This is Pinktober
We are in “Pinktober”, a breast cancer
awareness program charity drive to assist the poor under the care of the
Thanyarak Foundation (under the patronage of the late Princess Mother Sri
Nagarindra). Unfortunately, we are still looking for a cure for many
cancers, but the research is continuing.
In the meantime, early detection does give the cancer
sufferer a much better survival rate than otherwise. In
the UK they have actually been studying early detection with the National
Cancer Director Professor Mike Richards indicating that work is well
underway to catch more cancer cases earlier and improve the longer-term
treatment for cancer survivors.
Professor Richards said, “Cancer
treatment in Britain has improved vastly in recent years and we are now
beginning to see the impact on our survival rates.”
There is conflicting evidence as to the efficacy of
Breast Self-Examination (BSE), but if it provides a chance of early
detection, then as far as I am concerned, it is worth it. The process of
looking is called breast screening, but is still a subject that seems to be
controversial, though honestly, I do not know why. The sensationalist press
feeds on fear, and by instilling fear into women about breast cancer will
always sell a few more papers. Last decade, one of the international news
magazines had a front cover story on breast cancer screening, with the
inference being that it was probably all a waste of time. Despite mammograms
and suchlike, there were cases that escaped detection until it was too late
and other such negative predictions. Was it all then a waste of resources
Ladies, let me assure you that it is none of those.
Unfortunately, the cancer detection story is one that suffers from a problem
which can be associated with an inexact science. Since we can put men on the
moon, clone sheep (and even rabbits in Chonburi, apparently) and other
incredible facts, we should then be able to diagnose human conditions with
pin-point accuracy. Unfortunately, wrong! We’re getting better at it, but
we’re not there yet.
Diagnosis and detection are “real time” arts, not
sciences, even though we would like them to be. Sure, we use “science” as a
tool, but that is all it is. A tool to help us see the problem. Just like we
can use a telescope to see things at a distance - even if we can’t see the
object, that doesn’t mean to say it wasn’t there.
There has been a bit of that thinking with mammograms
of late. A lady has three clear annual mammograms and then finds she has
advanced breast cancer during year number four. Was the testing useless?
Again, I ask you to look at the “real time” situation.
So today cancer was found. When did it “start” to grow? This week, this
month, this year? The answer depends upon the type of the cancer. Some
fast-growing cancers would be impossible to pick up, even if the person had
monthly mammograms. The slow growing variety can be picked up years ahead.
Unfortunately, mammography cannot be a 100 percent indicator - we are not
that good - yet. But it is still one of the best diagnostic procedures we
have. And it is better than nothing.
Likewise, Breast Self-Examination (BSE) has its
detractors as well as its proponents. Sure, a lot depends upon how well the
woman carries out this self-testing, but again, surely it is better to look
than to carry on in blissful ignorance?
Breast cancer is like all cancers - the sooner you find
it, the sooner you can deal with it and the earlier treatment is
administered, the better the outcome. Studies from the American National
Cancer Institute show that 96 percent of women whose breast cancer is
detected early are still alive five or more years after treatment. That’s
not all doom and gloom, is it?
Remembering how to spell Alzheimer’s Disease!
If the symptoms of Alzheimer’s Disease
come about because the ‘electrical’ wiring in the brain gets tangled, then
there should be a way of untangling, should there not? After all, look at
the telephone wires in Asia. They just leave them tangled and run a new set!
So, is the answer to ‘senior moments’ re-wiring? Is all I have to do is get
my brain hot-wired into a wireless network plugged into Mr. Google and I can
meet the world head on?
However, we’re not quite at the re-wiring yet, so we
(you and me) have to retain as much cerebral function as we can. And it
turns out that it is not all that difficult.
We have known for some time that if you don’t use your
muscles, they waste away. By not using your hands for physical work, the
skin on your hands gets thin. However, we also know that if you use your
muscles again, the muscle tissue builds up and becomes strong once more. If
you use your hands again, the skin builds up and becomes thicker. The
message here is that all is not lost! Recovery is possible.
However, we were always told that the one organ of the
body that could not reverse the wasting process was the Central Nervous
System. Once it started to fail, that was it. Dementia was just around the
corner. Alzheimer’s Disease next week.
That view has been challenged and the results are
comforting, to say the least. Experiments have been carried out that showed
that by inducing stress in an animal resulted in chemicals being released.
This on its own was nothing new, but what was new was the fact that some of
these chemicals produced a difference in the brain’s anatomy! The idea that
the brain could not change was incorrect! It could be ‘short-circuited’
resulting in a new wiring pathway.
What was even more exciting was that if the animal was
restored to its own ‘safe’ and non-threatening environment, then the brain
reverted to its pre-stressed anatomy! It was possible to ‘re-wire’ the
In turn this has led to much research into the effects
of stress and its reversal, and then on to Alzheimer’s Disease (if I have
remembered to spell it correctly!) And if it were possible for its reversal
Returning to the research, we have shown that stress
can physically damage nerve cells used in storing memory. We have also found
that mindless watching of the goggle-box also produces a decline in brain
function. In fact, the numbers are more worrying than that. It has now been
found that people with no stimulating leisure activities, and who are couch
potatoes instead, are nearly four times more likely to develop dementia
compared to those people who have leisure stimuli and do not waste hours in
front of the TV.
Taking that a step further, and turning the scientific
data around to be useful, it has been found that in being the converse to
the couch potato, intellectually stimulating leisure activities had a
‘protective’ effect for the brain and its capabilities. What is more, they
have also found that if you are doing a job you enjoy, then this was again
protective, but a dull job with no stimulus or challenge was another way to
This does not mean that we all have to take up chess
tomorrow, because in place of intellectually stimulating hobbies, it has
been found that physical exercise itself stops memory loss and stimulates
growth of nerve cells.
Another protective factor appears to be marriage! Those
who have never married have twice as high an incidence of dementia than
those who are married. So there you are, rather than say that your wife is
driving you insane, it appears that she is driving you towards sanity
So the secret towards staving off dementia and Al
whatsisname’s disease is to have a job you enjoy, get some exercise, watch a
very limited amount of TV and settle down with a good cook (sorry, that
should have read “a good book”).
A weight loss diet - that works!
This particular article has been
requested so many times, it has almost become an annual event all on its
own. Obesity is the scourge of the developed world, and I am not pointing
fingers at any one country in particular. Our diets are far from healthy,
and the death rate from heart attacks is intimately related to diet.
The interest in this diet came after I noticed a friend
of mine had dropped some weight. “Fifteen kilos in two months,” was his
proud reply. He had done this by following a diet - and one that had
obviously worked! This is put forward as a seven-day diet, and although I am
not always in favor of ‘crash’ diets, this one does merit some study. It is
reputedly from Sacred Heart Memorial Hospital and is used in their cardiac
care unit for overweight patients to lose weight prior to surgery.
It states the first no-no’s as being bread, alcohol,
soft drinks, fried food or oil. Agree totally. Unfortunately, for a number
of people, those no-noes are their everyday dietary items!
After that there is a concoction called Fat-Burning
Soup (FBS) which you make up and keep in the fridge. You can have as much
FBS any time you feel hungry and have as much as you want. You are also
advised to drink plenty of water - 6 to 8 glasses a day along with tea,
coffee, skim milk, unsweetened juice or cranberry juice.
The physiology of hunger works that when the stomach is
empty, messages are sent to the brain to send down food. Fill the belly with
non-fattening food and the hunger pangs will be less, but the weight does
not go on.
Here is the recipe for the Fat-Burning Soup:
4 cloves garlic
2 large cans crushed tomatoes (810gms)
2 large cans beef consommé
1 packet vegetable packet soup
1 bunch spring onions
1 bunch celery
2 cans French beans (or fresh)
2 green capsicum
10 cups water
Chop all veggies into small pieces. Boil rapidly for 10
minutes stirring well and then simmer until veggies are tender. Add water if
necessary to make a thinner soup.
Now the other downside to dieting if food boredom. A
week of FBS, water and cranberry juice will sap the resolve of most
overweight people, so what this diet does is allow you to add different
items on a daily basis. Here are the suggestions.
Day 1, any fruit except bananas. Eat only soup and
Day 2, all vegetables. Eat as much as you like of
fresh, raw or canned vegetables. Try to eat green leafy vegetables. Stay
away from dry beans, peas, and corn. Eat vegetables along with soup. At
dinner reward yourself with a jacket potato and butter.
Day 3, eat all the soup, fruit and veggies you want
today. Don’t have the jacket potato today. If you have not cheated you
should have lost approx. 3 kg.
Day 4, bananas and skim milk. Eat at least 3 large
bananas and drink as much milk as you can today. Eat as much soup as you
want. Bananas are high in calories and carbohydrates, as is the milk but you
will need the potassium and carbohydrates today.
Day 5, beef and tomatoes. You may have 600 gm of beef
or chicken (no skin) and as many as 6 tomatoes. Eat soup at least once.
Day 6, beef and vegetables. Eat to your hearts content
of beef and veggies. You can even have 2-3 steaks (grilled) if you like with
leafy green vegetables. No baked potato. Be sure to eat soup at least once.
Day 7, brown rice, vegetables, fruit juice. Be sure to
eat well and eat as much soup as you can.
By the end of day 7, if you have not cheated, you
should have lost 7 kg. The theory is good, but I caution against losing too
much, too soon.
How to avoid
a Heart Attack
We all have to die of
something and if you are between 50 and 60 years of age you are most likely
to die from a coronary occlusion. That’s not a coronary ‘conclusion’ but the
end result is the same. And it is an unfortunate statistical truth that the
50-60 year decade is the most dangerous.
The simple term ‘Heart Attack’ covers
the situation where the artery supplying the heart with the oxygen rich
blood is blocked and the heart muscle then dies. If you are lucky it may be
just a partial blockage and you have some minor heart attacks before the
final, fatal one, which we call a ‘Myocardial infarction’.
Fortunately, if you can catch the
condition early enough you may live to get the three score years and ten
which we all expect as our birthright. However you have to recognize some
the early signs first.
The first step is to look at yourself.
Are you an overweight smoker? If so, stop smoking now. Stopping smoking is
the best thing you can do to give yourself a future with good health. Leave
exercise till you have shed some kilograms.
The second step is to note any chest
pains, particularly pains that come on with exercise, this we call ‘angina’.
Once again, now is not the time to take up exercise at the local gymnasium.
Likewise breathing difficulties with
exercise or any irregular heart beat which we call ‘palpitations’. Is your
blood pressure high? Have you had it checked?
After that, it becomes necessary to
examine your blood where we look for signs of diabetes, liver disease, blood
fats and kidney disease. All of these conditions can lead to coronary artery
disease and increase your chances of having an infarction (death of heart
That’s not the end of it, there are
more risk factors all you 50-60 year olds need to check. A chest X-Ray can
spot enlargement of the heart as well as calcium deposits in your aorta, the
main artery leading from the heart. An Electro Cardiogram (EKG) can show if
the heart muscle is functioning correctly. Forewarned is forearmed.
Another factor that should be explored,
is Family History. The tendency towards Myocardial Infarction runs in
families, especially the male members. Ask around in the family, it could be
If you have any of the above symptoms
or conditions, you very well may have coronary artery disease, a leading
cause of myocardial infarction.
As a sensible precaution, you should
see your doctor for evaluation of the condition of your coronary arteries.
There is a promotion this month which includes
ˇ Coronary artery CT scan and
ˇ Kidney and liver function tests
ˇ Physical examination by our
cardiologist and vital signs.
If you are between 50-60 it is well
worth your while looking at this promotion. Contact the Bangkok Hospital
Pattaya Heart Center Tel. 0 3890 9229.
Exercise for Health. Does that include sexercise?
Probably the commonest advice a doctor
gives is to lose weight and get some exercise. Does that ring a bell in your
memory? Was that part of the advice after your annual physical check-up?
Unfortunately, there seems to be very little real
understanding of what exercise should consist of, how often, what type, how
long, and what about sex? For example, I was reading an article on exercise
the other day and it said authoritatively that one should wear comfortable
clothing and socks with the correct size of non-slippery, shock-absorbing
shoes. If this includes sexercise, there are some strange shoe fetishes out
there that I haven’t heard of yet!
However, getting a little serious, exercise will be
good for you, provided that you pick a form of exercise that is not harmful
for you! Now I know that looks as if I have put my money on both horses in
the race, but take that sentence at its face value. Enough research has been
done to show that regular exercise is beneficial for everybody, in both the
physical and psychological aspects, but, and it is a big ‘but’, all forms of
exercise have relative bodily risks, and this has to be taken into account
before you buy a pair of expensive jogging shoes and tackle a 10 km trot in
the middle of the day. True stories – a medical colleague in Australia took
up playing squash when he turned 50 and dropped dead on the court of a heart
attack, and another acquaintance of mine turned 40, decided he wasn’t fit,
bought a bicycle to ride to work each day and was run over by a bus.
The same article that advised non-slippery shoes did
have some wise words, however. These included choosing appropriate exercise
according to your ability. Never exceed your limit. Remember that it is not
the harder the better. If you have acute medical problems (such as fever or
pain), stop exercising. If you have chronic medical conditions (such as
hypertension, diabetes, ischemic heart disease and arthritis), seek advice
from your doctor or physiotherapist beforehand. All of these I agree with.
If you are happy to take your body to your medical advisor when it is sick,
take it back to your doctor for advice on how to tone it up as well.
The other words of wisdom suggested that for prolonged
exercise such as hiking, continually drink water to supplement the loss of
body fluid due to sweating. Do not wait until you are thirsty. Take
appropriate breaks during exercise. Do not over-exert yourself. Forget about
“powering through the pain barrier.” Leave that for Olympic cyclists.
As well as the form of exercise, there is the
frequency. At least three times per week, 20-30 minutes (or more) is
necessary each time, to derive the maximum benefit. And always remember, if
there is dizziness, fainting, shortness of breath, chest pain, vomiting,
nausea or severe pain during exercise, stop exercising immediately and seek
medical advice as soon as possible.
Now I did mention at the start of this week’s article,
the word “sexercise”, and some of you have been impatiently reading, while
nervously fiddling with your expensive packet of Viagras, Kanagras, Cialis
and other lead-in-your-pencil medications (I draw the line at tiger willy).
OK, what about sex? The advisability of this form of exercise when you have
some chronic complaint (such as hypertension, diabetes, ischemic heart
disease, etc.) should be part of the advice you get from your doctor
beforehand. The danger of over the counter willy stiffeners is that you
don’t get advice with them.
Finally, the learned article did say, “Exercise with
friends. Company provides enjoyment, mutual encouragement and support.” That
goes for sexercise too!
La Maladie des griffes du chat
Ever tried to import
the family cat from your home country? Difficulty level 9. Well, one of the
difficulties relates to “La Maladie des griffes du chat” known in
English as Cat Scratch Disease.
Now most people know that dogs and bats
carry diseases, including the deadly rabies, but the other domestic pet, the
cat, carries its fair share as well. However, almost every household has at
least one cat, and often more, and cats get the run of the house. Cats are
affectionate, warm pets that will sit on your lap for hours, purring away,
while it licks your hands. During that time, it may even be giving you more
than love. It may be giving you a little present called Bartonella
henselae, AKA Cat Scratch Disease! Yes, your cat is a walking, purring
receptacle of illness.
Tell me more, you say, while wondering
if you should strangle the cat now or later! But first a little history. A
little over 50 years ago, the clinical signs of Cat Scratch Disease were
described, and despite 50 years in between, it is still in the feline
Cat Scratch Disease affects between
2-10 people per 100,000 head of population in America, so whilst it isn’t an
everyday diagnosis, most doctors will come across a few cases in their
The presenting symptom is a regional
swelling of the lymph nodes, generally in a young person or a child, and the
usual scenario involves a panicking parent who is sure the child has
What actually happens is that the cat
is carrying the organism known as Bartonella henselae, which is found
all over the world, and which it inoculates into the human system. This bug
in turn is trapped by the lymph glands, within which one almighty fight
takes place, with the end result being that the glands swell dramatically
and can even burst through the skin as a suppurating discharge. Other signs
and symptoms include a fever (cat scratch fever, for all you Ted Nugent
fans), sore throat and headache.
Now there are many causes for swollen
glands, fever, headache and sore throat, so how do we pick on the family
pussy cat? Quite simply, there will be a history of having been bitten or
scratched by the family moggy, and the inoculation site will drain into the
affected lymph glands.
So just how does the cat give you a
“shot” of bugs? Well, firstly somewhere between 20-40 percent of cats are
carrying the organism, and it lives in the cat’s saliva as well as in its
blood. While licking its claws, pussy cat leaves a collection of the
organism there, which in turn becomes yours when the cat scratches you.
Deliberately or accidentally.
Cat Scratch Disease, although generally
localized, can even end up infecting internal organs such as the liver,
spleen heart and brain, though this is very rare. For most people who
contract the illness they quietly recover, though it can sometimes take some
months. However, for people with compromised immune systems, spontaneous
recovery is not the norm. Children get the disease more than adults, because
children tend to spend more time with pets, and pull more than the
There is treatment, with one of the
most appropriate antibiotics being Doxycycline, while the most usually
available penicillins are fairly ineffective. There are tests which can be
done in the laboratory to prove or disprove infection by Bartonella
henselae, so what we call a “Definitive” diagnosis can be made. Again
you can see the dangers in self-medication. If you do indeed have Cat
Scratch Fever from the cat bite, the penicillin you bought is useless!
So should we all go out and take our
cats down to the vet and consign them to the great veterinary hospital in
the sky? The simple answer is no, but the moral to this tale is that we
should be on our guard. Cat scratches and bites should not be taken lightly.
Immediately after any injuries you should wash the wounds with soap and
water and after a thorough cleansing only then apply your favorite
antiseptic. At the first sign of problem, pop into my hospital and get it
checked. But just leave the cat at home!
What is chicken pox?
Chicken pox is a common
disease caused by the varicella zoster virus which is a member of the herpes
virus family. It is very contagious and usually occurs during childhood.
Adults can get the disease if they did not have it in childhood.
What are the symptoms?
Chicken pox most often begins with a
slight fever, body aches and loss of appetite. Within 1-2 days, the rash
appears usually starting on the chest or back. Initially the rash begins as
red spots which then rapidly form blisters and spreads to the rest of the
body. The blisters open and form a crust or scab within a few days. The rash
can continue to break out for 4-5 days as older lesions crust and heal.
Itching can accompany the rash along with fever, swollen lymph nodes, sore
throat and general body aches. It is unusual to have chicken pox more than
chicken pox contagious?
Chicken pox is contagious through
direct contact with the fluid in the blisters and by airborne droplets that
are inhaled. Incubation period is 7-21 days. A person is contagious from 1-2
days before the rash appears and until all the lesions form crusts. What is
Treatment is focused on relief of
symptoms. Antihistamines or baths with colloidal oatmeal may help relieve
itching. Tylenol or ibuprofen is used for fever or pain relief. Aspirin
should be avoided. Antiviral drugs such as acyclovir may be prescribed. (A
vaccine has been released.)
what is shingles?
Shingles is a painful skin eruption
caused by the varicella zoster virus, the same virus that causes chicken
pox. The virus remains dormant in a nerve root near the spinal cord after
chicken pox. Fatigue, emotional upsets, immune suppressive drugs (such as
corticosteriods), radiation therapy or unknown factors cause the virus to
reactivate. When it reactivates, it travels down the nerve to the skin.
Anyone can get shingles if they have had chicken pox but it is more likely
to occur in older people.
What are symptoms of shingles?
Pain usually begins along the nerve
before the rash appears. Itching, burning or weakness in the associated
muscles may also be present. The rash usually develops within a few days
after the pain begins. The rash appears as groups of small blisters on the
skin along the nerve tract. This often occurs on one side of the chest or
face, but may appear on any part of the body. The blisters crust and heal
during the next two weeks. Pain may persist for weeks or sometimes months
after the rash heals. There used to be an old wife’s tale that if the rash
went completely around the torso you would die. Take it from me – you don’t.
Antiviral medications such as acyclovir
can be used to reduce the pain and promote healing if started early in the
course of illness. Pain relief medicine and soothing soaks or lotions may
also be used.
However, there are vaccines available
for the person older than 70, though the immune boost seems to run out after
And like all vaccination programs need
to be followed correctly, taking the advice of the doctor. And yes, we do
have the Shingles vaccine. Telephone 1719.
A Day in the Life of
your everyday Doctor
Local readers of the
Medical Column know that I am an Australian trained doctor, but graduated in
the UK, worked in England and Gibraltar, returning to Australia as a ship’s
surgeon and after some years back in Australia came to make Thailand my
home, where I have been for the past 20 odd years.
Most readers also expect that the life
of a doctor is one of the safest professions and you will probably be
surprised to know that when my eldest son expressed a desire to study to
become a doctor I said “Don’t!” Some of the reasons for my negative approach
include my being attacked by patients with a pistol, a razor, and a machete.
And this was not as a doctor in the underworld, but as your average suburban
My first brush with danger came when I
scored the job of a locum tenens for a lady doctor in Amersham, a
quiet picturesque English town. I was offered a substantial salary, a petrol
allowance and a pleasant flat in town. I couldn’t believe my luck, but I
should have been warned when the locum who was just finishing met me as I
arrived for the job interview and who said, “Hit ‘em high.” The practice was
a typical English GP practice with its own rose garden and a senior doctor
who attended to the needs of private patients, while I got the National
Health Service patients, from a different socio-economic group.
I had been there about three months and
began to wonder how long the doctor was going to be away. When I enquired of
the practice manager, she said, “Didn’t you know why doctor was not coming
back?” When I replied in the negative she floored me with the information,
“Doctor was murdered on the golf course six months ago! Everybody round here
knows who did it, but the police don’t have enough evidence, and by the way,
you visit that patient every Thursday morning.”
Now the reason for the “Hit ‘em high”
became obvious. The British doctors knew about the shocking history of the
practice, but since I had been in Gibraltar for the past year I was not
aware or pre-warned.
The next Thursday morning saw me
somewhat in trepidation, waving my stethoscope around the front door, and
being ready to run at the first sign. It was always a relief when the
Thursday visit was over. I resigned shortly after.
Have you ever been threatened with a
machete in the course of your duties? I have. It was Xmas day when I
received a frantic phone call from the security guard from one of the
factories I used to attend when necessary. “There’s a bloke with a machete
walking round the factory looking for the Managing Director.” That certainly
took my attention away from Xmas trees.
With my heart in my mouth and a loaded
syringe of sedative in my pocket, I began walking round the deserted
factory, looking for the local mad axman. Spotting him was not too
difficult. Men waving size 10 machetes are not the usual in a brewery. I
Having decided I was no threat to him,
and having decided he was not looking for me, I told him we could wait in
the security area as the MD was on his way, and he could put the machete
down. While that was going on, the police had been called who stormed the
security area securing the man and his machete.
I went home and had a beer to celebrate
a somewhat different Xmas.
If the Editor agrees, I will write
another time about some of my other life’s excitements including a Colt 45
(Note: I know the editor, and he
Living with cancer
So you have just found
out you have “cancer”. What can you do? The first thing is to sit down and
take stock of your circumstances. All of us know that that piece of string
called “life” eventually comes to an end, but we don’t know when. The only
difference with you, is that your doctor has actually told you when your
piece of “life” string is due to run out.
Now whilst the immediate thought is
“How do I beat this?” there are many factors you have to consider in the
time ahead, and one of the main ones is called ‘The Quality of Life’.
Now is the time to talk with family,
friends and health care team. It is natural for a person with advanced
cancer to feel many emotions including anger, fear, and sadness. Just as you
may need time to adjust to this new phase of your illness, your family and
friends may also need time. If you are having trouble talking with family
and friends, ask your nurse, doctor, or counselor to gather everyone
together to talk.
This talking phase should also include
your getting to understand your cancer. This you do by talking with your
treating doctors, and also from information from reliable internet sites.
Note I say “reliable” sites. There are always plenty of sites ready to sell
you snake oil.
Now is the time to manage your
symptoms. Your quality of life is better if your symptoms are under control.
Talk to your health care team about the best way for you and your caregivers
to manage your symptoms.
Do not be afraid to ask your doctors
about any proposed modalities of treatment. Getting an extra two months of
life, but at the cost of the quality of life, may not be worth having.
Always keep that in mind. Quality of (the remaining) life is everything.
Be as active as you can. When an
illness progresses, it may be harder to do the things you have always done.
Talk to your health care team about what, if any, limitations you may have.
If your physical health allows, continue to exercise in some enjoyable way.
Or, if you find it is too much for you, take up a new hobby or find things
that you can still do and enjoy, such as reading, writing, creating a photo
album, or making a video for family and friends.
Let friends and family know what they
can do to help. What can you do for yourself? What is important to you? What
can friends and family do for you? What can all of you do together? Where do
you turn if you need extra help or care? If you are not up to being social,
let people know this as well.
Make your wishes known. Making the
decision to stop active cancer treatments can be a hard choice for a person
with cancer and their family. These are personal choices. If you are faced
with making these decisions, talk with your family and health care team
about your wishes and explore all of your options. You are still able to
make decisions about your life to the extent that you desire.
Maybe you want to give someone else
some of the responsibilities or share decisions about what to do. You may
want to create a health care proxy and/or power of attorney. This allows
someone who you choose to make health care or other decisions for you.
Whatever you choose, you are in control of your life and you know what will
work best for you.
You may also consider creating a
‘Living Will’ or giving specific instructions on what your wishes are if
your cancer progresses. This process helps make your end-of-life wishes and
desires known to family, friends, and your health care team and can help
ensure that your wishes are honored. These wishes may include funeral
arrangements or decisions about hospice care. Discuss with your family,
friends, and health care team your wishes regarding resuscitation.
Sorry if the column this week sounds a
little deep and dark, but it can give assistance to those who feel as if all
their options have gone.
The Tale of Tanujin
The item you are about
to read is one of my favorite medical case histories. Bruises on a child’s
body are often considered proof that a baby has been battered. A visible
bruise on the buttocks, the shape of a hand and five fingers is almost
‘undeniable’ proof. Or is it?
There was a very celebrated instance of
a GP in the UK having discovered that so many of the Asian babies in the
practice were showing signs of being ‘battered’ that the children’s welfare
people were called in and an enormous number of children taken away.
However, the highly observant GP was wrong!
In Thailand, and the rest of Asia, a
new-born baby with the ‘handprint’ bruise is very common, while child abuse
is not common at all. The problem, or rather the condition, relates back to
Genghis Khan and the Mongol hordes. It is a wonderful piece of folklore and
a fine example of applied genetics.
Let’s look at the folklore first, and
you are going to have to dig very deep to get this tale anywhere else! A
Mongolian baby, called Tanujin, was born just over 1,000 years ago, but did
not breathe. His father, in desperation, held his new-born son upside down
and smacked him severely over the bottom, so much so that the baby drew
breath and lived, but carried the life giving bruise for the rest of his
days. That baby later became Genghis Khan, (which means King of the Earth),
and by the time he died in 1227 he was the ruler of a large chunk of it,
including the area which later became known as Thailand.
History has chronicled that the Mongol
hordes raped, pillaged and annexed countries from China to Persia. His
highly mobile troops traveled the difficult terrain of Siberia. Famous
cities were captured and looted such as Tashkent, Baghdad (still a good
place to stay away from, thanks George) and Bokhara. Cities that surrendered
were spared but those that resisted were razed and the people slaughtered.
The Mongols conquered northern India and Afghanistan. In 1222, they defeated
the Russian and Bulgarian armies. At the time of Genghis Khan’s death, his
empire stretched from China’s Yellow River to the Dnieper, in Russia.
And now back to some interesting
folklore. The descendants of Genghis Khan also showed the hand-shaped bruise
on the buttocks, beginning with his four sons Ogdai, Jagatai, Juji and Tule,
who were given one quarter of the empire each after their father died. They
in turn passed on this ‘trademark’ and so this continues till today. If your
“Luk Krung” children have the sign of Genghis Khan, called Mongolian Blue
Spot, you can claim descent from the warrior king. However, there is quite a
number of you, so I think there won’t be much left in Genghis’ estate by
Now Mongolian Blue Spot, as a clinical
condition, is well documented, and I came across figures suggesting that at
least one Mongolian spot is present on over 90 percent of Native Americans
and people of African descent, over 80 percent of Asians, over 70 percent of
Hispanics, and just under 10 percent of fair-skinned infants (Clinical
Pediatric Dermatology, 1993).
Medically we describe Mongolian Blue
Spot as flat bluish to bluish gray skin markings that commonly appear at
birth (or shortly thereafter) and scientifically they are called Congenital
dermal melanocytosis. They are flat, pigmented lesions with nebulous borders
and irregular shape. They appear commonly at the base of the spine, on the
buttocks and back, but also can appear as high as the shoulders and
elsewhere. The medical text books also warn that occasionally Mongolian Blue
Spots are mistaken for bruises and questions about child abuse arise.
Obviously a text book that the UK GP did not read! Mongolian Blue Spots are
birthmarks, not bruises.
So, for all of you with children with a
peculiar blue birthmark on their bottoms, or for those interested in
checking friends and neighbors (or the young ladies dancing in the chrome
pole palaces), it seems fairly positive that the lineage is verified. You
really have found descendants of the man who conquered more of the world
than Alexander the Great. And guess what – my children have it too!
Prostate Cancer once more
I make no excuses for
running another article on Prostate cancer. Fifty percent of people in
Thailand are male and 98 percent of them have a prostate which can turn
nasty and bite them! (What happened to the 2 percent? They’ve had their
prostate removed already.)
However, a friend found that he had an
elevated Prostate Specific Antigen (PSA) and the following examinations
showed that the elevation was caused through cancer, not one of the other
causes of PSA elevation. Yes, PSA is not a go/no go test. Elevation of PSA
is a warning to go looking.
However, prostate cancer is common. The
statistics show that by age 50, almost 50 percent of American men will have
microscopic signs of prostate cancer. By age 75, almost 75 percent of men
will have some cancerous changes in their prostate glands. Do the maths. By
100 we’ve all got it!
So does this mean that life really ends
at around 76? Fortunately no. Most of these cancers stay within the
prostate, producing no signs or symptoms, or are so slow-growing, that they
never become a serious threat to health. The good news is you die of
something else before the prostate gets you! You die with it, rather than
from it. That is an important fact to take in. This we call watchful waiting
and serial PSA’s are the way to go, as well as getting friendly with our
The real situation is that a much
smaller number of men will actually be treated for prostate cancer. About 16
percent of American men will be diagnosed with prostate cancer during their
lives; 8 percent will develop significant symptoms; but only 3 percent will
die of the disease. Put another much more positive way, 97 percent won’t die
from their prostate cancer.
While some prostate cancers can be
‘aggressive’, breaking out from the prostate gland itself and attacking
other tissues, including brain and bone, fortunately this is the minority
scenario. The great majority of prostate cancers are slow growing, and it
can be decades between the early diagnosis and the cancer growing large
enough to produce symptoms. That’s the second important fact to take in.
So let’s look at diagnosis and get the
“blood test” out of the way first. The blood test is called Prostate
Specific Antigen, or PSA for short (we medico’s love acronyms). Up till then
we had another test called DRE (digital rectal examination), which, quite
frankly, was not all that popular. As medical students, we were taught “If
you don’t put your finger in it, you’ll put your foot in it!” Despite this,
‘buyer resistance’ was high, so when news came through about a “blood test”,
millions of men began rejoicing and the sale of rubber gloves plummeted.
Unfortunately, as I said earlier, PSA is not a go/no-go test. A normal range
test doesn’t guarantee you haven’t got it, and an elevated result doesn’t
automatically mean that you are about to claim early on your life insurance
(or your dependents, anyway).
However, there is good news. Serial PSA
examinations can show the rate of cancer growth, and the rate of increase is
Like many other cancers, prostate
cancer can only be fully diagnosed and ‘staged’ by biopsy. ‘Staging’ has
four main grades. Stage I cannot be felt and is diagnosed through
pathological testing. Stage II can be felt, but it is confined to the
prostate. Stage III is coming out of the gland and Stage IV has grown into
This is where you need to discuss your
options with our doctors. If you are a young man with stage IV, then you
have to make up your mind quickly. But if you are 75 with stage I or II,
then you have more time, as you will most likely die of other causes before
the prostate cancer gets you. For these people, “Watch and Wait” has much
going for it, but you must be prepared to get to know your urologist, so
pick a young one.
To increase your knowledge, Bangkok
Hospital Pattaya is running a free information seminar on Men’s Health on
Saturday 21st of
March from 9am.-12 noon. Be quick to register. Limited seats and for first
50 persons, you will get a free PSA and Testosterone tests. Telephone: 061-
386-6153 Email: [email protected]
Is EBM good for you?
The practice of
Medicine is a fascinating story that has unfolded over thousands of
years. “Healers” have been part of most societies, and in ancient China,
for example, you paid the doctor to remain well, not for treatment of
your ailment. Now there’s an incentive bonus for you!
Then there are different kinds of
“medicine” given such names as “conventional”, “alternative” and
These different ways at looking at
the same subject (making you well) can be quite confusing, and for me
much hangs on the term EBM, which stands for Evidence Based Medicine.
Mind you, it has also always been
the case where people like to throw stones at conventional clinical
medicine. Claims of over-servicing, over-prescribing and downright
fraudulent practices are thrown about, citing someone whose
uncle/friend/mother (delete that which is inappropriate) suffered at the
hands of “bad” doctors who misdiagnosed the illness and the patient
Now, there are certainly some “bad”
doctors out there, just as there are “bad” lawyers, “bad” real estate
agents, “bad” mechanics and just about any profession you would like to
think of. But they’re not all “bad”.
And me? I am a conventionally
trained British/Australian style medical practitioner who has spent a
lifetime practicing EBM. Practices that have been proven to work. Call
it “good” medicine, if you like.
I am also proud of my final exams
taken in the Royal Colleges of Physicians and Surgeons in London. I have
the honor to have my name listed in the ‘great book’ with luminaries
such as Hunter, Jenner and Lister. I am also indebted to my tutors
during the 12 months of ‘pre-registration’, where you apply your
knowledge under the supervision of accredited specialists. An arduous
road, but one that is a safeguard for you, the general public.
The ‘powers that be’ are also
ensuring that we keep up to date with a process called Continuous
Medical Education (CME). That medical education continues through to
today, with CME lectures being attended by my hospital’s doctors, and
myself. Fortunately for me, the slides are in English.
Those ‘powers that be’ also try to
ensure that we prescribe drugs that are efficacious, that have been
tested, and the evidence points to this. It is not anecdotal evidence,
but true scientific evidence shown by research in many countries, with
hundreds of thousands of patients. It is following that type of evidence
that I can recommend with all good faith that 100 mg of aspirin a day is
“good” medicine. I also know that if you are prescribed a ‘statin’ drug
it will lower your cholesterol levels. They have been tested.
I am also the first to admit that
we have sometimes managed to get it wrong. The Thalidomide story still
has living examples of this. However, the medical world-wide network is
cohesive enough to ensure that this drug was withdrawn. It is the checks
and balances system that has kept conventional medicine afloat.
I am often asked my opinion on
“alternative” medicine, and I try to avoid direct confrontation over
this. If devotees have found that they can diagnose tumors by looking at
patient’s auras through their third eye in the middle of their
foreheads, then I am genuinely pleased, in fact delighted, provided that
they have subjected the method to scientific scrutiny.
If various groups can actually cure
cancer, epilepsy, halitosis or lock-jaw by inserting dandelions into a
fundamental orifice, then again I am delighted. This is a medical
break-through, but as such, must be subjected to medical scrutiny. If
the method stands true scientific examination (not to be confused with
anecdotal ‘evidence’) then it will be adopted by everyone, complete with
thanks to those clever people who picked the dandelions in the first
place. Ignore the claims that “Big Pharma” is suppressing cancer
treatments. If someone has the answer, they will be multi-millionaires
As far as the majority of ‘folk’
remedies is concerned, I work on the principle that if you ‘think’ it is
doing you good, then it probably is. But don’t ask me to endorse
something that has not been scientifically tested.
When the ‘alternative’ group spends
more time proving their methods, instead of complaining about
non-acceptance, EBM practitioners will give them more credence.
Falling off the bed
Ever turned over in bed and the room
began to spin? And you were sober? It could have been Benign Paroxysmal
Positional Vertigo (BPPV).
This is a very distressing condition,
and much more common than you imagine. If you have it, after you move in a
particular way, you feel that the room spins around you and you cannot stop
it. It is like being so drunk that when you lie down on the bed the spinning
rotation is so bad you grip the edges of the bed to stop falling off? That
is what BPPV is like – but without the hangover the next morning!
The symptoms of BPPV include the
dizziness (vertigo), lightheadedness, imbalance, and nausea. Activities that
bring on symptoms will vary, but are almost always produced by a rapid
change of position of the head. Getting out of bed or turning over in bed
are common ‘problem’ motions. Because people with BPPV often feel dizzy and
unsteady when they tip their heads back to look up, BPPV is sometimes called
‘top shelf vertigo.’ Women with BPPV may find that having a shampoo can
bring on the symptoms. It also tends to be recurrent. So until you read
further, don’t look up or get your hair washed!
To understand BPPV, you have to
understand the workings of your inner ear. You have three semi-circular
canals aligned in different directions, which act like spirit levels (the
builders type, not the three fingers on the glass barman type) which have
cells with fine hairs bathed with fluid as your head moves in different
directions. The movement of the fine hairs sends electrical impulses to the
brain to tell it (and you) which way is “up”.
However, with BPPV, the natural
movement inside the semi-circular canals is disrupted, so the fine hairs
send the wrong signals to the brain, and being unable to work out which way
is really “up” the sufferer falls over, totally unable to save themselves
from hitting the floor. Debilitating and embarrassing! Ask anyone who has
The commonest cause of interruption to
the normal ebb and flow in the semi-circular canals is produced by something
we have called “ear rocks”. These are made up of crystals of calcium
carbonate, and we medicos call these ear rocks “otoconia”. Imagine these
rocks to be like sugar crystals in the bottom of your coffee cup. These now
swish around every time you move your cup, and likewise your “ear rocks”
swish around every time you move your head.
However, it is not all that simple (it
never is, is it?) as the commonest cause of BPPV in people under 50 is head
injury. In older people, the most common cause is degeneration in the
semi-circular canals of the inner ear. BPPV becomes much more common with
advancing age, but in 50 percent of all cases, BPPV is called ‘idiopathic’,
which is a fancy word we use when we don’t know!
Viruses can be accused too, such as
those causing vestibular neuritis, minor strokes such as those involving
anterior inferior cerebellar artery (AICA) syndrome, and Meniere’s disease
are significant but unusual causes. Occasionally BPPV follows surgery, where
the cause is felt to be from a prolonged period of lying on the back with
the chin raised (for the anaesthetic tubes to slip down your throat), or ear
trauma when the surgery is to the inner ear. The simple situation is that we
can make the diagnosis, but it can be harder for us to exactly pinpoint the
cause. To make it even harder, an intermittent pattern is common. Your BPPV
may be present for a few weeks, then stop, but then come back again.
Is there any treatment? Yes there is,
if ear rocks are the cause. Treatment usually consists of a series of
maneuvers you are put through which are designed to move the ‘ear rocks’
around till they no longer cause problems. These are demonstrated by the
Ear, Nose and Throat (ENT) specialists and usually result in around a 90
percent cure rate. The most common is called the Epley maneuver or the
particle repositioning or canalith repositioning procedure, but have your
ENT specialist show you how to do this.
The will you make in the
living not in the after-life?
I’m sorry, but I
have it on good authority that you can’t take it with you. And that’s
the reason why I’m not going. But to cover all eventualities, I have
made out a will. And so should you. That’s your dying will – but you
need to make another, and that’s called your “Living Will”.
However, there is confusion in the
minds of many people, as to what a “Living Will” actually is and what it
covers. First off, it is not euthanasia. I repeat, it is not euthanasia.
Borrowing from the Mayo Clinic in the US, it states on their website
“This written, legal document spells out the types of medical treatments
and life-sustaining measures you do and don’t want, such as mechanical
breathing (respiration and ventilation), tube feeding or resuscitation.”
The important words to note are “life sustaining” and “resuscitation”.
Neither of these concepts imply medically assisted suicide.
Once again from the Mayo Clinic,
“Injury, illness and death aren’t easy subjects to talk about, but by
planning ahead you can ensure that you receive the type of medical care
you want, to take the burden off your family of trying to guess at what
you’d want done.”
Remember that we are talking about
terminal situations here. Not situations from which it would be
reasonably expected that you will recover and still have a good quality
of life. A fractured hip when you are 90 is a serious situation, but
provided you are healthy otherwise, then it would be expected that you
would recover. You might need a stick for a while, but you would still
be able to have a beer with your mates or whatever your pursuits were
before the incident. In other words, the expectancy of a reasonable
quality of life is there.
However, if you are in the terminal
phase of metastatic cancer, which has progressed despite treatment, the
future quality of life is not there. Artificially prolonging life under
that situation is then covered by the Living Will.
As an example, note the following:
The Living Will is made while of
sound mind. It is not something you scribble out while lying in God’s
waiting room. An example of a Living Will. “Being of sound mind and
understanding all the implications, I ask that this document be brought
to the attention of any medical facility in whose care I happen to be,
and to any person who may become responsible for my affairs.
“This is my ‘Living Will’ stating
my wishes in that my life should not be artificially prolonged, if this
sacrifices my Quality of Life.
“If, for any reason, I am diagnosed
as being in a terminal condition, I wish that my treatment be designed
to keep me comfortable and to relieve pain, and allow me to die as
naturally as possible, with as much dignity as can be maintained under
“As well as the situation in which
I have been diagnosed as being in a terminal condition, these
instructions will apply to situations of permanently unconscious states
and irreversible brain damage.
“In the case of a life-threatening
condition, in which I am unconscious or otherwise unable to express my
wishes, I hereby advise that I do not want to be kept alive on a life
support system, and I do not want resuscitation, nor do I authorize, or
give my consent to procedures being carried out which would compromise
any Quality of Life that I might expect in the future.
“I ask that you are sensitive to
and respectful of my wishes; and use the most appropriate measures that
are consistent with my choices and encompass alleviation of pain and
other physical symptoms; without attempting to prolong life.”
Now those are only examples. The
Bangkok Hospital Pattaya has a pro forma Living Will, which was also
repeated in the Pattaya City Expats website, I believe.
The take home message is that a
Living Will is not euthanasia, and that you must lodge it, before you
need it! The responsibility is yours, as nobody else can say any
procedure was what you wanted (or didn’t want), if in the terminal stage
of your life.
Lies, damned lies and then there is statistics
Will you live forever?
I’m sorry to disappoint you, but statistically you have a 100 percent chance
of dying. Yes, forget about “health” medications, statistics will prove it.
Did you know, for example, that everyone dies within six months of their
birthdays? They do, either before or after (do the math). Did you know that
95 percent of all the people who died in Pattaya last year wore shoes? The
statistics would then have you believe that shoes were the greatest killer
of mankind (not sure where that puts flip-flops).
A couple of years ago, the Cancer
Council of Australia produced a sober warning message (at this time of year
anyway), “Quit drinking to cut cancer risk.” The Cancer Council went on
further to proclaim, “New evidence reveals the extent of alcohol’s
contribution to cancer.”
Now, having been photographed with the
odd glass of wine in my hand on more than one occasion, I was immediately
interested. Should I go on the wagon tomorrow? (“Today” was being a bit
soon, I thought.)
I continued reading, “Cancer Council
Australia has revised dramatically upwards its estimate of alcohol’s
contribution to new cancer cases and issued its strongest warning yet that
people worried by any link should avoid drinking altogether.”
It appeared that the cancers involved
were bowel and breast and the figures indicated that these were nearly
two-thirds of all alcohol-related cancers, overtaking those of the mouth,
throat and esophagus.
More chilling news was that the
Convener of the Public Health Association of Australia’s alcohol expert
group, said he would write to the Australia and New Zealand Food Regulation
Ministerial Council, to request it mandate health warnings on bottles. (It
may be of interest to you that in Thailand there is an anti-alcohol group as
well as the anti-smoking lobby).
Now there are many individuals
predicting the end of the world, as well as Scandinavian teenagers, so how
great a threat was this really? The group media release went on, “New
evidence implicating alcohol in the development of bowel and breast cancer
meant drinking probably caused about 5.6 percent of cancers in Australia.
This was nearly double the 3.1 percent figure it nominated in its last
assessment, in 2008.”
Using their own figures we are looking
at 94.4 percent were not caused by alcohol.
So now we are getting to the
nitty-gritty of all this. If we accept that they have managed to “prove”
(beyond reasonable doubt) that alcohol does indeed “cause” 5.6 percent of
cancers, what does this mean? Since breast and bowel cancers are only two
thirds of the alcohol-related cancers (their mathematics, not mine), this
means that together they make up 3.7 percent of the cancers in Australia.
Let’s split the figure and make it 1.85 percent each. I remain somewhat
underwhelmed, I am afraid. These figures can be read to suggest that 98.15
percent of breast cancers are not related to alcohol ingestion, and
similarly the figures for bowel cancer.
Now don’t get me wrong here. I am not
advocating we all get smashed every night, and indeed I do not think we
should drink alcohol every day. However there are greater risks from alcohol
intake than breast or bowel cancer. Liver damage for starters.
So if you are a person who likes a
drink or three and would like to check your liver function we do have a GI
and Liver Center that would be happy to check for you. Telephone 1719 for an