tree bark is being combined with radiation therapy to cure cancer, experts revealed yesterday. The ‘double whammy’ has proved 85 percent effective in laboratory trials. Last night the treatment was being hailed as a breakthrough.”

What this item does not tell you is, on how many subjects did they give the tree bark to, and in fact, was it tested on humans? I would need to know a lot more and see the “breakthrough” used for a significant period of time.

Hot on the heels of the tree bark, a trial of a Melbourne-developed drug shows four out of five patients had a positive result, with complete remission for one in five.

Melbourne-developed Venetoclax is one of a new generation of targeted drugs which attack specific cancer-causing biological factors like cell-structure mutations.

Actual patients were chosen for the trials, with one fighting a recurrence of chronic lymphocytic leukemia, a cancer of the blood and bone marrow, when he was chosen to take part in a trial in 2013.

He spoke on radio, saying “I think I was the eleventh person in the world to have it. It was amazing. It causes no side-effects. Nothing, absolutely nothing.”

Within a year his leukemia went into remission. However, it should be noted that leukemia is characterized by acute episodes and remission by itself.

Professor John Seymour, of the Peter MacCallum Cancer Centre, helped oversee the trial. He said the treatment worked in a very different way to traditional therapies. “Cells, when they are born, are destined to die and cancer cells and particularly leukemia cells delay that death by using a protein called BCL2 that stops the normal time of death. Venetoclax works by specifically blocking the action of that BCL2 and allows the cells to die in the way that they were destined to.”

Now here comes the nitty-gritty. In the trial nearly four out of five patients had a positive result, with complete remission for one in five patients. But on the other side of the ledger, some patients did have a negative result.

The developers of Venetoclax - David Huang and his team from the Walter and Eliza Hall Institute of Medical Research in Australia - were awarded the Eureka Prize for Innovation in Medical Research at this year’s ceremony.

It is further claimed that Venetoclax and targeted therapies are just one of a number of major breakthroughs in cancer research in recent years.

The area of research giving the most hope is immunotherapy.

Immunotherapy drugs work by harnessing the body’s own immune system to defeat cancer and a new dedicated immunotherapy lab at the just-opened Victorian Comprehensive Cancer Centre will focus on their development.

So far, they have been used most effectively in the treatment of melanoma, but the end result cannot be guaranteed. When the melanoma one patient had beaten a decade ago re-emerged in 2014 he was put on an immunotherapy drug, Ipilimumab (also known as Yervoy) that had only recently been approved for the Australian market.

Twelve months later, his melanomas were completely gone, and he has suffered virtually no side effects. “Truly amazing - the fact that it’s actually given me the position where I have not got cancer in my body is a great feeling,” he said.

However, where these drugs may work for some, for others the result may be doubtful. For that melanoma patient, he knows only too well that immunotherapy does not work for everyone. His wife developed melanoma about the same time as he did and she was put on another immunotherapy drug. The response was not what was hoped for and she was unable to tolerate the drug, and after two attempts it was decided that she would have to stop the treatment and the melanoma spread and she succumbed to the cancer.

So, be aware that “breakthroughs” are not necessarily heralding the end of all cancers, and even where the research results look hopeful, there is still a long way to go. And beware of snake oil salesmen.

Update September 17, 2016

A treasure trove in your bathroom?

I will never forget the time that a patient brought me a 1.5 kg New Year present. It was a present that he had saved for many, many months and had decided that I was the best chap to receive this.

It was a literal treasure trove in a large package. In fact it did contain all sorts of goodies. There were capsules, tablets and lozenges and in all kinds of wonderful colors. This would have been a toddler’s delight. And completely potentially lethal.

The package was the result of the patient’s cleaning out of his bathroom cupboard of outdated, or no longer needed, or even ‘unknown’ medicines. The man was not a hoarder, but knew that medications should be kept out of the reach of children, which he had been doing – for quite some time!

Now I am sure you remember the doctor telling you to keep on taking the medication right to the end of the course, but human nature, being as it is, when we start to feel better, we stop taking the meds. Right?

In theory, going right to the end of the course means that there are no tablets or whatever left – but there always is, isn’t there! There is also the other source of left over medication, and that is medication bought over the counter at your local pharmacy. Written in Thai is something on the outside of the packet, and of course you don’t read Thai either, and since you got better anyway, you stop these as well.

So there’s the scenario, a bathroom cabinet full to overflowing! When he started running out of room, the problem became apparent. How was he going to get rid of them?

He was savvy enough to know that if he just ditched them in the local rubbish bin, the recyclers would definitely consider them treasure trove, and he could foresee some untrained person attempting to differentiate the various pills and tablets and sell them somewhere. Paracetamol tablets do generally look the same after all, white round ones, but so also do many other medications, which are not as relatively safe to be taken indiscriminately.

He then thought about flushing them all down the toilet, but decided that 1.5 kg of strange tablets might just block the precarious plumbing that pervades in Thailand. When the locals are afraid of putting soluble toilet tissue down the loo, what would strange foaming tablets do? Let alone capsules and lozenges.

The next resort was to borrow a mortar and pestle from the local ‘som tum’ roadside kitchen and having ground them all to a paste then spread the resulting pulverized mass over the garden as a somewhat powerful weedicide. At least the grass would be germ-free! However, this was not really practical either, as the som tum lady couldn’t wait the several hours that was going to be necessary.

So I then became the last option, and with a smile he presented me with the aforesaid 1.5 kg bag, with wishes for a very Happy New Year.

Abandoning my initial thoughts of hurling them from the top of the 15 storey E Building and watching people scrabble for free tablets, I saw the chap in charge of Pharmacy at the Bangkok Hospital Pattaya who assured me that yes, they could dispose of the 1.5 kg bag and contents, as there was a service to allow total destruction of medications such as these, under very secure circumstances, run by the Thai government, and he would be happy to forward the 1.5 kg bag of goodies for the gentleman.

So there you are. It is probably a good idea as part of your Xmas preparations, to clean out your bathroom cabinet of old, half used, undated, expired and unknown medications, tablets, lozenges and mixtures. If the quantity is too great for flushing down the loo (and 1.5 kg is too great), then bring them to the hospital and we will ensure their safe destruction.

And, oh yes, you have a healthy year ahead too. And do try and follow the doctor’s instructions to the letter “Take until finished” or words to that effect, will ensure no more ‘left-overs’ in the bathroom!

Update September 10, 2016

The elixir of youth? Multivitamins?

The retirement age is creeping up. Even in Thailand’s civil service the retirement age looks like becoming 64. In Australia it is going to be 67. The world is becoming an old people’s home!

So we are all living longer, what can we do to get our arthritic hands on the elixir of youth? If you believe folklore, the answer to aging is multivitamins. Peddling mega-vitamins is a megabuck industry, credited with improving your health, your love life and fixing everything from falling chins to falling arches.

One trend is to take daily doses of antioxidants such as beta carotene, vitamin A and C or selenium to protect yourself against cancer, heart disease or signs of premature ageing. There is some scientific ‘proof’ that people who have a high level of antioxidants in their diet have a lower risk of heart disease and certain cancers. That is why the nutritionists say we should eat at least five portions of fruit and vegetables a day. However, other studies also suggest that taking those same antioxidants in pill form may not have the same effect and may even be harmful. Who do you believe!

“There’s still conflicting evidence about whether taking certain vitamin supplements can affect a person’s risk of cancer,” says Dr Alison Ross, at Cancer Research UK. “These products don’t seem to give the same benefits as vitamins that naturally occur in our food.”

The British Heart Foundation agrees. A spokesman saying, “Research does not support the claim that taking extra antioxidants in the form of supplements will benefit the heart.”

But surely, if this were the case, why do so many people pop the multivitamin pills? We know we need vitamins, and some of us may have poor diets. Replenishing the stores is then surely ‘good medicine’?

Let us listen to some experts in the field, and not the back of the cereal box. Catherine Collins, chief dietitian at St George’s Hospital in London says, “The whole idea that you must meet some vitamin and mineral target every day of your life is a marketing myth. You can eat lots of fruit and veg one day and not much the next but over a week you will still get the right amount of nutrients. There is very little scientific evidence that there is any benefit whatsoever in taking a daily multivitamin - even in old people. You cannot exist on a poor diet then shore yourself up with a multivitamin. The idea that taking high quantities of vitamins will give you a health boost - like putting premium petrol in your car - is complete nonsense.”

Dr Toni Steer, nutritionist with the British Medical Research Council’s Human Nutrition Research in Cambridge, states supplements cannot compete with real food because when we eat fruits and vegetables the vitamins and nutrients interact with other chemicals to produce positive effects on the body. “If these same vitamins are pulled out and isolated in pill form, there is no guarantee at all that they will have the same effect.”

Another nail in the multivitamin coffin came from the US journal of the National Cancer Institute which found that men with prostate cancer who took more than seven multivitamins a week were 30 percent more likely to get an advanced and fatal form of the disease. This came after a large, though hotly contested, review published in the journal of the American Medical Association which found that people who took antioxidant vitamin tablets (particularly vitamins A and E, and beta-carotene) were more likely to die earlier than those who did not. Oops! That isn’t something you will read on the back of the multivitamin bottle.

Let’s look at the old Vitamin C to ward off the common cold, as proposed many years ago by Linus Pauling. Common claim: one-gram doses will ward off or even cure the common cold. Reality check: the human body can absorb only 500 milligrams of vitamin C and will excrete the excess. Vitamin C reduces the average length of a common cold from five days to four and a half – if you are lucky. Finally, do I take multivitamins? No. But I did have an orange juice this morning.

Update September 3, 2016

Medicine in darkest SE Asia

My mother was in hospital in the UK. She spent three weeks there, but she should not have been there. Why? Because she was merely taking up a bed because the doctors in charge of her case had not yet made a diagnosis, so she had to stay in for further tests.

All that sounds quite reasonable, until you find out that to have an echocardiogram there is a wait of several days, and another wait for the results. Ditto for the 24 hour Holter monitoring. Ditto for blood tests. Ditto for anything else.

I did manage to talk to my mother. You ring the hospital and then get the telephone number of the ward she is in, as they cannot transfer your call, as there is some problem with the switchboard. Then you ring the ward directly, and the nurse will give you the telephone number of the phone they take to the bedside. “But please wait a few minutes, so we can take it to her while she waits for your call. You’re lucky today, the phone wasn’t working last week.” So eventually you do get to speak to each other.

In the chat, I found out that mother had a fall while in hospital and has hurt her hip. She could not get about and had to use a Zimmer hopper. Previously she could walk normally. I asked if she had had an X-Ray of the hip. Negative.

Now to put you right in the clinical picture, my mother was 91 years old, but totally with it mentally. However, her skeleton was showing the effects of 91 years on the planet. She has osteoporosis (thinning of the bones) that comes with age. In a previous fall some years ago, she broke her arm. As my radiologist son in Australia said when I told him of the latest details on his grandmother, “Any 91 year old who has a fall on to a hip has a fractured neck of femur until proved otherwise.”

So I rang the hospital and asked to speak to the doctor looking after her. I am sure he is a thoroughly nice chap, but it took me two days to manage to track him down in the hospital. I do hope there were no emergencies also trying to contact him in that time. He agreed that an X-Ray of the hip would be in order, so he promised he would arrange it. Of course that took a couple of days, and the results likewise, but he assures me there was no fracture. I wish I could have had as much faith in his diagnostic ability with X-Rays as he has. It would have been nice to get the hospital in the UK to email me the digital X-Rays for my radiologists here to look at, and also to young Dr. Corness in Australia. Unfortunately, this was not possible, and the treating doctor did not know if the hospital had an email address. I shouldn’t complain, as in 1815 when they laid the foundation stone for the hospital, the UK was a little too busy celebrating the Battle of Waterloo to worry about emails.

But back to mother occupying a bed in the UK for three weeks. The biggest hold-up seemed to be the fact that the cardiologist hadn’t seen her yet, and it is he who wanted further tests. To bring you right up to date, mother had a series of ‘fainting’ attacks causing the falls. I have witnessed one and the latest was while she was in the hospital, so presumably witnessed by the nursing staff, even if the doctor was still being elusive. There is a clear history.

I asked the treating doctor why mother had yet to see the ‘Great Man’ and was told that he had been on holidays, there was Easter, and there was only one cardiologist. So mother (and I) were left waiting.

In Thailand, the entire process would have taken three days at the outside. And I know the NHS is supposedly “free”, but is actually paid for by the public purse, filled by the taxpayers! With private medicine in Thailand, you really never had it so good!.

HEADLINES [click on headline to view story]

Another WHO-driven epidemic

Another ‘breakthrough’ or more false hopes?

A treasure trove in your bathroom?

The elixir of youth? Multivitamins?

Medicine in darkest SE Asia