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Vol. X No.18 - December 1 - December 31, 2011


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Doctor's Consultation  by Dr. Iain Corness

 

Genghis Khan and your children

Some medical facts: 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.  In fact, 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 also 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!


Stenting - a common procedure

The advances in cardiac surgery have been enormous over the past 20 years.  We have gone from some fairly primitive high-risk surgery, to some very, very sophisticated interventional techniques, which have given cardiac patients a new lease of life.  In fact, if the techniques that are available now, were able to be carried out 30 years ago, my father would in all probability, still be alive today.

However, before getting into modern life-saving techniques, a short review of cardiac pathology is in order.  Myocardial infarction is the common cause of cardiac muscle death, and finally ours.  (Make that “yours” as I’m not going yet!)

The heart muscle is supplied with oxygenated blood by its own system of arteries.  The heart does not get its oxygen from the blood in its chambers.  Instead, there is a network of ‘heart’ arteries (called the coronary arteries) which supply the cardiac muscle.  If any of these get blocked, this is known as a “stenosis” or an “occlusion”, which in turn can bring on the coronary “conclusion”!  The death of the muscle is called “infarction”.

The blockage is most often caused by Cholesterol, which gets deposited on the inside wall of the arteries and is called “plaque”, and then red cells stick on the surface of the deposit and it builds up from there.  If you have a 50 percent stenosis, you will start to get chest pains on exercise.  If you have a 100 percent stenosis, you may drop dead during the exercise.

To correct this problem, the only way we knew was to carry out an open heart operation, replace the blocked coronary arteries with vessels taken from other parts of the body, usually veins from the leg.  However, now we can leave your arteries where they are, but do something to relieve the stenosis, or blockage.  This is called “Angioplasty”.

One way is to send an inflatable balloon to dilate the blocked area, and this is known as coronary balloon angioplasty.  It is more formally known as percutaneous transluminal coronary angioplasty (PTCA): percutaneous meaning "through the skin," transluminal meaning "inside the blood vessel," coronary meaning "related to the heart," and angioplasty meaning "blood vessel repair."

Angioplasty involves creating space in the blocked artery by inserting and inflating a tiny balloon, which compresses some of the blocking plaque against the arterial wall.  When the balloon is deflated and removed, the plaque still remains compressed, clearing a space in the artery and improving blood flow.  While angioplasty does not always completely clear an artery, more than 90 percent of all procedures are immediately successful.

There are other techniques available, and the most common is by using “stents”.  This is called percutanous coronary intervention (PCI).  The success in today’s cardiac surgery is due in part to the increased use of these tiny wire mesh tubes called stents, which cardiologists began using in the 1990s to help keep arteries open following angioplasty.  About 70 to 90 percent of all angioplasty patients receive a stent, which is inserted permanently at the site of the blockage.

Stents can be used in a number of ways with angioplasty procedures.  A stent may be inserted during an original angioplasty to prevent possible arterial collapse and lower the chance of heart attack and re-narrowing of the artery (called re-stenosis).  A stent also may be inserted during a second angioplasty to prevent recurrent restenosis.  Stents can also be used in the unlikely event that an artery is injured by the catheter.  Experienced doctors are able to install stents in one or more arteries with a high probability of success.

The use of stents has decreased the abrupt and unpredictable closure of an artery, which necessitated emergency coronary artery bypass surgery.  Studies show stents are better than angioplasty alone in preventing re-stenosis, which is one of the most common problems associated with angioplasty.

Evidence suggests that angioplasty patients are doing better today because doctors are better able to target blockages, by using such techniques as the 64 Slice CT, so your interventionist is able to pinpoint the blockage with greater accuracy.  However, we will deal with the 64 Slice CT technology another week.


Statins are good for you

When I was in General Practice in Australia, the cholesterol-lowering drug Simvastatin became available.  After telling patients to cut down on animal fats to lower their cholesterol, there was now a drug that could help.

I was never one to be the first to prescribe new ‘wonder’ drugs, but with the cardiologists sending patients back on this drug regimen, I too began to prescribe it.  Simvastatin became one of the drugs I enjoyed prescribing most - it actually did work!  Not that other prescribed medications did not work, but Simvastatin produced an amazing lowering of the body’s burden of cholesterol very quickly.  And every time.

However, the long term results of any drug use are sometimes difficult to demonstrate at first.  After many years, does your blood pressure go through the roof?  Or do your dangly bits fall off?  In some instances it could be a case of ‘wait and see’.  However, as far as is possible, the results of longer term usage are looked at through many ways, including animal testing.  The poor old laboratory mouse is flat out keeping numbers up to scratch!

There is just so much information to collect - there are epidemiological results found from over hundreds of thousands of cases and critically reviewing the results at the end.  This is one of the ways that differentiates between the pharmaceutical industry and the “alternative” industry.

Now, a startling fact has emerged from one of the longer term examinations of statin usage.  It appears that statins safely reduce the risk of cardiovascular illness even years after treatment is stopped, according to a probe into the popular cholesterol-lowering group of drugs published in November.

A look at the background is justified here.  Statins work by blocking a liver enzyme that makes fatty molecules, which line arterial walls and increase the danger of heart disease and strokes.  With worldwide annual sales of more than 20 billion dollars, the drugs have been dubbed “the aspirin of the 21st century” because of their benefit and wide use.  However, lingering questions persisted about their long-term safety for the heart, liver and cancer risk.

In this latest examination, researchers at the Heart Protection Study Collaborative Group in Oxford in the UK looked at 20,536 patients at risk of cardiovascular disease who were randomly allocated 40 mg daily of simvastatins or a dummy look-alike (known as placebo’s) over more than five years.

During this period, those who took the statins saw a reduction in “bad” cholesterol (LDL) and a 23 percent reduction in episodes of vascular ill-health, compared to the placebo group.  The exhaustive study did not end there.  The monitoring of the volunteers continued for a further six years after the trial ended.  The investigators found that the benefits persisted throughout this monitoring period even among those volunteers who had stopped taking the statins.  Now that is somewhat amazing.  In addition, there was no emergence of any new health hazard among those who had taken, or were continuing to take, the drugs.

“The persistence of benefit we observed among participants originally allocated simvastatin during the subsequent six year post-trial period is remarkable,” said one of the investigators, Richard Bulbulia.

As far as cancer incidence was concerned, a number of cancers (nearly 3500) developed amongst the 20,536 volunteers during this follow-up period (roughly one in six), but there was no difference in cancer incidence between the statin and placebo groups.

Richard Bulbulia continued, saying, “In addition, the reliable evidence of safety, with no excess risk of cancer or other major illnesses during over 11 years follow-up, is very reassuring for doctors who prescribe statins and the increasingly large numbers of patients who take them long-term to reduce their risk of vascular disease.  A previous investigation in November 2010 found that long-term use of statins was less risky than thought for people with non-alcoholic fatty liver disease (NAFLD), a common liver ailment.

So what does all this mean as far as cardiovascular disease is concerned?  It has been shown, beyond doubt, that LDL cholesterol is a major factor in coronary artery disease.  It has now been shown that statins do reduce LDL, do reduce your risk, and appear safe and have lasting benefits.


Heredity - your parents are to blame

As medical knowledge continues to grow, we have found that for many conditions there are familial, or hereditary, factors as to whether you are going to have the same problems. Pity those who are orphans - they never get the ‘advance warning’ that children with both sets of parents get.

Of course, we all have much to thank our parents for. Just letting us grow up for starters. However, heredity is one of the ‘clues’ to your health in the future, and what you can do to enjoy a long, lively and healthy one. This is really where ‘thanks Mum and Dad’ comes in. One problem of being an orphan is that it leaves the person with no idea as to what ailments are going to befall them. Dad might have legged it or ‘fled the scene’, but did he live to tell the tale when he was 60?

With the increasing research into genetics, we are able to map out our likely futures and can predict such ailments as diabetes, epilepsy and other neurological problems like Huntington’s Chorea and Alzheimer’s Disease, some cancers such as breast, ovarian, lower bowel, prostate, skin and testicular, heart attacks, blood pressure problems, certain blood diseases like Sickle Cell anemia and so the list goes on.

However, you do not need to have multi-million baht examinations done on your DNA to see where you are headed, all you need to do is to start asking the older family members about your inheritance. Not the money - your genetic inheritance in the health stakes.

Have you ever wondered why the questionnaire for life insurance asks whether any close member of your family has ever suffered from diabetes, epilepsy and other ailments and then also asks you to write down how old your parents or brothers and sisters were when they died, and what they died from? All that they, the insurance companies, are doing is finding out the relative likelihood (or ‘risk’) of your succumbing early to an easily identifiable disease. This does not need a postgraduate Masters degree in rocket science. It needs a cursory application of family history.

If either of your parents had diabetes, your elder brother has diabetes, your younger brother has diabetes and your cousin has diabetes, what are the odds on your getting (or already having) diabetes? Again this does not need Einstein. The answer is pretty damn high! And yet, I see families like this, where the individual members are totally surprised and amazed when they fall ill, go to hospital, and diabetes is diagnosed.

It does not really take very much time over a family lunch to begin to enquire about one’s forebears. After five minutes it will be obvious if there is some kind of common medical thread running through your family. That thread may not necessarily be life threatening, but could be something like arthritis for example.

Look at it this way - your future is being displayed by your family’s past. This could be considered frightening, when your father, his brother and your grandfather all died very early from heart attacks. Or, this could be considered as life saving, if it pushes you towards looking at you own cardiac health and overcoming an apparently disastrous medical history.

This is where careful application of family history can be life saving. If there is a common thread, then go looking for it. This is the advantage that you get provided you are not an orphan. You know what to look for before it becomes a problem. Going back to the family with diabetes, what should the younger members do? Well, if it were me, I would be having my blood sugar checked at least once a year from the age of 20. Any time I had reason to visit the doctor in between, I would also ask to have the level checked. We are talking about a very inexpensive test that could literally save you millions of baht in the future, as well as giving you a better quality of life, and a longer one.

Ask around the dinner table today and plan to check your medical future tomorrow. It’s called a ‘Check-up’!


Despite your check-up, are you going to die?

There are many trusting souls that believe that because this year’s check-up showed no earth-shattering abnormalities, they are then fine for the next 12 months until the next check-up.  Almost like getting a warranty on yourself.  Ah, if only it were that simple.

Are you going to die?  Undoubtedly yes (but hopefully not in the immediate future, so let’s enjoy Xmas).  However, despite all the advances in medical science, the death rate will always be the same - one per person!  Being born is, after all, the very first step in the dying process.  One of the world’s great truisms - you are born, so that you can die.  It’s the old death and taxes routine.  You can’t escape the grim reaper or the Inland Revenue man.

Now, I fully realize that there are those of different faiths who are happy in their belief that there is an after-life, or reincarnation, or some other way by which they can do it all again, and I am not at cross purposes with that.  I am merely talking about the ‘here and now’ - the next life can look after itself, in my book, but I don’t want an early morning wake-up call either!

I want you to ponder on the following: in our respective lives, there will be those of us who seem to fly though it all, the veritable ‘butterflies’ who flit from flower to flower, savoring, tasting and, need I say it, enjoying.  Eventually, they run out of puff and quietly fold up their wings and pass on.  On the other hand there are those of us who stumble like buffalos from one disaster to the next, one illness to another and eventually succumb - a victim of some tragedy.  Almost as if it were written in the stars (but it isn’t).

Does the first group have a charmed life and the second are only living on borrowed time, or was it really written in the stars?  Being personally of the ilk that does not believe in prophecy, until one of the seers or fortune tellers round the place predicts the winning lottery numbers for himself, I shall disregard the ‘prophecy’ concept.  Those people who do believe in the itinerant gypsies with crystal balls, should stop for a moment and enquire as to whether the prophecies have made the fortune teller the fortune that should be well within their grasp.  I can tell you the answer already!

However, let us look at the butterflies and the buffalos.  As far as ‘borrowed time’ is concerned, both are in the same situation.  Our lives are fleeting visits to planet earth, and that’s all.  Like going on holidays, you try to make the most of your two weeks on the Costa Plenty, so also you should make the most of your next six months in Thailand.

“Six months!”  I hear you shout.  “Is that all I’ve got?”  In a way, yes.

You see, it is difficult to look ahead much further than that in the medical sense.  So much can happen.  Six months is enough time for a fulminating infection to carry you off, or to develop an aggressive cancer that will do the same.

So if we are looking at six months worth of future, how can we make it such that it is not this coming six months, but six months way in the future?

The answer is still a simple medical check-up.  This will predict your future life for you, much better than the Indian fortune teller with a turban and a well thumbed set of Tarot cards.  Advance notice of when the Bank of Life is going to foreclose comes from your medical records, not the soothsayers.

But what is the difference between the butterflies and the buffaloes?  Nothing really.  Both are on “borrowed” time.  It is merely different attitudes to life and living.  You can complain about only having a handful of rice, or be thankful that you’ve got something to eat, many do not.  The butterflies have it right.  They remain carefree and enjoy life, no-matter how short, while the buffalo carries the world on its shoulders to its grave.  The choice is yours.


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