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Update July, 2019

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Update by Natrakorn Paewsoongnern


Biting on a bullet!

Surgeons can be the ‘prima donnas’ of medicine, if you like. It is the surgeons who get the headlines in the newspapers. It is the surgeons who are the stars in movies and TV. Who can remember the irascible surgeon Sir Lancelot Spratt (Dr. In The House, 1954) or the young surgeon Dr. Kildare (1961)? Slightly more recent, the American surgeons in M*A*S*H?

However, surgeons have been around for many centuries and have their own Royal College. The origins of the first Royal College of Surgeons go back to the fourteenth century with the foundation of the ‘Guild of Surgeons Within the City of London’. There was dispute between the surgeons and barber surgeons until an agreement was signed between them in 1493, giving the fellowship of surgeons the power of incorporation. In 1745 the surgeons broke away from the barbers to form the Company of Surgeons. In 1800 the Company was granted a Royal Charter to become the Royal College of Surgeons in London. A further charter in 1843 granted it the present title of the Royal College of Surgeons of England (of which I proudly say I am a member).

We marvel at the surgical advances in the past century, but while I take my hat off to the surgeons, the real praise goes to the anesthetists. Without the advances in anesthetics, brawny assistants would still be holding patients down while surgeons attacked with scalpels and saws and the patient lay there biting on a bullet.

The first anesthetic agent was ether, dribbled on to a mask to knock the patient out and allow the surgeon to take his time and become meticulous in his approach. The first public demonstration of ether anesthesia took place on 16 October 1846, at Massachusetts General Hospital in Boston. The anesthetist was William Morton and the surgeon was John Warren; and the operation was the removal of a lump under the jaw of a Gilbert Abbott.

While there have been enormous advances since then, I can remember being a medical student and assisting at an operation in outback Australia in 1964. The anesthetic was ether, dribbled on to the patient’s gauze mask by the matron of the public hospital, and it was a Caesarian section for twins. There was no air-conditioning and it was 43 degrees in the theatre, where the fumes were making us all woozy. Amazingly everyone survived the ordeal, mother, twin sons, the local doctor, the matron and me.

Despite outback Australia, anesthesia progressed in the rest of the world. Chloroform was introduced by James Simpson, the Professor of Obstetrics in Edinburgh, in November 1847. This was a more potent agent but it had more severe side effects, including sudden death. However, it worked well and was easier to use than ether and so, despite its drawbacks, became very popular.

The next major advance was the introduction of local anesthesia – cocaine – in 1877. Things definitely did go better with ‘coke’! Then came local infiltration, nerve blocks and then spinal and epidural anesthesia, which in the 1900s allowed surgery in a relaxed abdomen, and is still used today, especially in obstetric anesthesia, where the mother can be anaesthetized without the baby being affected as well.

The next important innovation was the control of the airways with the use of tubes placed into the trachea. This permitted control of breathing and techniques introduced in the 1910s were perfected in the late 1920s and early 1930s. Then came the introduction of intravenous induction agents. These were barbiturates which enabled the patient to go off to sleep quickly, smoothly and pleasantly and therefore avoided any unpleasant inhalational agents. Then in the 1940s and early 1950s, there came the introduction of muscle relaxants, firstly with curare (the South American Indian poison, but not administered by native blowpipe) and then agents less dangerous.

Anesthesia is now very safe, with mortality of less than 1 in 250,000 directly related to anesthesia. Nevertheless, with today’s sophisticated monitoring systems and a greater understanding of bodily functions, the anesthetic profession will continue to strive for improvement over the next 150 years.”

On behalf of all patients requiring surgery in the future I thank the anesthetists. No longer do they have to bite on this bullet!

Influenza and the WHO

I am no great lover of the World Health Organization (WHO). I have to query the decision to make Zimbabwe’s despot the ambassador? I do also believe that the WHO “needs” epidemics to generate funding, to keep going. But then, I may be an old skeptic.

Here are some of the WHO “killer” epidemics. We should not forget the panic with the Swine flu (also H1N1) a few years ago. Bulletins from the WHO every day added to the panic. The word “pandemic” instills fear and even hysteria.

Where WHO let itself and us down was the fact that WHO did not tell the media that the immediate danger of viral infections has two requirements – how easily it passes from one host to another and how lethal is the ensuing infection.

The ‘pandemic level 6’ only referred to the contagious nature of the virus and H1N1 is certainly highly contagious. However, with only around 4000 deaths in the world from that 2009 Swine Flu virus, just how lethal was it, when the seasonal flu kills 36,000 people each year just in the US alone, and 200-300 people in Thailand? Read those numbers again – 200-300 people from the seasonal flu in Thailand! That’s from the “nothing out of the ordinary” flu!

Right, what can you do about avoiding a full-blown influenza infection this year? Quite simply, flu vaccination can keep you from getting sick from flu. Protecting yourself from flu also protects the people around you who are more vulnerable to serious flu illness. That’s the contagious nature again.

Flu vaccination can help protect people who are at greater risk of getting seriously ill from flu, like older adults, people with chronic health conditions and young children.

Flu vaccination may also make your illness milder if you do fall ill.

Flu vaccination can reduce the risk of more serious flu outcomes, like hospitalizations and deaths.

A recent study showed that flu vaccine reduced children’s risk of flu-related pediatric intensive care unit (PICU) admission by 74 percent during flu seasons from 2010-2012. Yes, a 74 percent reduction.

One study showed that flu vaccination was associated with a 71 percent reduction in flu-related hospitalizations among adults of all ages and a 77 percent reduction among adults 50 years of age and older during the 2011-2012 flu season.

Flu vaccination is an important preventive tool for people with chronic health conditions. Vaccination was associated with lower rates of some cardiac events among people with heart disease, especially among those who had had a cardiac event in the past year. Flu vaccination also has been shown to be associated with reduced hospitalizations among people with diabetes (79 percent) and chronic lung disease (52 percent).

Vaccination helps protect pregnant women and their babies for up to 6 months after they are born. One study showed that giving flu vaccine to pregnant women was 92 percent effective in preventing hospitalization of infants for flu.

Other studies have shown that vaccination can reduce the risk of flu-related hospitalizations in older adults. A study that looked at flu vaccine effectiveness over the course of three flu seasons estimated that flu vaccination lowered the risk of hospitalizations by 61 percent in people 50 years of age and older.

There are special vaccination instructions for children aged 6 months through to eight years of age as some children require two doses of influenza vaccine. Children in this age group who are getting vaccinated for the first time, as well as some who have been vaccinated previously, will need two doses. Your child’s health care provider can tell you whether two doses are recommended for your child.

A complicating factor comes with the annual make-up of the actual vaccine itself. Since the viral strains dominant in any particular year can change, this does mean you should top up your immune status with an annual jab.

In some quarters there is still resistance to influenza immunization as well as the childhood vaccinations, but to be honest, I cannot understand why. Sure, there are risks involved with immunization, but those risks are very, very small compared to the risks in getting the flu.

Honest research?

News of the latest earth-shattering breakthrough crossed my desk last week, complete with the promise that this new treatment will stave off Alzheimer’s and Parkinson’s disease and will help me live to be 120.

Now, that makes me think about whether I actually want to live to be 120. Watching the natural progression of aging in myself, I have this feeling that 100 will be enough. I could do without the Alzheimer’s and Parkinson’s though.

The new pill is actually an old pill called Metformin which is used in the treatment of diabetes, and the first trials on metformin will be next year in the hope it may return what is considered to be very promising. If successful, it would mean that a person in their 70’s could have the same biological age as a healthy 50 year old. Projecting that further, it might mean that at 120 the person will be like a spritely 100 year old?

Professor Gordon Lithgow of the Buck Institute for Research on Aging in California, who will lead the study, said, “If you target an aging process and you slow down aging then you slow down all the diseases and pathology of ageing as well. I have been doing research into aging for 25 years and the idea that we would be talking about clinical trial in humans for an anti-aging drug would have been thought inconceivable. But there is every reason to believe it’s possible. The future is taking the biology that we’ve developed and applying it to humans.”

According to the research people, they have already conducted tests on animals which show it significantly extends their lives.

Belgian researchers tested metformin on a species of roundworm and found that they not only aged more slowly, but also stayed healthier for longer.

Now that may be so, but also stretches research into incredulity. Animal experiments are generally done on species that have something in common with humans, hence beagles, laboratory rats and mice and the odd chimpanzee. But roundworms? Come on!

However, the Food and Drug Administration, the American regulator, has given the go-ahead for the same trials in humans, so if you find someone crawling along on their belly on your lawn, you’ve just spotted a 120 year old volunteer.

Scientists believe that metformin could hold the key to anti-aging because it boosts the number of oxygen molecules released into a cell. This appears to boost their strength and ability to survive for a longer period of time.

The trial, known as Targeting Aging With Metformin, or TAME, is due to begin in the US next winter.

Scientists from various universities and organizations are raising funds and attempting to recruit 3,000 adults aged 70 to 80 who have or are at risk of cancer, heart disease or dementia.

This is where the whole thing becomes more than somewhat silly. Everyone aged 70-80 is more at risk of cancer, heart disease or dementia than anyone younger. This easily proved.

And here is more evidence that academia can fiddle the figures when required. Cardiff University uncovered anecdotal evidence that patients given metformin for diabetes lived longer. Oh yes? This was despite the fact that those with the illness tend to have shorter life expectancies because they are more prone to heart attacks, strokes and kidney damage.

University researchers with “anecdotal evidence.” May I remind them that “evidence” requires hard facts, not anecdotes! And remind myself to steer clear of Welsh universities.

Never forget that what keeps scientific research going is “money”. When you have a research laboratory, you need money to keep it going. And the best way to raise money is to promise breakthroughs, especially cancer and anti-aging. Nobody wants cancer and nobody wants to die. As I write this, there are people scouring the globe looking for a “cure” for their cancer, and for many, there isn’t one, but they are prepared to clutch at straws. Wouldn’t you? Wouldn’t I? (No I wouldn’t.)

So should all the diabetics I know start celebrating while waiting for their expected century? No, is the answer, and that statement was all done without fancy titled “research” trials.

HEADLINES [click on headline to view story]

Biting on a bullet!

Influenza and the WHO

Honest research?