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Update by Natrakorn Paewsoongnern

Doctor's Consultation  by Dr. Iain Corness


“Sugar”? One lump or two?

Diabetes (“sugar”) is in the news again, but it isn’t “good” news. There are 60 million people living in the UK (I’d probably say ‘surviving’ in the UK is more accurate) and 2.1 million of these have been diagnosed as Diabetic, of which 1.8 million had the Maturity Onset form of the condition. Official estimation from the UK would also suggest there were another 1 million walking around with Mature Onset Diabetes that did not even know they had it. That’s a worry. Not for me, but for them.

So who gets it? Are you more than 40 years of age? Are you overweight? Do you have a blood relative who has Diabetes? If you answered “yes” to any of those questions, then you may have Mature Onset Diabetes. If you answered “yes” to all three, then it is pounds to peanuts that you do have it. (If you come from Holland, you can make that Guilders to gooseberries!)

Just exactly what is Diabetes? Quite simply, it is an inability of the body to handle glucose correctly. Insulin is produced by the pancreas to keep the glucose system in balance and if the insulin production is lacking, this is called Type 1 Diabetes. With Mature Onset Diabetes (also called Type 2, or Non-Insulin Dependent Diabetes Mellitus) the cells become less responsive to insulin, and there may be a reduction in insulin levels as well.

Insulin is necessary for the body to be able to use glucose for energy. When you eat food, the body breaks down all of the sugars and starches into glucose, which is the basic fuel for the cells in the body. Insulin takes the sugar from the blood into the cells.

When glucose builds up in the blood instead of going into cells, it can cause many problems. First off, your cells may be starved for energy, so you begin to feel tired. Secondly, over time you may develop heart disease (cardiovascular problems), blindness (retinopathy), nerve damage (neuropathy), and kidney damage (nephropathy).

So how do you know if you have developed (or are developing) Mature Onset Diabetes? The main symptoms to look for include a lack of energy, hunger (which comes from the fact that the cells are ‘starving’), excessive passing of urine combined with thirst and a dry mouth, insufficient sleep because of the need to pass urine at night (though this may be due to prostate enlargement in males) and blurred vision (again not to be confused with reading difficulties – short arms – which is called Presbyopia and occurs after 40 years of age), slow healing of minor cuts and sores.

How does Diabetes cause such diverse symptoms? Large blood vessels may be damaged by atherosclerosis, which is a major cause of coronary artery disease and stroke. Other long-term complications result from damage to the small blood vessels throughout the body. Damage to blood vessels in the light-sensitive retina at the back of the eye causes the visual impairment (diabetic retinopathy). Diabetes also increases the risk of developing cataracts.

If diabetes affects blood vessels that supply nerves, it may cause nerve damage. There may be a gradual loss of sensation, starting with the hands and feet and sometimes gradually extending up the limbs. Loss of feeling, combined with poor circulation, makes the feet and legs more susceptible to ulcers and gangrene. The nerve and blood vessel damage may also produce impotence in men (which Vitamin V may not be able to fix).

Damage to small blood vessels in the kidneys may also lead to further complications. Damage to the nerves controlling the body’s internal functions (autonomic neuropathy) can lead to problems with low blood pressure on standing (postural hypotension) or disturbance of the GI tract (vomiting or diarrhea) and increases the risk of sudden cardiac death.

So if you think you might have it, or are a likely candidate, what next? A simple trip to your doctor and some inexpensive blood and urine tests will confirm or deny.

In the initial stages, dietary measures may be sufficient to control this condition, but oral medication and sometimes insulin injections become necessary as it progresses. But find out if you have it first!

Yellow Liver, Yellow Liver (sing along)

What is your most important organ? Ask any man and he will undoubtedly point to his bladder’s siphon hose. But it isn’t. The liver is one of the more important organs you possess. Without it you will die, whereas you can get by without a kidney, or a lung or a thyroid, or even Willy the Wonder Wand (a delicacy enjoyed by Isaan ducks, I believe)! Yes, I’d rate my liver fairly highly.

Think of your liver as a filtering and de-toxifying device. Chemicals are taken up by the liver, to be broken down into non-toxic chemicals, all to protect your system. Clever organ your liver, to know what’s good for you and what isn’t.

The most well known liver toxin is our old friend Ethanol, more usually referred to as booze. There is “common wisdom” that says certain types of booze are more damaging than others, but that just isn’t so. Irrespective of the color or shape of the bottle it came in, ethanol is ethanol, is ethanol. It is the percentage of alcohol that is the important factor. That alcohol affects the liver is generally accepted, with the end result being called Cirrhosis, a fibrous hardening of the liver which then becomes unable to carry out its job correctly. Toxins build up. You feel unwell and it’s all downhill from there.

Some proprietary or prescription drugs can produce an inflammation of the liver tissues too. Or worse, produce a breakdown of the liver tissue itself. Amongst these is the headache medication paracetamol (the ubiquitous medication you can even buy in the corner stores), but before you throw them out of your bathroom cabinet, it requires some heavy and very frequent dosage of paracetamol to do this.

Other prescription items that may produce liver problems include Methyldopa, several penicillins, Simvastatin (the cholesterol lowering drug), Diclofenac (a non-steroidal anti-inflammatory) and Ketoconazole (anti-fungal). But it is rare – so don’t stop taking your prescriptions yet!

Prescription drugs can be dangerous (even though you can get most of them over the counter in Thailand), but that’s why they have a PI (patient information) leaflet inside the box (the bit you throw away and don’t read). Probably if you read about it, you wouldn’t take it!

However, what about “Health food” preparations? The purveyors of these all cite the fact that the ingredients are “natural” so everyone assumes that this means “safe”. Not so, I’m afraid. Lead, for example, is a naturally occurring compound, and not much good for young kidneys. However, since we are talking about liver problems, hands up all those of you who have heard of Echinacea? Supposedly fixes everything from falling hair to fallen arches – but is it “safe”? Well, Echinacea, along with Kombucha Tea are two of the commonest compounds showing a well documented history of being toxic to the liver. So if you’re sipping Kombucha tea because you’ve drunk too much alcohol last night, I would suggest that you change to water, or go back to booze (stop hangovers – stay drunk)!

Others for sale in the Health Food shops with known toxic effects on the liver include Evening primrose oil, Valerian, Chaparral, Japanese Daisaiko-to (for dyspepsia), Chinese Jin-bu-huan and several forms of herbal teas such as those from Heliotroprium, Senecio crotalaria and Symphytum. Makes you think that the shops that sell them may be incorrectly named, doesn’t it!

So how can we see what stage your liver is at after the onslaught of liver toxins? There is a new test called Fibroscan which can show if your liver is in trouble. My hospital’s Gastrointestinal and Liver Center can arrange it for you.

But while the column this week seems to be spreading doom, gloom and disaster, it’s not quite that bad. The liver is a very powerful organ and is capable of regenerating itself quite quickly, so in most cases of toxicity following ingestion of chemical compounds (including alcohol), by stopping taking it the liver recovers and the patient feels well again.

So remember that if you are taking anything regularly and you feel unwell, it may be the liver – but tell your doctor everything you have been taking! And no thanks, I’ll give the herbal tea a miss today.

Back Pains? Get down on your hands and knees

One of the commonest ailments to result in a GP consultation is low back pain. The cause of this is locked in the history of the development of mankind. You see, when we walked on all fours, we didn’t get low back pains at all, because our spines were designed to be horizontal and weight was carried on the back, just like a horse does today. The design of the vertebrae is such that the spine in the horizontal position ‘locks’ to be able to weight bear.

Now, here’s where it all went wrong. We decided we looked much better standing upright and we could walk much quicker using our hind legs only. This meant that our spine was now vertical and we could bend it backwards and forwards. Backwards and the bones all locked together again, but forwards and the vertebrae unlock making the spine unstable.

The next factor was we began to try and lift weights in this new upright position. We bent forwards (unstable) and lifted items like that. The era of low back pains had arrived.

Many generations development of our ancestor (called Homo erectus) kept that low back weakness and we are now Homo sapiens, older but not much wiser. Our spines are still weak. Our lumbar discs cause pain.

Many years ago I was a surgical assistant to a spinal surgeon, and the best description of the surgery was operating at the bottom of a red inkwell. Fortunately modern technology has made removal of a disc an operation that can be carried out as a minimally invasive procedure.

Let’s begin then with the “slipped disc” problem. First thing – discs do not “slip”. They do not shoot out of the spaces between the vertebrae and produce pain that way. The disc actually stays exactly where it is, but the center of the disc (called the nucleus) pops out forwards through the edge of the disc and hits the nerve root. When this happens you have a very painful condition, as anyone who has had a disc prolapse will tell you. Think of the pain when the dentist starts drilling close to the tiny nerve in your tooth. Well, the sciatic nerve is a large nerve! When the nucleus of the disc hits the sciatic nerve, this produces the condition known as Sciatica - an acute searing pain which can run from the buttocks, down the legs, even all the way through to the toes.

To accurately work out just what is happening requires bringing in specialist doctors who can carry out extremely intricate forms of X-Rays called CT Scans, Spiral CT’s or MRI that will sort out whether it is a disc prolapse, arthritis or another soft tissue problem. The equipment to do these procedures costs millions of baht, and the expertise to use them takes years of practice and experience. This is one reason why some of these investigations can be expensive.

After the definitive diagnosis of your back condition has been made, then appropriate treatment can be instituted. The forms of treatment can be just simply rest and some analgesics (pain killers), physiotherapy, operative intervention or anti-inflammatories and traction.

It is important to find the real cause for your aching back, as well as standing erect. The treatment for some causes can be the wrong form of therapy for some of the other causes. You can see the danger of “self diagnosis” here. Beware!

So what do you do when you get a painful back? Rest and paracetamol is a safe way to begin. If it settles quickly, then just be a little careful with lifting and twisting for a couple of weeks and get on with your life as normal. Might even be a good idea to miss the next couple of golf games. If, however, you are still in trouble after a couple of days rest, then it is time to see your doctor and get that definitive diagnosis. You have been warned!

There is a Spinal Minimally Invasive surgeon in my hospital. One of my colleagues at Bangkok Hospital Pattaya has just had that procedure and was walking pain-free the next day and ran a marathon the week later.

Coprolalia, effing and blinding

It has been shown to the satisfaction of the medical world, that humor and a good laugh really is good medicine. Some hospitals even employ clowns to brighten up the days of the inpatients. And no, I am not the clown.

However, one of my favorite jokes involves a parrot that was prone to ‘bad’ language, and consistently used the “F” word. After threatening the talkative bird with dire consequences, its owner put it in the freezer for five minutes. After being retrieved from the freezer, the parrot was asked if it would now behave. “Yes,” said the shivering parrot, “I won’t say the ‘F’ word again, but tell me what did the effing chicken say?”

“Effing” and “Blinding” are forms of expression used by (almost) all of us when taken to psychological extremes by some particularly vexatious situation. Shut in the freezer might be one of them.

Inappropriate use of the F word (there are some appropriate situations, in my mind at least) is part of an interesting condition known as Tourette’s Syndrome. These are involuntary movements (and sounds) and can be related to the magic “F” word, and is usually seen in children (not parrots) around the age of 5-7 years. Boys outnumber girls three to one!

So is this just a case of little Johnny parroting off (sorry about that, couldn’t help myself) “dirty” words he has heard at home? Actually no. This is a developmental problem that comes under the general heading of ‘Tics’ (as opposed to ‘ticks’ that are parasitic problems).

Tic disorders can affect up to almost 20 percent of children at some stage of their development. At one end of the spectrum are children with brief episodes of single tics, whereas at the other are children with chronic multiple tics, including our friend Tourette’s syndrome.

Tics are abrupt and recurrent involuntary motor or vocal actions. Motor tics include eye blinking, grimacing, nose twitching, lip pouting, shoulder shrugging, arm jerking, head jerking, kicking, finger movements, jaw snapping, tooth clicking, frowning, tensing parts of the body, and rapid jerking of any part of the body are simple tics. More complex ones include hopping, clapping, touching, throwing, arranging, gyrating, bending, biting the mouth, the lip, or the arm, head-banging, picking scabs, writhing movements, rolling eyes upwards or side-to-side, making funny expressions, sticking out the tongue, kissing, pinching, writing the same letter or word over and over, and tearing paper or books.

However, the tic can also be vocal, with simple ones being coughing, spitting, screeching, barking, grunting, gurgling, clacking, whistling, hissing, sucking sounds, and syllable sounds such as “uh, uh,” “eee,” and “bu.” The complex vocal tics can involve complete phrases such as, “Oh boy,” “you know,” “shut up,” “you’re fat,” “all right,” and “what’s that.” Take that a little further and you get repetitive bad language (which we call Coprolalia, because we love big words) and that is the best known example of Tourette’s syndrome.

Children who have these tics can be looked upon as fools by their peers, and there is a no more predatory group than other children. Parents also can feel helpless in these situations. Form the medical point of view, one has to treat the entire family, not just little Johnny washing his mouth out with soap!

Most children with tics can lead normal lives, and the tics themselves slow down in teenage years. Parents should be encouraged to get support for themselves from various organizations such as the Tourette Syndrome Association ([email protected]). With a good understanding of tics and related problems, including acceptance from teachers and education of the child’s peers, most children with tics do not need regular medical follow up.

Parents and children need to understand that although all these symptoms relate to an underlying brain disorder, breaking the cycle may be extremely simple—for example, just allowing the child to have a short “tic break” in a long school lesson may be enough.

Drug treatment can be used, though there are differences in opinion on the efficacy, with some researchers claiming only 30 percent can be helped; however, tic severity and frequency can be reduced. Studies of Risperidone in Tourette’s syndrome have shown that it can help.

HEADLINES [click on headline to view story]

“Sugar”? One lump or two?

Yellow Liver, Yellow Liver (sing along)

Back Pains? Get down on your hands and knees

Coprolalia, effing and blinding