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
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
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
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
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
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?
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
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
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
“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
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
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
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
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