A common cancer

THE liver is the second largest organ in the body, and performs a variety of functions that are vital to life. These include the filtering and processing of blood; bile production; producing proteins, glucose and cholesterol; storing fat-soluble vitamins, glycogen and iron; metabolising drugs, glucose and haemoglobin; and even a role in immunity.

That’s an impressive resume, and it’s safe to say that when something adverse happens to the liver, life as we know it will never be the same.

Unfortunately, many things can go wrong in the liver, and probably the worst of the lot would be cancer.

In fact, liver cancer is the sixth most common cancer worldwide. Worse, it’s the third most common cause of cancer-related death. This is probably due to the fact that there are typically no symptoms of the disease until the cancer is in its later stages.

Dr Mellor ... Those living with hepatitis C, hepatitis B viral infection, as well as those with alcohol-related cirrhosis, are at most risk of developing chronic, cirrhotic liver disease. Hence, they are ultimately at higher risk for hepatocellular carcinoma (liver cancer).

Hepatocellular carcinoma (HCC) is the most common form of liver cancer, and is responsible for about 90% of the primary malignant liver cancers seen in adults.

The current five-year survival rate for patients with liver cancer are as follows: Europe, 8.6%; United States, less than 10%; and Asia, less than 10%, for inoperable tumours. These are very depressing figures indeed.

According to consultant oncologist Dr Matin Mellor, approximately 75 to 80% of all HCC occurs in Asia. “In some parts of Asia and Africa, HCC is the leading cause of cancer mortality.”

Risk factors

It has been noted that liver cancer disproportionately affects men, with about three times as many men developing the disease as women.

Although the overall cancer incidence and mortality are decreasing in the United States, both the incidence and mortality of liver cancer are increasing worldwide.

There are a few major risk factors for the development of the disease, but the most significant one is chronic, cirrhotic liver disease. Cirrhosis is the widespread disruption of normal liver structure by fibrosis and the formation of regenerative nodules that is caused by various chronic progressive conditions affecting the liver, such as alcohol abuse.

“Those living with hepatitis C (HCV), hepatitis B viral infection (HBV), as well as those with alcohol-related cirrhosis, are at most risk of developing chronic, cirrhotic liver disease. Hence, they are ultimately at higher risk for HCC.

“Worldwide, 75 to 80% of HCC cases are related to chronic HBV or HCV infection,” noted Dr Mellor.

Other risk factors include:

·Obesity – non-alcoholic fatty liver disease (NAFLD) and non-alcoholic steatohepatitis (NASH).

·Diabetes

·Long-term exposure to aflatoxins (naturally occurring toxins produced by many species of fungus that can be found in tree nuts, peanuts and other oilseeds).

·Tobacco use

·Long-term use of anabolic steroids.

·In some parts of the world, water contaminated with arsenic.

Symptoms and complications

It is often said that the symptoms of liver cancer only appear late into the disease. The signs and symptoms may include the following:

·Unexplainable weight loss

·Ongoing lack of appetite

·Feeling very full after a small meal

·A hard lump on the right side just below the rib cage

·Pain around the right shoulder blade

·Yellow-green colour to the skin and eyes (jaundice)

·Discomfort in the upper abdomen on the right side

·Unusual tiredness

·Nausea

Many of these symptoms can also be an indication of liver cirrhosis.

Liver cirrhosis leads to many complications. There can be fluid accumulation in the abdomen (ascites), risk of infection to the lining of the abdomen (bacterial peritonitis), enlarged spleen, distended and/or swollen veins, brain dysfunction (hepatic encephalopathy), malnutrition, and of course, HCC.

According to Dr Mellor, HCC usually presents in patients aged 40 to 50 years old, and about 40% of these patients do not show any symptoms during diagnosis.

“Diagnostic tests for HCC include a full history and examination, liver function tests, ultrasound and other forms of radiology such as CT or MRI scan, and tumour markers (in the case of HCC, it’s alpha-fetoprotein serology).

“Once a diagnosis is confirmed, the cancer is then staged. Staging is used to determine prognosis and guide treatment,” said Dr Mellor.

“Staging HCC is difficult because most patients have underlying liver disease, and key prognostic indicators are not clearly defined. In addition, there isn’t a universal satging system that is used worldwide. There are a few around, and it depends on the doctor’s personal choice as to which one is used.

“But in general, the guidelines recommend that HCC staging systems should consider the tumour stage, liver function, health status, and impact of treatment,” he added.

Prognosis and treatment

A person’s prognosis depends on both the extent of liver disease, as well as the cancer. In general, a majority of patients present with intermediate or advanced disease, which does not bode well for future prognosis.

Treatment options for liver cancer depend on the stage of the malignant disease, underlying liver function and the patient’s overall condition.

Surgery offers the best chance to cure patients with liver cancer. If the cancer is found at an early stage and the rest of the liver is healthy, surgery with or without liver transplantation may be curative. However, only about 15% of patients are operable.

“For early stage HCC, surgery (which could be partial or total removal of the liver), or other techniques such as percutaneous ablation (a needle probe is inserted into the liver tumour, usually under ultrasound, CT or MRI, and radio-frequency oscillations used to kill liver cancer cells).

“For the intermediate stage, transarterial chemoembolisation (TACE) is used,” Dr Mellor explained.

TACE exposes the tumour to high concentrations of chemotherapy and confine the agents locally as they are not carried away by the bloodstream. At the same time, this technique deprives the tumour of its needed blood supply, which can result in the damage or death of the tumour cells.

Treatment options for advanced patients are limited. There is a drug, sorafenib, which is the first approved systemic therapy for HCC, and the only one shown to significantly improve overall survival in patients with the disease.

References:

1. World Health Organization. Hepatitis B. Available at: http://www.who.int/csr/disease/hepatitis/whocdscsrlyo20022/en/. Accessed May 8, 2008.

2. Mayo Clinic. Liver Cancer. Available at: http://www.mayoclinic.com/invoke.cfm?objectid=C2850661-4805-4AD6-905AD30E9FC79DB2&dsection=5. Accessed May 8, 2008.

3. International Agency for Cancer Research. GLOBOCAN 2002. Available at: http://www-dep.iarc.fr. Accessed May 12, 2008.

4. Ferlay J, et al., GLOBOCAN 2002. Cancer Incidence, Mortality and Prevalence Worldwide. IARC CancerBase No.5, Version 2.0. IARCPress, Lyon, 2004. Available at: http://www-dep.iarc.fr. Accessed May 12, 2008.

5. Berrino et al., “Survival for eight major cancers and all cancers combined for European adults diagnosed in 1995-99: results of the EUROCARE-4 study.” The Lancet Oncology 2007: 8: 773-783.

6. American Cancer Society. What are the Key Statistics About Liver Cancer? Available at: http://www.cancer.org/docroot/CRI/content/CRI_2_4_1X_What_are_the_key_statistics_for_liver_cancer_25.asp?sitearea==. Accessed May 8, 2008.

7. Teo, T.K. and Fock, K.M. “Hepatocellular Carcinoma: An Asian Perspective.” Digestive Diseases 2001:19: 263-268.

8. National Cancer Institute. Cancer of the Liver and Intrahepatic Bile Duct. Available at: http://seer.cancer.gov/statfacts/html/livibd_print.html. Accessed Accessed May 8, 2008.

9. Ries LAG, Melbert D, Krapcho M, Mariotto A, Miller BA, Feuer EJ, Clegg L, Horner MJ, Howlader N, Eisner MP, Reichman M, Edwards BK (eds). SEER Cancer Statistics Review, 1975-2004, National Cancer Institute. Bethesda, MD, http://seer.cancer.gov/csr/1975_2004/, based on November 2006 SEER data submission, posted to the SEER web site, 2007.

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Kebaikan makan pisang

PISANG murah dan mengandungi potasium yang amat berguna dalam menentang masalah kesihatan seperti strok.

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PISANG sering menjadi pencuci mulut di negara ini. Secara amnya, kandungan potasium pisang menyebabkan ia disyorkan oleh para doktor untuk pesakit yang kekurangan sumber itu.

Sebagai contoh, sebiji pisang sepanjang 22 sentimeter (sm) mengandungi 600 miligram potasium.

Pakar perunding diet, Indra Balaratnam berkongsi maklumat berguna tentang khasiat buah pisang.

Menurut Penolong Setiausaha Persatuan Pakar Diet Malaysia itu, kajian makmal menunjukkan pisang mengandungi kanji sebanyak 20 peratus dan gula satu peratus.

“Ketika pisang berubah warna menjadi kuning dan sedia untuk dimakan, kandungan gula akan berpecah kepada 66 peratus sukrosa, 14 peratus fraktosa, dan 20 peratus glukosa.

“Pada amnya, pisang bebas daripada lemak, kandungan garamnya rendah serta kaya dengan vitamin serta potasium.

“Ini menyebabkan semua jenis pisang dikategorikan sebagai berkhasiat.

“Apatah lagi ia senang untuk dimakan dan dihadam khususnya oleh bayi berusia enam bulan dan ke atas.

Khasiat

“Tidak ada kesan sampingan pada kesihatan walaupun pisang itu manis kerana kandungan gula dalam pisang adalah semula jadi,” katanya.

Kata beliau lagi, terdapat perbezaan antara pisang yang dimakan begitu sahaja dengan kerepek pisang atau pisang goreng.

Menurut beliau, pisang yang digoreng atau dibuat kerepek mengandungi lemak.

Jadi, adalah selamat jika pengambilan pisang goreng dikurangkan kepada seminggu sekali atau sebulan sekali.

Jika digoreng, kandungan khasiat serta vitamin dan zat-zat lain dalam pisang akan berkurangan sebaliknya kandungan lemak akan bertambah.

Ujar beliau, pisang juga dianggap penting dalam bidang perubatan. Di Thailand, misalnya, wanita hamil digalakkan oleh doktor untuk makan pisang bagi memudahkan proses bersalin. Ia juga membekalkan tenaga bagi melawan dan menyembuhkan penyakit.

Beberapa kajian antarabangsa mendapati hampir 15 jenis masalah kesihatan boleh dikurangkan dengan memakan pisang.

“Antaranya, penyakit anemia iaitu kekurangan hemoglobin dalam darah boleh diatasi dengan memakan pisang kerana ia membantu meningkatkan pembentukan hemoglobin.

“Kandungan potasium tinggi dalam pisang turut menolong merendahkan tekanan darah serta mengurangkan risiko strok,” jelas beliau.

Tambah beliau, selain itu, kandungan fibernya yang tinggi dapat membantu masalah pembuangan air besar secara normal setiap hari.

Ia turut mengurangkan tekanan kerana sejenis protein dikenali sebagai Trytophan yang ada di dalamnya membantu menenangkan fikiran serta otak orang yang berada dalam tekanan.

Katanya lagi, orang yang bergelut dengan penyakit ketakutan, obesiti dan tabiat rokok, digalakkan mengamalkan pemakanan pisang dan mereka dipercayai mampu bebas daripada masalah itu secara beransur-ansur.

Kajian turut membuktikan bahawa seseorang yang berdepan masalah mabuk hamil khususnya wanita yang berasa mual dan muntah pada beberapa bulan pertama kehamilan, boleh mengambil pisang untuk mengelak masalah itu.

Di samping itu, mereka yang menghadapi masalah kegemukan akibat tekanan di tempat kerja boleh diatasi dengan memakan pisang setiap dua jam.

Ia dapat membantu menghilangkan tekanan kerja selain mengawal kandungan gula dalam darah. Bahagian dalam kulit pisang pula membantu memulihkan kegatalan akibat gigitan nyamuk.

“Apa yang penting, kita perlu memberi tumpuan pada kesihatan dengan mengamalkan tabiat makan pisang.

“Bagi anak-anak, kita sangat mudah untuk menyuruh mereka makan pisang kerana ia manis dan lembut. Ia boleh disediakan dalam bentuk kek, mufin dan roti pisang,” katanya.

Laris

Pisang boleh diperoleh sepanjang tahun. Di negara ini, pisang rastali, emas, tanduk, abu dan berangan adalah yang paling laris. Ia turut menjadi tumpuan peniaga pisang goreng dan kerepek.

Seorang peniaga buah-buahan di Pasar Keramat, Kuala Lumpur, Ramli Mat Dalip, 42, berkata, pisang sentiasa menjadi pilihan orang ramai dan ia adalah salah satu buah yang boleh didapati sepanjang tahun.

Kata beliau yang berniaga sejak 15 tahun lalu, pisang berangan dan abu sering dibeli peniaga kerepek atau kuih.

Bagaimanapun, katanya, pisang emas dan berangan memang laris dijual dan dibeli pengguna kerana rasanya manis dan boleh dimakan begitu sahaja.

“Dari segi harga, tidak banyak perbezaan kerana harga pisang mengikut jenisnya iaitu dijual sekitar RM2.80 hingga RM3 sekilogram.

“Permintaan terhadap pisang pada musim perayaan khususnya Tahun Baru Cina, Hari Wesak dan Deepavali juga memberangsangkan.

“Pengguna kerap datang meminta pisang emas dan rastali kerana saiznya kecil iaitu di antara tujuh hingga 10 sm.

“Mereka akan menggunakan pisang itu dalam upacara sembahyang selain untuk dimakan,” katanya.

Sementara itu, seorang lagi peniaga Romlah Ahmad, 31 menjelaskan, berbanding buah-buahan lain khususnya yang diimport, pisang tidak menghadapi masalah kenaikan harga.

“Pisang tidak menghadapi masalah itu. Harganya di mana sekali pun lebih kurang sama iaitu kekal sekitar RM2.80 hingga RM3.50 sekilogram.

“Lagipun pisang dikatakan paling berkhasiat dan kaya dengan zat dan vitamin. Tidak hairanlah jika orang ramai gemar memakannya,” katanya.

Dalam pada itu, seorang pensyarah sebuah kolej swasta di ibu negara, Daljit Kaur, 36, berkata, beliau dan keluarga gemarkan pisang kerana kebaikan yang diperoleh daripada buah tersebut.

Katanya, sejak kecil lagi beliau suka makan pisang dan pernah sekali beliau berdepan dengan seorang rakan yang mempunyai masalah kekurangan hemoglobin dalam darah dan mencadangkan supaya dia makan pisang untuk mengatasi masalah tersebut.

“Selepas itu, saya dapati kesihatannya bertambah baik bahkan setahun kemudian, boleh dikatakan dia bebas sepenuhnya daripada masalah itu.

“Selain itu, ketiga-tiga anak saya yang berusia di antara enam hingga 13 tahun juga gemar makan pisang setiap hari.

“Mereka nampaknya sihat dan tidak menghadapi kesukaran untuk membuang air besar lagi,

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My obsession

Obsessive compulsive disorder (OCD) is a chronic condition which is usually associated with obsessive thoughts and compulsive behaviour.

THERE are some people who cannot stop thinking about, or doing, certain things, for example, washing hands. Whether these repetitive thoughts or behaviour are normal or otherwise depends on their effects on a person’s relationships and social life.

Many normal individuals, particularly children, have occasional obsessional thoughts or repetitive behaviours, but they do not cause distress or impair daily functions. If they do, then it is no longer within the realms of normal mental functioning.

An obsession is an unwanted, unpleasant or frightening thought, image, or urge which occurs repeatedly and results in anxiety and distress. A compulsion is a repetitive, intentional behaviour or mental act that a person feels compelled to do to avoid or undo the effects of an obsession.

For a person who is obsessed about avoiding a disease, the compulsion to wash his hands frequently helps ease that obsession.

For example, a person who is obsessed about acquiring a disease may feel compelled to wash his hands on every occasion he touches any object.

Obsessive compulsive disorder (OCD) is a chronic condition which is usually associated with obsessive thoughts and compulsive behaviour. OCD is diagnosed if it causes distress, occurs for more than an hour a day, and/or interferes with activities of daily living.

OCD is a common mental health condition. It usually occurs in young adults, but can occur in older people. However, it can occur at any age, including childhood. Males usually develop symptoms earlier than females.

Many cases of OCD are undiagnosed because the sufferers do not know that it is a treatable condition. Some of those who realise that OCD is an illness may be reluctant to seek help or cannot accept that they have a mental condition.

Causes

The causes of OCD are unknown, although several theories have been put forward.

There is evidence suggesting that OCD may be due to genetic factors. Although no specific gene has been found, there is evidence that OCD occurs in families, with a sufferer having four times the likelihood that another family member has OCD. OCD has been shown in studies to be associated with tics, which are rapid, repeated involuntary muscle contractions.

OCD sufferers have been shown to have abnormalities in the parts of the brain that deal with emotions, eg increased blood flow and activity in these areas of the brain.

These abnormalities return to normal following successful treatment.

Although the role of serotonin, a brain chemical that transmits information from one brain cell to another, in OCD is unknown, medicines that increase brain serotonin have been used successfully in its treatment.

There have been reports of OCD developing in children and young people following a streptococcal infection. This may be due to interaction between antibodies and a certain part of the brain.

Adverse life events like divorce or bereavement may trigger OCD in people who are predisposed to it. Stress worsens OCD, although it is not causative by itself.

Overprotective parents may increase the likelihood of developing OCD.

Clinical features

Although OCD affects people differently, there are particular cycles of thought and behaviour. They usually consist of:

·Obsession, in which there is an overwhelming, constant concern or fear.

·Anxiety that results from the obsession.

·Compulsion, in which there is compulsive behaviour to decrease the anxiety and distress.

·Compulsion brings relief, but this is temporary as the obsession recurs, causing the cycle to start all over again.

The types of obsessions vary, but the common ones include fear of acquiring a disease, fear of causing harm to own self or others through a deliberate act, mistake, or accident, and a need for orderliness or symmetry.

The compulsions are varied, but the common ones include hand washing, cleaning, checking, counting, arranging, repetition of words or thoughts, and seeking reassurance.

There is nothing shameful about consulting a doctor. During the consultation, the doctor may use a questionnaire to determine if a person has OCD. The questions may include:

·Is there a lot of washing or cleaning?

·Is there a lot of checking things?

·Is there any troublesome thought that does not go away?

·Do daily activities take a long time to finish?

·Is there concern about putting things in a particular way order?

·Are these problems troubling?

If the initial screening suggests OCD, an assessment of its severity will be carried out. There are various methods which assess the impact of OCD on a patient’s daily life. It is vital that there is openness and honesty when undergoing the assessment as it will ensure appropriate treatment.

There are three levels of severity of OCD:

·Mild functional impairment, which occurs less than one hour in a day.

·Moderate functional impairment, which occurs one to three hours in a day.

·Severe functional impairment, which occurs more than three hours in a day.

The complications of OCD include depression and poor quality of life.

Management

The treatment modalities for OCD are behavioural therapy and/or medication.

Cognitive behavioural therapy (CBT) involves graded exposure and response prevention. This involves identification of situations that cause anxiety in order of severity. There is, then, an identification of tasks leading to the situation that cause anxiety to a level that a patient can cope with without carrying out the compulsion. This exercise is repeated a few times daily. With each exercise, the anxiety decreases and lasts for a shorter time.

Upon overcoming a step, the patient proceeds to a more difficult task exposure until all the situations leading to the anxiety has been overcome.

CBT is a proven and effective treatment for about 80% of patients with OCD.

The medications used in the management of OCD are selective serotonin reuptake inhibitors (SSRIs) and tricyclic antidepressants (TCAs). They can take about 12 weeks before their effects are obvious. It is usual for the doctor to advise treatment for at least 12 months.

Sometimes, the doctor may carry out blood pressure measurements, electrocardiograms (ECG) and regular blood tests for patients on medications.

The SSRIs and TCAs can only be taken under a doctor’s supervision. It is essential to keep the doctor’s appointments to monitor progress and response to medication. It is advisable to consult the doctor if there are troublesome side effects of the medications and/or prior to cessation of medication.

SSRIs increase the brain’s levels of serotonin, a compound which is thought to improve a person’s mood. They are as effective as the older TCAs, but have fewer side effects. The side effects of SSRIs, which include dry mouth, nausea, poor appetite, headaches, blurring of vision, sweating, feelings of agitation, inability to sleep, and decreased sex drive, ease off with time.

As there are reports of increased risk of self-harm and suicidal tendencies with SSRIs, it is important to let family member(s) or a close friend know and ask them to inform the doctor if they notice changes in the patient’s behaviour. The doses of SSRI prescribed in OCD are usually higher than in depression as there is evidence that lower doses are ineffective. There may be a temporary increase in anxiety at the commencement of SSRIs, but this will go away within a few days in most patients. If this does not occur, or worsens, consultation with a doctor is advisable.

An alternative SSRI may be prescribed if there is no improvement after about three months of the initial medication. The duration of treatment depends on a patient’s response.

When a decision is made to cease taking SSRIs, the dose will be gradually reduced. Sudden cessation or the missing of a dose of SSRI may result in withdrawal symptoms like nausea, vomiting, headache, sweating, dizziness, numbness, tingling and sleep disturbances, which may be severe.

TCAs increase the brain’s levels of serotonin and noradrenaline. Their side effects include dry mouth, blurred vision, constipation, problems passing urine, blurring of vision, drowsiness and sweating, and these ease off after about 10 days. TCAs are usually prescribed if SSRIs do not help because they have more side effects than the SSRIs. OCD with mild functional impairment is usually treated with cognitive behavioural therapy (CBT). OCD with moderate functional impairment is usually treated with a more intensive CBT or SSRIs. The doctor may refer such cases to a specialist.

OCD with severe functional impairment is usually managed by a specialist with a combination of intensive CBT and SSRIs or TCAs. OCD in children is usually managed by a specialist who is experienced in treating them.

Surgery has been used as a last resort in selected cases of OCD in some countries. The surgery involves using an electric current or a pulse of radiation to destroy (ablation) a small part of the limbic system which is involved in emotions, behaviour, and memory.

Although this procedure has not been subjected to clinical trials, the Royal College of Psychiatrists of the United Kingdom found improvement in more than 50% of patients. However, there was no improvement, or worsening, in about 15% of the patients. The risks include memory loss and confusion, which could be severe and irreversible.

OCD is a treatable condition. The majority of patients will be completely cured with treatment. The severity of OCD would be reduced in others, with a positive impact on their quality of life.

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Wnt tentukan rambut beruban

SAINTIS telah menemui protein yang mengakibatkan rambut beruban.

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GABUNGAN dua jenis sel stem iaitu sel folikel dan sel melanocytes akan membentuk rambut manusia yang berwarna.

Baru-baru ini, saintis dari Pusat Perubatan Universiti New York telah mengenal pasti sejenis protein yang mengkoordinasikan pigmentasi warna oleh dua jenis sel tersebut yang dinamakan sebagai Wnt.

Kandungan Wnt menentukan warna rambut yang akhirnya berubah menjadi uban.

Kekurangan protein tersebut dalam sel melanocytes menyebabkan rambut bertukar menjadi kelabu.

Profesor Mayumi Ito menjelaskan, manipulasi terhadap protein Wnt secara genetik boleh menghentikan rambut daripada beruban.

“Kita tahu bahawa sel stem folikel rambut dan sel melanocytes yang menghasilkan pigmen rambut sama-sama menghasilkan warna rambut tetapi bagaimana ia berlaku kita tidak ketahui.

“Kami telah mendapat petunjuk bahawa Wnt adalah penting untuk menyelaraskan aktiviti kedua-dua sel tersebut untuk mempigmentasikan struktur rambut.

“Rambut beruban adalah ditentukan oleh Wnt,” katanya dalam jurnal Cell.

Tidur mengiring ke kiri elak keguguran

WANITA hamil yang tidur mengiring di sebelah kiri pada hari-hari terakhir sebelum proses bersalin dapat mengurangkan risiko kematian bayi.

Kajian yang dijalankan di Universiti Auckland, New Zealand menjelaskan bahawa wanita yang tidur mengiring pada sebelah kanan pula berisiko dua kali ganda untuk mengalami masalah tersebut.

“Wanita mengandung yang tidur dalam keadaan terlentang mahupun mengiring ke kanan dalam tempoh yang lama mengakibatkan pengaliran darah kepada bayi terbatas.

“Namun, keputusan kajian juga menunjukkan bahawa risiko kematian bayi adalah berkait rapat dengan rutin tidur yang lebih lama daripada biasa dan juga kekerapan tidur pada waktu siang,” kata Tomasina Stacey dari Jabatan Obstetrik dan Ginaekologi.

Pengkaji menjelaskan bahawa wanita mengandung tidak perlu risau kerana kadar risikonya amat kecil iaitu 3.39 daripada 1,000 kelahiran bagi mereka yang tidur mengiring dan 1.96 bagi yang tidur mengiring ke kiri.

Stacey bagaimanapun menjelaskan kajian yang disiarkan dalam British Medical Journal (BMJ) itu merupakan sebuah hipotesis baharu dan perlu dikaji secara lebih mendalam lagi.

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Coping with creaky joints

Osteoarthritis, the bane of old age, can be slowed down through various measures.

WOMEN fare badly as far as architecture is concerned (no offense to those in the profession)! What I am referring to is the skeletal scaffolding that upholds the vanity of our body. As the flow from the spring of eternal youth ebbs, the bones and joints crumble, buckle and creak, especially when we move into the fifth decade of senescence.

If Marilyn Monroe were still alive today, those shapely legs would be O-shaped, as the knees would have bowed.

Driving a vehicle downhill is one of those times we treasure our brakes. As we step on it often enough, we would smell the burning of rubber as frictional forces are exerted on the pads. Over time, and with overuse, the brake pads are worn off.

Natural predisposition: Almost everyone above the age of 70 has some degree of osteoarthritis, but women are more prone than men.

In the same fashion, our joints become thinned out with repetitive use. As for the car, there are spare parts, but unfortunately, there are none for our joints.

Osteo (bone) arthritis (joint inflammation) was initially thought to be wrongly coined as the earlier definition of creaky joints solely referred to wear and tear or degenerative joint disease.

Now the term has become more apt as researchers have indeed found elements of bone changes and joint inflammation in the midst of mechanical breakdown.

Drying up!

Osteoarthritis is the most common cause of a painful joint, largely affecting the knees. Almost everyone above the age of 70 has some degree of disrepair, but women are more prone than men.

To the lay person, osteoarthritis means age-related “drying up” of joint lubricant. Of course, there’s more than meets the eye. Weight-bearing joints like the knee have a layer of rubbery cartilage that acts like a cushion, dissipating the forces between the thigh and leg bones. Lining the joint cavity is a silky membrane called the synovium, which secretes joint fluid.

The latter is nutritive, protective, lubricating, and acts as “shock absorber”. Enveloping these structures is the protective fibrous covering called the joint capsule.

As the clock ticks, the weatherbeaten cartilage undergoes degradation and loses it sponginess, thinning out until bone rubs against bone.

Like the opening of an old door, the joints creak, crack, and grind each time they bend, causing pain and stiffness, especially in the morning.

By placing the palm over the affected joint during movement, one can sense a grating vibration (known as crepitus), as the thickened and swollen synovium rubs over itself.

Over time, the effect of body weight causes new irregular bone formation just beneath the cartilage and surrounding the knee, leading to little projections called spurs (osteophytes). Some may break off and become a “loose body” within the joint.

The ligaments and muscles around the joint weakens, giving rise to instability during locomotion. Externally, there is broadening of the knees, and in some cases, deformity ensues.

In our early days of mobility, we can descend a flight of stairs in a heartbeat. As for the sufferer with osteoarthritis, just getting down from the car is agonising. The facial grimaces mirror the excruciating pain tearing the joint, especially after prolonged periods of sitting.

This reflects an underlying inflammation. One literally carries the limb onto firm ground, before the tedious process of mobility can even get started.

The stabbing pain that synchronises with each step worsens with movement, as bone grinds over each other. Soon, the synovial membrane becomes inflamed, swells up, and secretes inflammatory fluid into the joint (effusion), increasing the rigidity of an already inflexible joint.

Invariably, the pain and discomfort is verbalised, quite incessantly, for sympathy and empathy. Every time I meet my old folks, they never fail to describe their misery.

Apart from age, there are other contributory causes of osteoarthritis, namely previous injuries or accidents. Athletes and footballers are prone to ligament and cartilage tears. The weakened structures and abnormal weight bearing renders this group of people more prone to osteoarthritis in later years.

Other causes of joint inflammation, such as rhuematoid arthritis, gout and joint bleeding sets the stage for more trouble.

Obesity, limb deformities and mechanical stress on the major joints also pave the way to the orthopaedic surgeons office.

Hereditary

There is, certainly, a hereditary tendency to develop osteoarthritis as well. I know of a family of sisters who limp into my office, taking turns to get pain relief.

As a matter of fact, I too realised where I got my knobbly fingers from! The little bumps on the end joint of the fingers are known as Herbeden’s nodes, which can at times become tender and swollen.

Age and acceleration of degenerative changes open up a pandora’s box for a host of other painful situations apart from the knees.

“Pain in the neck” symptoms are often due to a condition known as cervical spondylosis. The condition is often triggered by awkward positioning of the neck and prolonged postural strain, precipitating the sharp, lightning pains and numbness that may shoot down the arm. This is due to little spurs that pinch on the nerves coming out from the spine.

Diagnosis of osteoarthritis is confirmed through radiologic studies or specific scans. Blood tests are unhelpful.

Treatment of osteoarthiritis is as recurrent as the symptoms are. Most times, the only offering on the table is pain relief. Other times, another type of furniture beacons ... the operation table!

Physiotherapy and strengthening exercises are helpful for some. A new approach is the injection of a “joint lubricant” (viscosupplementation), which offers temporary relief.

Various types of surgery are available, and the ultimate changeover is joint replacement.

The realm of treatment is necessarily condensed as they are in the hands of well qualified professionals.

What is more pertinent are measures one can adopt to reduce the burden of painful creaky joints. It is necessarily DIY, as certainly no one can do it for us.

The direct link to food is weak, but generally, it is good sense to adopt an “anti-inflammatory” diet, which essentially includes high fibre, low glycaemic carbohydrates.

Plant-based proteins and fatty fish are healthy choices, unless they are deep frozen, canned, or preserved. Good fats (mono and polyunsaturated fats), especially a dose of omega-3 fatty acids through fish oil supplementation and flax seed oil, keep the joints greased and “cool” (the anti-inflammation effect).

Obesity, being an aggravating factor, should be taken by the horns as the damaged joints are carrying the weight of more than one person. Dietary modification veer towards healthy weight management.

Many nutrients have purported effects that minimise the inflammation and pain of osteoarthritis. As degradation of cartilage is a destructive process, free radicals accumulate and increase the oxidative stress level within the joint.

Dietary vitamins A, C, and E are the primary antioxidants. Minerals such as manganese and selenium have regenerative function for natural or endogenous antioxidants. Ginger and tumeric extracts have been used with variable results.

The hottest cake with candles lighting on and off is glucosamine. Although the verdict is not unanimous, chondroitin has joined the bandwagon.

The glucosamine/chondroitin story

Glucosamine made its entry into mainstream medicine 20 years ago, amidst great resistance from doctors like yours truly, who had little faith in nutritional approaches then. Reluctantly, doctors began to take notice when patients reported improvements.

Today, there is hardly any osteoarthritic sufferer who walks into a consultation room and exit without a prescription for glucosamine.

Glucosamine is a simple amino-sugar which is derived from the exo-skeleton of crustaceans and is the building block for cartilage. Its mode of action is the retardation of the thinning of cartilage and apparently reduces the pain in some patients.

There are various forms of glucosamine, and the most researched is glucosamine sulphate.

Chondroitin is a natural component of cartilage that keeps it supple. Commercially, it is sourced from animal or shark cartilage. The evidence on osteoarthritis is a little erratic, with some studies implicating benefit while others point out that it is no better than placebo.

Study design, materials used, and interpretation of results, can be confusing even to the scientific community. Conflicting reports tend to cast doubts on the efficacy of nutritional supplements. In the absence of side effects, if one finds glucosamine or chondroitin beneficial, why not try it?

During a spell of poor judgement, I jogged and jiggled with two dumbbells every morning and developed a painful swollen knee. As I am not a great fan of drugs, I opted for nature’s healing, without much resolution.

Finally, reluctantly, I opened a bottle of glucosamine sulphate for the acid test. The result was better than I expected at the end of three weeks.

Anecdotal again, but I have learnt to trust the endpoint more than any meta-analysis.

The hypothetical question is: Can we prevent osteoarthritis?

With positive pessimism, the answer is we can slow down the onset through a healthy lifestyle, with emphasis on maintaining ideal body weight, balanced nutrition, and the right choice of supplements.

The wear and tear will come as sure as age, but we can choose not to be one of the statistics before our time is up.

Unfortunately, most of us treat our body like a machine, visiting the mechanic in a white coat only when the spare parts squeak, squeal, or fall apart.

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Shopping for doctors

Seeking second, third, or fourth opinions when it comes to diseases, especially cancer, is not uncommon.

THE next time you hear a group of doctors utter the word “shopping” disdainfully, you can bet it is not Harrods, Saks Fifth Avenue, or the Galeries Lafayette they are talking about.

To these shopping havens, doctors and their partners give of their time and money approvingly and willingly.

The shopping doctors describe, with a sneer, refers to patients asking around for opinions on their disease and how to treat it.

A patient who needs to undergo surgery to remove a brain tumour trudges around, a bag of x-rays and scans tightly tucked under her arm, from neurosurgeon to neurosurgeon. Sometimes it is two surgeons she sees. Often, it is more.

Patients have been known to see as many as six surgeons before deciding on the One.

The patient with breast cancer shops twice. She must shop around for the breast surgeon for the surgical part of the treatment, which involves removing part or whole of her breast.

Following the operation, she shops again for the oncologist, who will administer the follow-up treatment, which is usually chemotherapy, radiotherapy, and endocrine therapy.

What accounts for shopping?

The first reason is cost. Prices for a surgical procedure or a course of radiotherapy or chemotherapy are compared. To some patients, the lower the price tag, the better.

The second reason is bedside manner. The doctor who chews pumpkin seeds whilst consulting or who constantly checks the TV monitor for the latest share prices may lose the potential customer. Conversely, the charmer who speaks confidently, looks the patient in the eye, and has a firm handshake, is all set.

The third reason why patients compare and contrast doctors is that they want to hear what they want to hear. A patient having undergone surgery for colon cancer, sees four oncologists. Three of them recommend a six-month course of chemotherapy. The fourth one says no, and the patient happily goes along with this naysayer.

The fourth reason for shopping is that some patients need to slake their intellectual thirst. They want the doctor to make sense and to clearly articulate the treatment algorithm. The most eloquent doctor is chosen.

It is often a combination of reasons, but I think the upshot of it all is trust.

As I have always said, the relationship between a doctor and a patient is a special one. You must trust someone who will provide comfort, hope, and healing in times of adversity and illness, someone whose decisions may make the difference between life and death.

Many of us doctors see the same patient not once, not twice, but 50 to 100 times in all. The heart patient trusts his cardiologist and sees the same cardiologist for two, three, four decades. The endocrinologist who looks after diabetics similarly examines the same patient five to 10 times a year.

Rheumatoid arthritis is a crippling and chronic disease, but it usually does not kill. Again, if you trust your rheumatologist, why change?

And yet patients do change doctors whom they may have been seeing for a long time.

For oncologists, change is not uncommon. A patient, whose cancer is getting larger and spreading to more organs, abandons his oncologist and seeks another. He thinks the second (or third or fourth) oncologist may have a new trick up her sleeve. He may think the treatment given by the first oncologist may not have been optimal.

Any long term relationship can sour for any number of reasons. Friends and relatives try to do good by recommending other oncologists, and often, a cancer patient tries his best to please all around him.

They acquiesce to the suggestion to change doctors. The patient can have a religious epiphany and seek an oncologist of the new same faith.

Strangely though, I have not heard of a cancer patient who abandons all religion and seeks an oncologist who is an atheist.

Change the pilots midway through a long haul flight by all means, but provide the second set of pilots with the history of the flight. Where did the flight take off from? What were the weather conditions? How much fuel did the aircraft start with? Were there any anomalous readings on the dials during the first part of the flight?

Patients who change doctors midway through a long term treatment regime or surveillance programme should request of the doctor a long and detailed medical report. Everything should be in the report. From the diagnosis to any revised diagnosis. All the results of blood assays and imaging scans. The surgical procedures done and the drugs (and dosages) given must be clearly spelt out.

The question of offending the doctor should not ever arise. In the same heartbeat, the doctor should not hesitate in giving that detailed report. It is for the good of all the doctors concerned, and more importantly, for the well being of the patient.

Shopping can be therapeutic. Flying can be smooth. Seeing doctors should be both.

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Big isn’t always better

Acromegaly is often waved off as ‘gigantism’, but what many fail to see is the layers of pain and suffering that engulf those afflicted by it.

NOBODY called him Little Robert. Sure, he was only eight, but he towered above everyone else at six feet (1.8m). By the time he turned 12, he had already grown a foot taller. At the age of 18, he stood at eight feet, four inches (2.54m) tall and weighed 390 pounds (177kg).

He wore size 37 (US) shoes and his clothes had to be custom-made with three times the normal amount of cloth. He couldn’t fit into the family car, and so his father had to remove the front passenger seat – Robert could then sit in the back and stretch out his long legs. Frankly, that was the least of his problems.

His large feet had little sensation – he could not feel any chafing until blisters formed. He dreamt of becoming a lawyer, but the simple task of walking from one campus building to another proved to be too strenuous.

All Robert wanted was to live a normal life, but he was often written off as a “freak”. He was once quoted as having said: “It’s not my fault that I am this way.”

He passed away when he was only 22 in 1940, due to a septic blister on his right ankle. His final height was eight feet, 11 inches (2.72m).

He was Robert Pershing Wadlow – the tallest man in the world. His name appears in the Guinness Book of Records, but the fact of the matter is: he never did find out why he was born that way.

He wasn’t just someone “born tall”; what he had was acromegaly, a medical disorder caused by a small tumour in the pituitary gland, which produces excessive amounts of growth hormone. His condition has also been described as gigantism, which is pre-pubertal acromegaly.

Growth unlimited?

The pituitary is a small gland, about eight to nine mm in diameter, located below the brain. Its main function is to produce hormones that are essential for everyday living. The presence of a tumour will cause the enlargement of bones of the extremities, face and jaw, as well as an increase in hand and feet size.

According to Wouter W. de Herder and Jean Périé in “Acromegaly and gigantism in the 20th century”, people afflicted with the disease had it tougher in the past, and not just because there was no treatment available at that time; those with physical abnormalities were often used as show objects, either willingly or by coercion.

Mary Ann Webster was an acromegaly patient in the 1900s who shared all the classic physical symptoms of the disease: a prominent jaw, bulging forehead, as well as enlarged hands and feet.

When her husband died suddenly in 1914, she had no choice but to search for an adequate source of income to support her children. And so she entered (and won) an “Ugly Woman” contest. From then, she appeared with much success in countless circus sideshows.

People afflicted with acromegaly had it tougher in the past, and not just because there was no treatment available at that time; they were often used as show objects, either willingly or by coercion. – Photo courtesy of Novartis

But as expected, she was often made an object of ridicule up until her death in 1933. She was 59.

What not many people knew was that the mother of four had to deal with years of excruciating headaches, loss of vision, and joint and muscle pain, because of her condition.

Being “different” was certainly a profitable profession, though one was exploited in “freak shows” more often than not. Those who suffered from acromegaly were troubled by various disorders, yet nobody could get past the fact that they were “weird-looking”.

Finding the right cure

While gigantism can now be identified and treated at a very early stage, acromegaly still goes undiagnosed – some, for up to eight years.

Senior consultant physician and endocrinologist Dr Nor Azmi Kamaruddin, who is also president of the Malaysian Endocrine and Metabolic Society (MEMS), has only identified 60 acromegaly patients in the country since 1994.

“Everywhere around the world, acromegaly is regarded as an ‘orphan’ disease. On average, there are 40 to 125 cases of acromegaly per one million population. For a country of 26 million, there might be 1,000 to 3,000 patients with acromegaly, yet a lot of them remain undiagnosed,” he says in an e-mail interview.

But being tall does not necessarily equate to having acromegaly, as in the case of China’s Yao Ming (NBA star) and Bao Xishun, who is currently the world’s tallest living man at seven feet, nine inches (2.36m). Some just have taller genes than others.

After her husband’s death, Mary Ann Webster entered and won an ‘Ugly Woman’ contest and later worked in circus sideshows to support her children, all the while battling her loss of vision, excruciating headaches and typical joint and muscle pain. – Photo courtesy of Novartis

For adults afflicted with acromegaly, instead of growing taller, they actually grow “bigger”.

“If the disease starts after adulthood, all the bones have already fused and lost the ability to lengthen. Thus, the most common symptoms involve changes to the facial features and the size of hands and feet,” says Dr Nor Azmi.

Although the tumour giving rise to acromegaly is not cancerous, it does bring with it a host of other diseases, such as diabetes, hypertension, kidney stones, certain cancers, and arthritis. As the tumour enlarges, it may compress the optic nerves, resulting in restricted vision, and later, blindness, adds Dr Nor Azmi.

For the treatment of acromegaly, a patient has three options: surgery, radiotherapy, and medical therapy. “If the tumour is less than one cm in diameter, the chance of cure through surgery is about 90%.

Radiotherapy is usually reserved as a second line treatment for patients whose tumours were not cured through surgery,” says Dr Nor Azmi.

“Medical therapy comes in the form of injections of hormones that either block the production of growth hormones (somatostatin analogues) or oppose the action of growth hormones (pegvisomant). The major constraint to these two forms of treatment is cost, and the fact that they may have to be administered for life.”

The cost of a monthly injection of somatostatin analogues range from RM4,000 to RM6,000, while that of pegvisomant could go as high as RM150,000 per year of treatment.

If left untreated, acromegaly can be fatal. “Further hormonal deficiencies will develop over the years. These will affect the general well-being of the patient as these hormones are essential for cardiovascular health, intellectual function, overall metabolism and sexual function.

“Together with diabetes and hypertension, excessive growth hormones result in deaths due to heart diseases and strokes, not to mention a small increase in the incidence of cancers. A medical emergency called pituitary apoplexy, which is a haemorrhage of the pituitary gland, may lead to death due to the dramatic loss of pituitary hormones,” explains Dr Nor Azmi.

“If the condition is cured, most of the facial and skeletal abnormalities regress to a certain extent; complications such as diabetes and hypertension will improve significantly. Vision defects in most instances will improve unless the condition has been left unattended for years.”

Acromegaly happens, but not always out of the blue. “The condition cannot be prevented. However, in a small percentage of patients, the disease is hereditary – members of the family can then be screened for acromegaly at an early stage,” says Dr Nor Azmi.

Identifying acromegaly

According to Dr Nor Azmi, acromegaly is diagnosed using an oral glucose tolerance test (oGTT) that measures the by-product of the growth hormone secretion called Insulin-Like Growth Factor-1 (IGF-1) in the blood.

“During the oGTT test, the patient is given a drink of glucose while the blood levels of growth hormone are measured every half an hour over a two-hour period. Normally, growth hormone levels will come down with the administration of glucose, but not so in the case of acromegaly.

“Once the blood tests confirm the presence of excessive growth hormones, the patient will then undergo an MRI of the pituitary area of the brain to determine the precise size of the tumour in the pituitary gland.”

There is no gender difference for the condition. “But since it is a slow, progressive chronic disease, it tends to occur more commonly in adults,” says Dr Nor Azmi. Also, if you have both diabetes and hypertension, it doesn’t necessarily mean that you have acromegaly.

“Both diabetes and hypertension are very common in most countries of the world. They tend to occur together. The conglomerate of these diseases is called metabolic syndrome. The presence of both conditions in an individual in almost all cases is not due to acromegaly.”

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The allergy march

The source of your child’s allergies may be you.

ALLERGIES may be downright annoying, but it is quite amazing when you get to know what it really is. To appreciate what an allergy is so that we can control it rather than let it control us, we must first understand the body’s immune system.

The immune system is a wonderfully efficient defence mechanism that prevents infections. Its job is to recognise foreign invaders and react by producing antibodies to fight these foreign invaders that cause infections and diseases. Except sometimes, the immune system overreacts to substances that are actually not harmful to the body. This is when allergies occur.

For people who are prone to allergies, almost any substance can cause an allergic reaction. Common culprits are substances that are found in the home like dust mites, traces of household detergents, cleaning fluids, moulds, certain types of foods, and even pets. Things that we come in contact with every day can become a problem to an allergic person.

Outside the home, there is also a host of environmental allergens like pollen, pollution, chemicals and smoke that can make life a misery for people with allergies. If the allergies are not dealt with or managed, the body is at risk of being unable to function normally.

Allergy spectrum

Allergens provoke symptoms ranging from mildly annoying to fatal. The more tolerable symptoms are itchy and watery eyes, sneezing, breathing difficulties, asthma, and itchy inflamed skin in the case of hives and eczema.

On the other hand, an allergic person may also encounter more serious conditions that can lead to a fall in blood pressure, or anaphylaxis, a life-threatening condition in which the symptoms include swelling of the throat and mouth, constriction of respiratory passages, nausea and unconsciousness. Any allergen can cause this condition, but the most common culprits are foods, insect stings and drugs.

The march begins

An allergy may go through several stages known as the allergy march. This may start as early as during pregnancy. Then in your child’s early years, he may develop common signs of allergy such as vomiting and diarrhoea, or colic.

The clinical picture may progress to eczema which causes dry, red and flaky patches on the skin; at around the same time, food allergies could appear. There would then be some decrease in symptoms of eczema or occurrences of food allergies as children grow older.

However, later stages of the allergy march would present themselves with nasal symptoms (rhinitis) such as blocked and runny nose, itchiness and wheezing or asthma.

Whilst this is the norm of the allergy march, the reverse may occur. Eczema may present itself later in life, preceded by asthma or rhinitis. This reversal of sequence of clinical symptoms is sometimes referred to as the reverse allergy march.

Allergy tracing

Correct diagnosis and the ability to determine the root cause of any ailment are the most effective ways to find a solution. Although not all allergies are inherited, the cause of allergies in a high percentage of people can be traced back to their parents.

If one parent has allergies, then the child is considered to be in the high-risk category, and he has a 20%-40% chance of having allergies. If both parents have it, then the probability could increase to 50%-80%. It is thus important to find out as early as possible if the parents of a child have allergies. If the test results are positive, then the next step is to take preventative measures to reduce allergies.

At the end of the day, there is a multitude of factors that can trigger off allergies. Prevention is possible if it happens at an early stage of a person’s life. – Article courtesy of the Malaysian Society of Allergy and Immunology

For more information, visit www.allergymsai.org.

Quick facts

• About 35% of children are affected by allergies.
• Almost 60% of all allergies appear during the first year of life.
• About 50% of children with food allergy will go on to develop other allergies like eczema, allergic rhinitis or asthma in later life.
• The vulnerability to allergies is hereditary.

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All about aspirin

Learn a bit about this old, but still very useful, drug.

I HAVE heard so much about aspirin. I see it all the time on pharmacy shelves. My parents take one tablet every day. I’ve been told all sorts of things about this ‘wonder drug’, which people say can prevent heart attacks and strokes, and even decrease the risk of cancer. Is this all true?

Aspirin is truly a remarkable drug. It has a very interesting history. It is actually acetylsalicylic acid, which is a mild painkiller.

It works by inhibiting the production of prostaglandins. Prostaglandins are chemicals produced in our body that play a role in clotting our blood and sensitising our nerve endings to pain. Therefore, if aspirin blocks this chemical, we would feel less pain.

Additionally, our blood will not clot that easily. That is why people who take aspirin find their clotting process a little delayed after they sustain a wound.

How old is aspirin?

It is believed that the first records of aspirin were written by Hippocrates, the father of modern medicine. And he lived circa 400 BC.

He wrote about a powder made from the bark and leaves of a willow tree that relieved headaches, pains and fevers.

In the 19th century, scientists found out that the willow tree contains salicin. They then began to isolate the compound.

Then in 1899, a German scientist called Felix Hoffman, who worked for the pharmaceutical company Bayer, gave the formula to his father who had arthritis. It worked so well that Hoffman convinced Bayer to market the new drug.

Aspirin was patented in 1900. Yes, that’s how old it is.

The term “aspirin” has its own roots as well. The “A” is from acetyl chloride. The “spir” is from spiraea ulmaria, the plant salicylic acid it is derived from.

Aspirin was first sold as a powder, and later as tablets. After Germany lost the First World War, Bayer was forced to give up the aspirin trademark.

What should aspirin be used for?

Since it is such an old drug, aspirin has been studied for over a century in a wide variety of clinical trials for many uses. These are some of its indications:

Pain relief: Aspirin is still effective as a mild pain reliever, although it has been superseded by paracetamol and other non-steroidal anti-inflammatory drugs.

But it still can be used for headaches, painful periods, joint pains, etc.

It also can be used for fever.

Prevention of cardiac events: This is what aspirin is primarily used for these days in millions of patients worldwide. Its prevention of blood clotting comes into play here.

An aspirin a day can actually thin your blood and reduce the risk of clots forming in your blood vessels.

These clots are the precursor to heart attacks and strokes. So if you have risk factors for these, it is good to take aspirin.

Once you have had a cardiac event or a thromboembolic stroke (the kind of stroke caused by a blood clot going into your brain), you would have to go on aspirin for life.

There are, of course, other alternatives to aspirin today, such as Cardiprin (easier on your stomach) and Plavix. But aspirin remains a very cheap and good alternative.

Aspirin is also used to treat rheumatic fever and Kawasaki Disease.

In that case, to prevent heart attacks and stroke, even though I am normal, shouldn’t I take one aspirin a day?

That hypothesis may be true, but not everyone should take one aspirin a day.

People who should take aspirin regularly are those who are at risk of getting heart attacks or stroke, or who have had either.

Aspirin has side effects that you may not want to expose yourself to unnecessarily if you don’t need to take it.

Risk factors for getting a heart attack or stroke include:

> Smoking

> High blood pressure

> High LDL (bad) cholesterol

> Diabetes

> Family history of heart attacks or stroke

> Lack of exercise

> Stress

You should always consult your doctor before taking aspirin.

What sort of side effects would I get from aspirin?

Not everyone will get side effects. The majority of people taking aspirin may not get any side effects at all, other than your blood taking longer to clot when there is a wound.

But the main side effects people fear from aspirin are gastrointestinal ulcers and bleeding, and also tinnitus (a buzzing sound in the ear in the absence of external sounds).

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Breakthrough for prostate cancer

Two new therapies for advanced prostate cancer reflect the enthusiasm that doctors hold for the future treatment of this disease.

CANCER of the prostate (CaP) is the most common cancer (other than skin cancer) in males in Western countries. In the US, it has been estimated that about 200,000 men were diagnosed with CaP in 2009, with more than 27,000 dying from the disease.

The prevalence of CaP in Asian countries is rapidly increasing as a result of the increased consumption of Western-style meals (diet has been strongly implicated as a risk factor for CaP).

In Taiwan, currently, CaP is the third most common cancer in men, and the numbers affected are still on the rise.

The hope for advanced prostate cancer patients is even brighter when these innovative therapies are non-invasive and may just require taking a few pills per day. – AFP

A question of castration

Cancer of the prostate is an androgen-receptor dependent disease, and the treatment for advanced prostate cancer is androgen deprivation therapy (ADT), or in layman’s term, depriving the cancer of testosterone.

For decades, ADT has been the most effective and successful treatment for prostate cancer. However, in nearly all cases, the cancer eventually progresses after 12 to 48 months despite ADT, depending on how extensive the disease, host factors, and inherent tumour characteristics or biology.

The cancer invariably develops new tumour characteristics and clinical behaviours after treatment with ADT. This newly evolved cancer is known as castration-resistant prostate cancer (CRPC), which is inevitably fatal. The transformed and fiercer cancer thrives and spreads rapidly despite the body having very low testosterone levels.

The current treatment for CRPC is chemotherapy, using a standard docetoxel-based regime. However, the prognosis remains poor, and median survival with chemotherapy is less than two years.

There is currently no standard of care for patients who fail chemotherapy, and the results of all existing therapies are very poor.

This pathetic and pessimistic scene is going to change within the next few years. Over the past few months, the US Food and Drug Administration (FDA) has approved three new drugs for terminal stage CRPC, and two have already demonstrated the potential of extending patients’ lives.

Further, a whole host of revolutionary therapies, mainly oral medications, will come soon. Many of these new targeted or boutique drugs, which include denosumab, cabozantinib, MDV 3100, ARN-509, and TAIC-700, are in the late stages of development, and are near to final regulatory approvals.

We are certainly living in very exciting times where the bleak future of advanced castration-resistant prostate cancer patients are showered with optimistic rays of hope.

Becoming hormone refractory

How do prostate cancer cells evolve, grow, and spread rapidly despite very low testosterone levels in the body? Several things can result in this change:

· Genetic changes in the prostate cancer cells, or mutation resulting in more or different androgen receptors, result in the tumour thriving on very low levels of testosterone.

· The prostate cancer cells acquire the ability to produce their own testosterone from cholesterol molecules. This was certainly an unexpected discovery by medical researchers.

· The cancer cells develop mechanisms to evade detection by the body’s immune system, thus the body’s immune system is unable to recognise the tumour. The cancer cells can do this by creating changes that keep the immune killer cells in an immature state, allowing the tumour cells to spread throughout the body with impunity.

The recent launch of two innovative therapies for CRPC has brought about tremendous interest and excitement to urologists and oncologists worldwide. This is truly the beginning of many new effective therapies for end-stage prostate cancer patients, bringing realistic hope to these terminally-ill patients.

Two new drugs

Below are the two therapies recently approved by the FDA that have proven to increase patients’ survival:

· Provenge is the first FDA-approved immune-boosting treatment that prolongs the life of advanced prostate cancer patients. In pivotal clinical trials, the Provenge-treated patients lived significantly longer than men treated in the control group. A 22.5% reduction in the risk of death was recorded.

Treatment with Provenge, also known as Sipuleucel-T, involves removing a small quantity of patient immune cells in a specialised centre. These cells are sent to the company’s manufacturing facility. After about three days, the patient returns to the centre to receive an infusion of the boosted immune cells, which aim to kill off prostate cancer cells.

These newly boosted cells are also able to recruit other immune fighters or killer cells in eradicating prostate cancer cells. The entire Provenge treatment is repeated three times over a period of about four weeks.

The most common side effects that occur with Provenge treatment occurs one day after the infusion of the boosted immune cells. These side-effects include chills (7% of the patients), fever (23%), fatigue (16%), nausea (14%) and headache (11%). Most of these flu-like symptoms are temporary. In the clinical trials, less than 1% of the patients stopped treatment because of side effects.

The median survival benefit of Provenge therapy is about 4.1 months. About a third of the men in the pivotal trials were still alive three years after the treatment.

· The other breakthrough treatment for CRPC approved by the FDA about a month ago is Abiraterone. This is a pill with a low rate of side effects and has been shown to improve the life of CRPC patients who have failed all other treatments, including chemotherapies.

The oral medication is able to suppress androgen production in the adrenal gland, the testes, as well as in the prostate cancer cells. It is otherwise known as a true “de novo” androgen synthesis inhibitor, which practically wipes out all androgen manufacturing processes in the entire body of cancer prostate patients.

In clinical trials, patients were given 1,000mg (four pills) per day for a 28-day cycle in combination with prednisone 5mg. This regime has proven to be safe and effective in prolonging the life of CRPC patients.

There was a 35% reduction in the risk of death as compared with placebo plus prednisone, with a median survival of 14.8 months among patients who received abiraterone acetate plus prednisone, versus 10.9 months among patients who received placebo and prednisone.

The Abiraterone group of patients also show significant improvement in x-ray findings, a longer time to disease progression, and longer progression-free period. Side effects include hypertension, low potassium levels, and lower-limb swellings, are generally tolerable, and can be controlled with low dose prednisolone.

The Abiraterone research has enable medical scientists to understand in detail the biology involved in the progression of metastatic CRPC and this augurs well for researchers to develop more effective targeted approaches to further improve the outcome of treatment for CRPC patients.

Bright future

With the advent of truly effective therapies which can prolong survival of CRPC patients, the light at the end of the tunnel is ever brighter. The knowledge leading to the development of these two totally different therapies for CRPC has certainly opened up new pathways for the development of many more new targeted therapies.

There is every hope that the future management of CRPC or prostate cancer will follow the developmental paths of treating advanced testicular cancer, which was a fatal disease before the development of an effective chemotherapy regime. The early chemotherapy trials for advanced testicular cancer prolonged life by about four months, (like Provenge and Abiraterone). But today, more than 90% of all advanced testicular cancer cases are curable.

Testicular cancer is one of the few cancers that is considered totally curable and the patients go on to live a normal, full healthy life. In the coming decade, we will definitely see many more targeted therapies which could prolong lives. Using a combination of these therapies, which are proven to prolong survival, there is every hope that nearly all cases of prostate cancer at any stage may be totally curable.

The hope is even brighter when these innovative therapies are non-invasive and may just require taking a few pills per day.

These recent spectacular breakthroughs in treatment of CRPC have brought back memories of a dear friend and colleague who battled CRPC for a couple of years. We had tried practically every therapy available, including current hormonal and chemotherapies. He succumbed to the battle just weeks before the availability of these two FDA approved revolutionary therapies.

The battle against many cancers has taken centre stage. We are certainly racing against time to bring hope to the lives of patients who are unfortunate to have incurable cancer at this point in time.

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What causes cancer?

You can reduce your risks of getting cancer if you keep clear of avoidable cancer-triggering factors.

THE big “C” is the single most frightening condition that any woman can imagine in her lifetime. Every woman wants to prevent it, and avoid ever having to hear the diagnosis from her doctor.

Before you can know how to prevent cancer, you have to know what causes it. Cancer is a complex disease, as it is not a single condition, and does not have a simple black-and-white cause.

There are many different types of cancer, up to at least 200 types, because they can affect any organ or tissue in the body. Then, each cancer has its own causes – not all are related, and some are very specific.

So, as you can see, it’s not as simple as putting the blame on one cause. You need to understand the multifactorial nature of cancer in order to adopt holistic changes to your lifestyle that will help you reduce the risk of cancer.

The big bad C

Cancer is essentially a disease of the cells, where individual cells become abnormal and multiply out of control. Cancer can occur in any of the cells in the body, as everything in our body, including our organs, bones, muscles, skin and blood, is made up of millions of tiny cells.

If cancer occurs in the cells of the skin, then the person has skin cancer; if it is in the cells of the breast, then it is breast cancer.

Cancer starts from the genes of one abnormal cell. In a normal cell, there are genes that control how the cell divides and multiplies – a cell becomes abnormal if those genes are damaged or mutated. This causes the cell to start multiplying out of control, to form a cancerous (or malignant) tumour. This tumour may form a lump or a patch of cells that can be seen on a scan.

Every person has a risk of developing cancer, simply because we are made up of cells. There is nothing that can completely prevent cancers from developing because nature cannot be controlled.

However, there are certain biological, environmental and lifestyle risk factors that increase the likelihood of cell mutations. These could range from cigarette smoke and asbestos, to certain viruses.

If you reduce these risk factors in your life, you would contribute towards dramatically diminishing the chances of getting cancer. In other words, don’t give your cells a chance to go bad!

Cancer triggers

We all know that smoking leads to lung cancer. This is because cigarettes and cigarette smoke contain cancer-causing substances that are carcinogenic, like benzenes or ammonia. These carcinogens, which turn cells cancerous, are one of the main causes of cancer.

The longer the duration, and the greater the amount of carcinogens that you are exposed to, the greater your risk of developing cancer. The most commonly known carcinogens are tobacco smoke (causes cancer of the lung, mouth, throat, oesophagus, bladder and pancreas), asbestos (causes mesothelioma), and radiation from UV rays or radioactive materials.

Certain viruses and bacteria can also lead to cancer. This doesn’t mean that you can “catch” a cancer the same way you catch a viral influenza. What happens is that the virus or the bacteria causes cell mutations that lead to cancer.

The hepatitis B and C viruses can increase the risk of liver cancer, while the human papillomavirus (HPV) can lead to abnormalities in the cervical and genital cells that may become cancerous after several years.

There are vaccinations for hepatitis B and HPV, so that can protect yourself from these infections. Furthermore, women should have regular Pap smears to pick up any possible HPV infection and treat it early.

One type of bacteria known to play a role in cancer is Helicobacter pylori, which infects the stomach lining and eventually leads to inflammation and increased risk of cancer. H. pylori infection can be treated with antibiotics.

Lifestyle factors

Some risk factors for cancer are beyond our control. For instance, age increases the likelihood of cancer, but we cannot stop the hands of time from advancing. You are more likely to develop cancer the older you get, because the mutations in the cells take a long time to develop and turn into cancerous cells.

When you are older, your body’s immune system is also weaker and less able to resist the development of abnormal cells or repair them. This is the same reason that certain types of cancer are more likely in people with weakened immune systems, like organ transplant patients who take immunosuppressive medications, people living with HIV and AIDS, or those who have disorders that affect their immunity.

There has been a lot of debate in recent years about whether your diet and physical activity has an impact on cancer development. Increasingly, scientists are starting to say “yes”, as research shows that certain foods have cancer-protective properties, while others can increase the risk of cancer.

Fruits and vegetables are rich in vitamins, minerals and antioxidants that strengthen the body’s immune system and protect it from damage caused by age, the food we eat, and environmental factors. All the different-coloured fruits and vegetables, such as green broccoli, orange carrots, red cabbage, blueberries and purple eggplant, contain unique compounds that may protect against cancer.

Eating at least five servings of colourful fruits and vegetables every day is the easiest form of defence against cancer and keeps the body generally healthy.

Eating too much of high-fat foods is thought to contribute to the risk of cancer, because it is most likely to cause obesity. Along with lack of physical activity and overindulgence in alcohol, obesity has a strong link with certain types of cancers, such as colorectal cancer.

Some of my patients have read emails or heard claims that food additives and artificial sweeteners are carcinogenic. These claims can cause a lot of unnecessary fear in people. All ingredients in our food products are regulated by the Health Ministry, and these products would not be approved if they were shown to cause cancer.

If you are wary, you can reduce your intake of artificial sweeteners and processed foods, so that you consume mostly natural ingredients. However, there is no need to be paranoid, as it would take huge amounts of any substance to cause serious harm – and it is rarely possible for a person to consume so much of any product or ingredient.

Born with cancer?

Some of my patients have asked me whether they have “cancer genes”, because many of their close family members, like their mother, sisters, and aunts, have developed cancer.

Some people may be born with a genetic mutation in their cells that makes them “genetically predisposed” to developing cancer. However, it doesn’t mean that they will definitely get cancer, just that they are at higher risk because they already have one of several mutations needed for cancer to develop.

One instance of genetic predisposition is the BRCA1 and BRCA2 breast cancer genes, where women who carry one of these genes may be at higher risk of developing breast cancer than women who do not have the gene. These genes can be identified through genetic testing.

However, all this talk about genetic predisposition can be misleading. Some women think that just because they have the genes, they are doomed to cancer. Other women think that just because they do not have the genes, they will not get cancer, so they do not have to do breast self-examination or go for regular medical checkups.

Let me use BRCA as an example again. Less than 5% of all breast cancer is due to the mutated BRCA1 or BRCA2 gene – which means at least 95% of breast cancer out there is caused by a multitude of other factors, some of which I have described above.

That is the most important take-home message for cancer prevention – there is not one single cause for cancer, but a combination of risk factors and triggers. There are many things that have to happen before cancer can develop – for instance, whether you have the genetic make-up, have been exposed to carcinogens, how you eat and exercise, and the general state of your health, all of which will have to cause several genetic mutations before cancer develops.

The best advice I can give women is to live healthy, think positively, and always be in control by managing your health. By reducing all of the risk factors listed above, you are giving your body a fighting chance to keep cancer at bay.

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Blood work

HE comes early in the morning, right on time, at 7am, with his little trolley filled with the tools of his trade. Then he proceeds to methodically extract blood from warm, living bodies, carefully making sure that he doesn’t inflict unnecessary pain on his ‘victims’.

This is real life, not reel life. Its’s not Bill Compton in True Blood supplementing his food source, but a young doctor doing the rounds, checking his patients.

The blood that is taken will be sent to the lab for analysis, and the patient’s condition assessed once the test results are out.

To some, it’s a daily ordeal, especially those with serious conditions. For others, it might be one test before admission, and one before discharge.

C-reactive protein is an indicator of inflammation in the body. Elevated levels may indicate inflammatory diseases such as rheumatoid arthritis, lupus, or vasculitis.

Blood tests are part and parcel of daily living for many patients who’re in hospital, especially those with serious conditions. But for those lucky ones on the other side of the fence, what part do blood tests play in our lives?

Safeguarding health

According to medical practitioner Dr C.S. Foo, blood tests have a role in safeguarding health, especially those living with chronic conditions.

“Take the example of a person with high cholesterol. I would do a blood test every three or six months to check his progress. Otherwise, it’s an annual check-up to make sure that everything is fine,” he observes.

Blood tests are but one of the many tools that doctors use to help them with their work. As Dr Foo observes, it’s but one small part of the process.

“The doctor needs to take a full history and carry out a thorough physical examination on the patient. Based on what he finds, then other tests could be indicated if he suspects something amiss,” he explains. “It could be just a blood test, or there may be a need for scans and other tests.”

Blood tests are very common aspects of a doctor’s work. They help doctors check for certain diseases, and they are useful to assess the progress of the disease, as well as treatment effectiveness.

Some of the common blood tests include a full blood count, blood chemistry tests, blood metabolic profile, and even cancer markers.

“A full blood count is useful to detect many conditions, such as thalassaemia and bone marrow problems. This is the haematological component of the test.

“Then there’s the lipid profile. I do tend to look at triglyceride levels, what with the prevalence of the metabolic syndrome these days. (This is generally defined as disturbed lipid levels, central obesity, high blood pressure, abnormal glucose levels. The definition differs, depending on which authority you’re referring to.)

“Liver function tests are useful, and in my case, I usually look for fatty liver disease when I order it for some of my patients,” explains Dr Foo.

“HbA1C is important, especially with the prevalence of diabetes these days. It’s an indicator of a person’s average glucose levels for the past two to three months, and can help identify those who have pre-diabetes,” he adds.

The blood reveals many secrets of the human body, and as such, blood tests have remained important tools of the medical trade. It says much that the basic form of the test hasn’t changed for the past 20 years or so, though new elements have been added in.

“These days, we can also look at homocysteine and C-reactive protein, indicators of inflammation in the body,” notes Dr Foo.

According to Dr Foo, some cancer markers may be useful, especially if the person is older and has a family history of certain cancers. “These may make us more careful, and we may check accordingly,” remarks Dr Foo.

In general, most blood tests do not require any special preparation, and the whole process should take only a few minutes. There are, however, some tests that may require advanced preparation. For example, fasting blood glucose requires fasting (about eight to 12 hours before the test).

And really, having your blood taken is not such a painful process, so long as the person taking it is experienced at it.

Test results can be obtained anywhere from a few minutes to a few weeks, depending on what you’re being tested for.

When in doubt, ask

There have been many reports of unnecessary tests being carried out on patients. It’s important for patients to ask their doctors why such tests are being done.

After all, it’s your body that’s being poked and prodded, and you have the right to know why.

Dr Foo advises: “It’s no use having a blood test if you do not know what it’s being done for. And once you get the results, you should be seeking the advice of your doctor as to what you should do next.”

Yes, otherwise, it’s just a bunch of abbreviations and numbers attached to them, without any meaning at all to the average man or woman.

In general, Dr Foo recommends an annual blood test for adults, just to make sure that everything is fine.

At the end of the day, blood work may make many of us uncomfortable, but if it helps us keep healthy, it’s a discomfort that we should be able to put up with. After all, it’s only once a year ... we hope.

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