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Doctor's Consultation  by Dr. Iain Corness


The fun that comes with getting older

I celebrated another birthday last week. “Celebrated” is probably the wrong word at my age. “Cried” would probably have been more appropriate as one watches the years tick by and you are left wondering just how many more are left. Despite everything, you cannot live forever. Probably a good thing as a world populated by centenarians would be a trifle daunting and overcrowded too.

As part of the “celebrations” I looked at the statistics in the hospital as far as in-patients were concerned. Well over 50 percent of those lying in a bed were over 60 years of age. Would I be next? The down side of getting older, perhaps? And many of them had brought the problem on themselves, unfortunately. Unchecked hypertension leading to a stroke is regrettable. Unchecked blood sugar leading to the amputation of a limb double ditto. Lung cancer after a lifetime of smoking triple ditto. With some preventive maintenance in the form of regular check-ups many of these in-patients could have avoided hospitalization.

However, as we get older we have to learn to accept some restrictions in our daily living, as well as some unwelcome additions. I have found that after sitting at my desk for a while and then getting up, the first few movements are more staggers than steps until the knees start working again. I remember what a fast runner I was, indeed a schoolboy champion, but these days I want to ignore that I get breathless after 50 meters and the legs give out, and the pace is certainly not that of a 16 year old athlete.

I have found that I can easily use the stairs to ascend one floor, but two floors produces painful upper thighs. Physical restrictions such as these destroy my self-delusions that I could easily out-run my children over 100 meters. It isn’t really fair, is it?

I mentioned additions that aging brings to the lifestyle. One is having to get up at least once a night to have a pee. Twice if I have been silly enough to have several drinks before bed. Another is the reading glasses that I need to read the newspaper, or even the computer monitor. I have to buy shirts with a pocket, just for carrying spectacles as I am too vain to wear them on a string around my neck. I don’t really want to advertise the fact that I am over the age of 40 (and a couple of decades on top of that as well). It is also necessary to have several pairs, spares in every office and another for home and another in the car, as like the American Express advertisement says, “Don’t leave home without them.”

Many years ago, when I was trying to deny I really needed glasses, I took a young lady to dinner at an Italian restaurant. Finding that the dimmed lighting made reading the menu impossible, I gambled on a minestrone soup and a scallopini al limone. The waiter looked impressed and carefully recorded my choices, only to return a couple of minutes later saying, “The chef would like to know where you saw the minestrone, because it isn’t on our menu.” My deception was uncovered. My age revealed and my chagrin made public.

I was out in a car the other night, driven by a friend of similar age to myself. Before crossing Sukhumvit Road he wound down the tinted glass driver’s side window. “I find I am having trouble judging distance and speed of oncoming traffic at night, but it’s better with the window down.” I commiserated with him as I do exactly the same, signs of early cataract formation in us both. Getting older isn’t all beer and skittles.

However, getting older still beats the alternative! So what can you do to remain “young”, well as young as possible? Try to avoid the excesses of life and living. It is indeed the middle way is the best way. Try to avoid getting overweight, and check your weight on the same set of scales each week. If you are getting heavier, restrict the intake for a few days.

No secret formula - just the middle way.

Work is the curse of the drinking classes

It was way back in the 1700’s that a Dr Bernardino Ramazzini (1633 - 1714), an Italian physician published a book on occupational diseases, “De Morbis Artificum Diatriba (Diseases of Workers)”. That makes him, in my eyes, the father of modern Occupational Medicine.

However, Occupational Medicine is still one of the lesser known medical specialties. This is the study of worker health, how the workplace affects health, the man-machine interface, industrial exposure to contaminants and many other occupational hazards. One example of occupationally induced conditions is known as ‘Vibration White Fingers’ and comes under the general umbrella of an interesting set of conditions known as Raynaud’s phenomenon.

Since doctors like to have conditions named after them, Raynaud’s phenomenon comes from Dr. Maurice Raynaud, a French physician who published a report in 1862 of a young woman whose fingertips changed colors when she was cold or under stress. He is credited with the discovery of the condition.

Raynaud's phenomenon, sometimes called Raynaud's syndrome or disease, is a disorder of blood circulation in the fingers. This condition is usually produced by exposure to cold which reduces blood circulation causing the fingers to become pale, waxy-white or purple. This condition is sometimes called “white finger,” “wax finger” or “dead finger”. These attacks occur when the hands or the whole body get cold either at work or at home.

Household or leisure activities resulting in cold exposure can include washing a car, holding a cold steering wheel, or the cold handlebars of a bicycle. Attacks of white finger can also occur when a person is outdoors watching sports, or while gardening, fishing or golfing in cold weather.

Typical attacks occur with tingling and slight loss of feeling or numbness in the fingers, blanching or whitening of the fingers, usually without affecting the thumb, and pain, sometimes with redness, which accompanies the return of blood circulation generally after 30 minutes to two hours.

Many cases of Raynaud’s phenomenon are such that we cannot identify the cause. To escape the embarrassment of admitting that we just don’t know, we call this “primary Raynaud’s phenomenon” or even “constitutional” white finger. However, when we do know the occupational cause of Raynaud’s phenomenon we call it “secondary Raynaud’s phenomenon!”

In the occupational sphere, there are many causes of this secondary condition. It is most commonly associated with hand-arm vibration syndrome but it is also involved in other occupational diseases. Awareness of the condition can help prevent the disorder from occurring or progressing, as if not detected in the early stages, the disorder can permanently impair blood circulation in the fingers.

Although Raynaud’s phenomenon is not life threatening, severe cases cause disability and may force workers to leave their jobs and workman’s compensation issues may end up in courts of law. Although rare, severe cases can lead to breakdown of the skin and gangrene. Less severely affected workers sometimes have to change their social activities and work habits to avoid attacks of white finger.

The underlying cause relates to the physiology of maintaining an even body temperature. Usually, the body conserves heat by reducing blood circulation to the extremities, particularly the hands and feet. This response uses a complex system of nerves and muscles to control blood flow through the smallest blood vessels in the skin. In people with Raynaud’s phenomenon, this control system becomes too sensitive to cold and greatly reduces blood flow in the fingers.

Exposure to vibration from power tools is by far the greatest concern in secondary Raynaud’s. Hand-held power tools such as chain saws, jackhammers and pneumatic rock drillers and chippers can cause "hand-arm vibration syndrome." This disorder is the “vibration white finger,” “hand-arm vibration syndrome (HAVS),” or “secondary Raynaud’s phenomenon of occupational origin.” However, Ramazzini did state in his book that repetitive violent movements can produce this condition many years before.

In early years, before the cancer-causing effects of vinyl chloride monomer were known, workers exposed to high levels of this chemical also experienced Raynaud’s phenomenon. So that is the story of Raynaud’s phenomenon. Fortunately, in our warm tropical climate it is rarely seen, other than the occupational secondary variety.

More (ton) on BSE

Some time ago I used this column to suggest to women that they should do Breast Self Examination (BSE). This produced a response from Dr Michael Moreton, the former International Medical Coordinator at the Bangkok Hospital Medical Center in Bangkok. I took the liberty (with his permission) to reprint his letter and it is still relevant today.

He wrote, “I was a specialist in Women’s Health care for many years and the techniques used to screen for Breast Cancer are of special interest to me. I agree wholeheartedly that Breast Self Examination (BSE) is a useful method of monitoring the breasts. Every woman’s breasts are different in texture and the patient becomes an expert in her own breasts and can recognize changes that a doctor might miss. I suggest to patients that a good time is in the shower or while waiting for the water temperature to stabilize before getting into the shower.

“It is important to know the correct technique. You should press the breast tissue between the chest wall and the flat pads of your fingers, do not use the tips of the fingers. When you have your next physical exam ask your doctor to demonstrate how do this. Every doctor has had the experience of a woman coming to see them and telling them that they have a breast lump and it is only with the woman’s instructions that the doctor can feel the lump. It’s a good technique; we both recommend that you do this self-examination regularly.

“The debate about Mammography swings one way and another. The modern machines now use a digital technique. This has several advantages. With the older machines there was a worry that repeated mammograms might even cause cancer due to radiation. There is no chance of that now. With the computer we can also zoom in to worrying areas and get more information. Digital also has the advantage that the pictures can be sent electronically for a second opinion or put on a disk so that you can keep the pictures and show a doctor in another country if that is your wish.

“Ultrasound can also be useful in certain situations. In order to perform mammography, the breast has to be compressed between two plates and X-rayed, in women with small breasts this can be difficult and U/S may be a better method for these women. Similarly, women with breast implants may be additionally assessed with this method. If I am particularly interested in one area of the breast I will ask the technician to look carefully at the area. The U/S can be angled in from different directions and this can be useful in examining a worrisome area of the breast. Most modern U/S machines also have a Doppler ability and they can identify areas of the breast with a particularly rich blood supply, which can be a sign of trouble.

“Another technique that has been discussed for several years and that you may read about is Thermography. In this method the patient is placed in a cool room and photographs are taken with a temperature sensitive camera. Hot spots on the breast can be identified. The problem is that not all hot spots are caused by cancers; I am not too enthusiastic about this method.

“The most exciting thing on the horizon is the use of genetic studies in assessing the chances of cancer in any one patient. We know that there are two genes BRCA1 and BRCA2 which can be inherited and will increase the chances of cancer developing. When this blood test is perfected any woman will be able to have a blood test to see if she has a high risk or a low risk of getting breast cancer. Then different screening programs can be arranged.

“A few dietary steps can be taken which may help to reduce the chances of cancer. A diet full of fat is thought to be dangerous; one more reason to avoid them. One positive step that mothers should take is to breast feed their babies as it is found that this activity is protective.”

(Thank you Dr. Moreton for reinforcing the message on BSE. From here, it is up to you, ladies!)

Check-ups at a bargain price

Many people work on the principle that they would rather not know about any underlying or sinister medical conditions they may have. After all, we are all going to die one day, aren’t we? I have always said that despite all advances in medical science, the death rate will always be the same - one per person!

However, check-ups are inherently involved in that important feature called the Quality of Life. Longevity alone, with no quality, just isn’t worth it in my book. Or yours, most likely, otherwise you would not be reading this column.

The guiding principle behind check-ups is to find deviations from normal health patterns at an early stage. Early enough that the trend can be reversed, before damage has occurred. Examples of this include Blood Pressure (BP), a significant factor in poor health in the future if unchecked now. High BP can affect many organs in the body, not just the heart. But an elevated BP generally gives no warning symptoms.

Another example is blood sugar. Again, it requires sky-high sugar levels before the person begins to feel that something might be wrong. And by then the sugar levels have affected vision, the vascular system and many other systems, all of which can decrease your quality of life in the future. Amputation of a limb is a common result of unchecked blood sugar levels. A situation that nobody would wish for themselves, I am sure.

Respiratory conditions also rate high on the list of medical events that can decrease your quality of life. Yet the majority of these can be found early, and treated successfully.

Cardiac conditions and abnormalities, be that in anatomy or function, can also very adversely affect your quality of life, but are very easily found during a routine check-up. Various blood tests and an EKG can show just how well the cardiac pump is functioning, and how well it will continue to function in the future. The inability to walk more than 50 meters certainly takes the fun out of shopping, yet this can be predicted - if you have some serial records!

Another of the silent killers can be discovered in your lipid profile, with Cholesterol and its fractions HDL and LDL, being intimately connected with your cardiac status. Again, a situation where detecting abnormalities now can mean that you can get through the deadly 50-60 year age bracket in the future with clear coronary arteries and a clean bill of health.

There are actually so many of the conditions that can affect your enjoyment of the future that can be discovered early. Renal (kidney) function and liver function can be monitored through an annual check-up, as can prostate size (indicated by the PSA blood test) or breast tumors (by mammogram).

So, hopefully I have influenced you enough to begin to think about an annual check-up. If you are under 40 years of age, and think you are in good health (non-smoker and moderate drinker) then every two years will be fine. If you are older than 40, then make it an annual event. It is good ‘insurance’ for the future.

And what degree of check-up should you go for? If you are in tip-top health and previous check-ups have been normal, then go for the simple screen - however, if you are a smoker, or have some previous results outside of normal, move up a notch to the more comprehensive tests. I would also suggest that if you are over 50, look for the more detailed check-ups.

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 and money?

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 brain.

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 too.

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 head downhill.

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 instead.

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

1kg carrots

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 fruit today.

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 muscle).

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 very important.

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 Electrocardiogram

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 population.

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 medical lifetime.

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 lymphatic cancer.

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 occasional tail.

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 once.

Is 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 the treatment?

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.)

So 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 80.

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 GP.

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 waved back.

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 and Jesus.

(Note: I know the editor, and he agrees.)

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 today.

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 local urologist.

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 more significant.

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 nearby tissues.

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 “complementary”.

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 died.

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 overnight.

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 had BPPV.

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 the circumstances.

“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 appointment.

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