Hunter's Hunted

I write this post as a tribute to a young little soul that had laid to rest in peace earlier this week.

In paediatrics, students are trained to do a quick but thorough general examination as that yields the most findings and guide our further examination. Most of the time, we like to divide the patients into 'syndromic' facies and 'non-syndromic' facies. So one fine day in Teluk Intan, I came across this boy, with a typical 'syndromic' facies. I couldn't make out what syndrome he has, but generally, he looks too small for his age. There were abnormal movements as well. He loved to do 'scratching' activities, which is purposeless from my point of view.

The main reason that he came in was due to pneumonia. He had multiple episode of similar illnesses in the pass, according to his sister. As usual, when we as student do not understand certain things, we go straight to the case note. He had what we called a mucopolysaccaride metabolism disorder, leading to what we called as Hunter Syndrome. That raised further questions to me that night, as I never heard of this illness before.

Usually, Hunter Syndrome is a progressive illness with no successful therapy so far. The victims will live up to adolescent or late teens and usually die of the complication of the disease. This is one of the rare illness that we don't want to get. Maybe that is why he succumbed this time. I talked to the mother before, she was already in the stage of acceptance before the child passed away. She said it will do both of them good, as he doesn't need to suffer any longer and the parents can concentrate on the other siblings. So she opted not for intubation in case her child fails to breath by himself and refuses any artificial ventilatory support.

When the child was gone that day, the mother cried her heart out. The whole family cried for his loss. That makes me think again. No matter what the mother opted for, I will support her decision anyway. They were the one that faced him everyday. Sometimes, there were no right or wrong answers. There is only choice. With any choice made, we sacrifice certain things. What matters is how big the price we pay. when we earn something, we will give up something. Isn't that the way of life?

I just hope that this boy found his lasting peace. Sadhu.

Obesity and Adiposity: Friend or Foe?

People are in denial, I am also in denial. Obesity... it is always a weighty issue. Whenever climb onto the weighing scale, the mood of day can change. If I indulge in something good previously, I will cautiously check the scale, fine-tune the '0' mark and then only weigh. If the weight just maintained, I would be very happy. On the contrary, if I add another precious kilos onto my already 'heavyweight' frame, the following days will be dreadful.

Why are people getting obese? As far as I understand, the body weight is maintained by a balance of input and output. Input is from what we take or drink. Output is the energy expenditure. Obesity occurs when the balance of input is more than output. Too much input occurs when we overeat. Too little output means we lead a sedentary life style, working 9 to 5 in front of computer and is a potato couch. Simple explanation, rite? Not so...

Our desire to eat is govern by a complex brain activities called the satiety centre and hunger centre. Long time ago a bunch of scientist did experiments onto mouse; first they destroy the part of the brain believed to be satiety centre, thus the mouse always in hunger and no end to eating. In the end, they produced a super-obese mouse (pity the mouse). Based on the concept, some slimming medications were created so to decrease our desire to eat, which are of amphetamine-based.

Genetically modified mouse that knows no satiety.

Furthermore, our eating habit is also governed by our mood. We overeat when we are happy. During festivals, we (over)eat to celebrate. When we are sad, eating sometimes help to calm the mood and sooth the nerves. When we are promoted, feast. When we are demoted, compulsive eating. Chinese New Year, bigger feast. Our life has been surrounded by this concept of live to eat instead of eat to live.

The simplest method to determine whether you are simply overweight or obese is using a body mass index (BMI) calculation. The formula is:

BMI = (Weight in kilogram)/(Height in meter x height in meter)

For Asians, the body fat is more compared to Caucasians in similar BMI value. So we adopted a lower cut-off point for BMI. Normal range would be between 18.5-22.9. Below that is underweight. Overweight is a general term to grade a BMI more than 23. For a range of 23 to 27.4 is considered pre-obese. 27.5 to 34.9 is Obese Type I which has moderate heart and diabetes risk. 35.0 to 39.9 is Obese Type II. More than 40 (Obese Type III), you are running into a very high risk for all the disease of the rich people.

Other method of measuring cardiovascular risk is by taking a waist circumference. For men, the risk is increased when WC is more than 85 cm whereas for women, it is more than 80 cm.

So, Now you know where you stand. How do we tackle the problem?

1. Determination. Do you feel like you want to have weight loss? What is your target weight? How much to lose in how long a period? What method to achieve weight loss? If you have no answer to all the questions above, you are not yet ready. Buckle up, my friends. Determination is the first step to success and to maintain weight loss.
   
2. Keep a food diary. Record what you have eaten over 24 hours. Include all the main meals and snacks. Be honest to yourself. This will ensure that you aware of what you are taking, and not to be excessive.
   
3. Regular exercise. No one can help with this except you. As mentioned above, you need to have good output, so to tip the scale to a negative balance. Exercise for about 30 minutes for most days in a week. Studies shown that exercise help to makes you feels better, not to mention healthier as well. Some mild degree of hypertension can actually be controlled by exercise alone.
4. Food intake. Although some fad diets claim to help achieve weight loss, I personally don't recommend them. Stick to what is easy to attain, cost-friendly and most importantly, palatable. Don't try out fancy fancy stuff that in the end you cannot stick to your plan and all equal to zero.
5. Drugs. There are various types of medication used, but I will only discuss a few. First type is Orlistat, which is able to decrease absorption of fat from alimentary tract. Next types are appetite suppressant such as Sibutramine and Phentermine. Sibutramine not only reduced the appetite, but also help in increasing the metabolic rate. However, the use of this medication in hypertensive person must be cautious. Phentermine is amphetamine-based medication which has side effect of increase blood pressure and insomnia. Otherwise, medications that was proven to be ineffective are cellulite treatment, dietary supplements such as chitosan, fibre capsule and herbal preparations. Laxatives like slimming tea should not be used because of ineffectiveness in treating obesity. Usage of amphetamine, dexamphetamine and thyroxine is dangerous, and should not be used at all. Please consult your doctor about the choice of treatments.
   
6. Surgery. It is reserved for severe and morbid obesity where reduction of 50 to 100kg is required. Type of surgery includes gastric reduction by doing a vertical banding of the stomach or inserts a constriction bands around the stomach. Other types includes gastric bypass, which is to shorten the gut and induced malabsorption. Liposuction is not for generalized obesity, but to help getting rid of local fat or for cosmetic reasons.
   

Always ask for help. Ask your doctor about options available. They should be able to help you. You are not alone.

Doctor Shopping: How Good Is It?

At the time of writing this post, Malaysia is having a Year End Sale. It's near Christmas holiday and now is school holiday. Every shops in town is throwing crazy deals to attract customers. I had to admit, Malaysians love shopping! If you go to any of the big shopping complexes now, you will face with huge crowd. Even parking your car also is becoming a problem. These kind of shopping promotes growth of economy, and help Malaysia building a stronger nation, but I am going to discuss about a kind of 'shopping' phenomena that will affect the nation. It is called 'Doctor Shopping'.

Basically, 'doctor shopping' does not mean doctors going out to shop. No. It means you and I, people that goes from one doctor to another doctor to get treatment. I will tell you how it cause negative consequences on you. Before that, I want to share a case:

I had a young patient about 4 months old, that came in with shortness of breath and fever for 1 week duration, which is worsening until she cannot feed. So naturally, the anxious mother brought her to the emergency department and the baby was then admitted. Upon history taking,I found out that prior to this, the mother had brought her daughter to a general practitioner, lets say Dr Ay, on day 2 of fever. Dr Ay had prescribed her some medications includes antibiotics type P and paracetamol. So the baby was on this set of medications for 3 days. The symptoms of fever and shortness of breath was not improving, but all the way worsen. The anxious mother became more anxious. Naturally, she thinks Dr Ay sucks, and the medication was not effective, thus losing faith in him. Since she had 'discharged' Dr Ay, and then seek for another Dr, let say, Dr Bee. Dr Bee, without having any knowledge that she already went to Dr Ay and received some medications there, manage this poor child with another set of medications that include antibiotic type Q and also some paracetamol. The mother gladly stopped the antibiotic P and starts taking antibiotic Q. 3 days down the line, the fever and shortness of breath not only worsen, now the baby can't even feed at all and had to be admitted to the ward.

This is what usually happens in Malaysia and I have to emphasis that it is not right! First of all, medicine starts with trial and errors. Even the best specialist also based on this concept, albeit with better percision and less hit-and-miss. No one knows a diagnosis of certain illness, we can only make our best guess aided with some examinations and investigations. However, if the first arrow miss the mark, we have to change the diagnosis. This will only happen if the patient have follow up and came back to us for progression. That is how things goes. In above example, the mother should bring he baby back to Dr Ay for follow up because Dr Ay knows her progress of illness and what to give subsequently. Instead, the mother brought the baby to Dr Bee, who had started the trial and error cycle again. Worse still, there were no knowledge of the child being partially treated with the medications.

Subsequently, it will lead to what we called as multidrug resistant strains. This is what happens: when one person is having an infection and was on antibiotic A, the antibiotic will react to kill the bacteria. However, antibiotic requires few days to reach its maximal actions, usually 5 to 7 days. Less than that, it will only partially kill the bugs. If we stop the antibiotic before its maximal activity, the bugs will react by creating new genes that is able to withstand the antibiotic, subsequently leads to failure of the antibiotics. Once it had fight through several types of antibiotic, a big problem starts. Currently, we have few antibiotics left to fight these 'superbugs' and there are more and more 'superbugs' emerging due to inadequacy of treating the infection. Once the bug is resistant to all antibiotic, there is no way to fight the infection.

Back to the baby, she had developed pneumonia. Since she is partially treated with antibiotic, so we have to hit with a stronger antibiotic, to prevent the emergent of the resistant strains. This leads to longer hospital stay, increased medical cost and disruption of family dynamics. 'Doctor Shopping' is a bad habit of Malaysians that requires change, for a better health care tomorrow.

Alternative Medicine: The Good, The Bad and The Ugly

I am always a bit jittery when someone asked me:" What do you think of this product X? Is it good for my diabetes? Because I heard my diabetic medications will shrink my kidneys, is that true?" This sort of questions always pop up if I went back for Chinese New Year celebrations, where the uncles and aunts will start to pull out their supplements and ask me the benefit of it. Some of them are selling the products and sort of ask me to tell them whether it benefits them in certain medical conditions or not. If I started to say something, they will quote and make me reassure their product is safe and effective. This is like a free ads. So I choose not to comment.

But silence for too long is not good... Long before the emergence of modern medicine (or Western medicine), people use to seek healers in the past for all sorts of ailments. The principle of treatment includes chants, herbs and offerings to God. This kind of treatment had rooted deep into our Malaysian Society. Among the Malays, they will go and seek the bomoh for their ailment and Chinese will go to the Sing Seh. Sorry, I do not know about the Indians. It had been the basis of treatment until the arrival of modern medicine. So it is not uncommon to see a patient that went to a doctor as well as seeking advice from traditional healers.

Throughout evolution, the Western medicine improves in leaps and bounds. With the discovery of new investigation tools, new drugs, new antibiotic for treatment of bacterial infection, and new technique of treating illness, there is booming of modern medicine. But the core of the treatment remains the same. It is still evidence-based medicine.

Generally, we do not say no to patients who takes alternative medicine. Some supplements are good. We even prescribe supplements to patients such as ginko biloba for memory, vitamins and so forth. But I am sick of people making 'claims'. 'Taking this product and I guarantee you no need to take anymore medicines' ' Why taking the pills when you can have something natural to cure your illness?'

First of all, you must understand the illness you are having. How the disease affects your life and how to overcome the disease. If it is going to be long term, there is absolutely NO way to cure by just 1 dose. Understand how the medications given by the doctor work. Ask questions to your doctor. If someone promote you a product, ask them what medication is that, and how the medications can help you. Ask yourself, do you need to take it? Is there an indication for it? Are you able to pay for it? As most of the 'natural' stuff are expensive while it is readily available, do you really must take it? Ask them to show proof. Proof on how the medication works and what are the side effect of taking it. If the proof is based on an opinion, most likely the resource is unreliable. In modern medicine, we tested our medicine with randomized trials and continuous experiments. It is released to public only when it is found to be safe and effective. Even when released, if the drug found to cause certain side effects, it will be withdrawn.

What about those wonderdrugs that can cure all types of illnesses known to man? Whatever condition you have, just take the wonderdrug and you will get cure. Are you sure? Just think, if there are such a wonder drug, wouldn't the pharmaceutical company had already research it and used it to help mankind?

One piece of advice: Do consult your doctor before taking any medication outside the prescription if you are taking long term medications. Some drugs will interact with the other, causing the effect to be less, or become toxic. My professors used to tell us, they had done research on the raw tongkat ali (Eurycoma longifolia) roots found in the road-side stalls in Chow Kit Road. What they found was the content of steroid in the roots were exceptionally high. Steroids does help in symptoms but in the long run, it will damage the kidney, causing high blood pressure and many more side effects. As an end user, we have the rights to choose what is best for us and what is not, so be a wise one.

Tongkat Ali roots

Tiger penis - Traditional chinese medicine

Smoking: When TAK NAK! become NAK TAK?

There is no need to emphasize how smoking can do to your health. But some would say: "My dad smoked, but he never died of lung cancer. And there are so many smokers out there, I wouldn't be the unlucky one." "If smoking is bad, the government should had ban the sales of cigarettes." "I am already hooked. If choosing between stop smoking and die, I would rather choose death."

EXCUSES~

There are things that you lose with smoking:

1. Your white, beautiful and strong teeth
2. Your breath - stinks with cigarettes
   
3. Your fertility - both men and women will suffer from subfertility
4. Your time with the loved ones as smoking shorten your life and well as the one around you
5. Your freedom as you can't go in certain public like cinema, petrol kiosk, bank and many more
6. Your enemy, if you smoke around them, they will die faster

TAK NAK! is a failure. Government spent millions in promoting public health awareness on stop smoking. On the other hand, cigarettes is so readily available, even the teens can get their hand on the cigarettes with ease. There are shopkeeper out there who only think of profit-making, think that they are above the law and sell the cigarettes to the young one. This is bad. At home, the parents smokes, setting examples for the children to follow.

Imagine, if a person is smoking a pack of cigarette (20's) a day, it will cost around RM 7 per day. In a month, he will use up RM 210 just for cigarettes. In 10 years time, if he stop smoking, he saved RM 25,200! This is enough to pay for a car or to save for children education fund. What more, this figure does not include the expenses spent on petrol to go to buy the cigarettes, the cost for getting chronic cough, and the time lost because of fallen ill.

Prevention is always the best way to be healthy. Nicotine found in the cigarettes is a substance that cause physical dependence as well as phychological dependence. There will be withdrawal symptoms if a chronic smoker suddenly stop smoking. Glad, there is treatment to reduced these symptoms. It is called nicotine replacement therapy(NRT). It is available in most government and private hospital and clinics. Basically, it is substitute for what is loss, and it can be in various forms. There are gums, patches and inhalers to help reduce withdrawal symptoms. Mind you, the cost of NRT can be high, but in view of the long term cost, it is still cost effective. Do consult your local clinic or hospital for this service. The following are the number to call for smoking cessation clinics:






and the website for a full list of smoking cessation clinics and some relevant web addresses:

http://www.infosihat.gov.my/Klinik%20Berhenti%20Merokok.html

http://www.infosihat.gov.my/TakNak.html


Some examples of nicotine replacement therapies

Coffee: Eye Opener or Brain Killer

I have to admit, I am addicted to coffee. But 1 out of 2 of my friends are on coffee everyday. Be it a caramel machiato, nanyang memorably or a simple nescafe, I had to take 1 cup every morning to keep me alive. I can skip breakfast, but not this. Everyday, I took an average of 2 cups of coffee. It started to sound like cigarette already.

I started to drink coffee during my secondary school age. I remembered it was an Indocafe. The taste was very bitter but still nice. My favorite cup? 1 teaspoon of coffee + 3 teaspoon of Milo + sugar. Yummy! Now I still drink this way, only without sugar. They called it mocha, but I prefer to called it Neslo.

So does coffee do you any harm? We have to look at it at 2 angles: dependence and intoxication. Not surprisingly, coffee can cause dependence, but surprisingly, it causes only psychological dependence. There was once I was on Atkin's diet. They recommend the users to stop coffee. So I did. First of all, I know if I am off coffee, there will be severe, head crushing, brain-burning headache. I will be a total useless junk. So I pick a time where I don't need my brain: holiday. And next thing I need is lots of paracetamol. So, I went through hell for the first 2 days. gradually, on the 3rd day. the withdrawal became much better. On the 4th, I can function partially and the next day, I can do my usual things again! Furthermore, I felt much better, more alert when I am off coffee than when I am on. Unfortunately, when I had stress for exam, the coffee drinking habit comes again and I am hooked till now.

The other aspect is intoxication. Believe it or not, some of you all actually drink until you get light-headedness. This is part of the intoxication symptoms. Others are feeling your heartbeat beating too fast, sleepless, restless, increase the frequency to go to toilet and abdominal organ upsets. There is no specific intoxication level. Some can take 5 cups without symptoms but some will have symptoms even before reaching the bottom of the first cup. It is usually dependent on the age. Younger than 35 years (like me!) will usually not suffer from intoxication.

Do you need treatment for caffeine dependence? Personally, if it does not bothers you, why bothers? Seek help if you think it affects your function.

Suicide: It's not the end

What an irony! My first post is all about the end. I have encountered a few case of suicide before, even been consulted by a counselor regarding a young school-going child that is suicidal. Just how common is suicide in our community? In Malaysia, it is highest among the Indian population, and the prevalence is 157 over 100,000 people (Maniam, 1988), which converts to about 3 in 2000 people that commit suicide. Not much, eh? Wait until you think of the burden of suicide to the family members, the society and the healthcare burden.

How wide is the scope of suicide? Do we only consider those who deliberately taking his/her life is suicidal? No. Not only that, those who pray to have their life ended also considered suicide. Those who has thought of death is also a potential suicidal. Thus, it is utmost important to take note of all these early signs before everything is too late.

How do we know if a person is suicidal? In another word, who are more at risk of committing suicide? First of all, if you noticed anyone that persistently complaining of sadness or simply look sad and down, these people needs attention and we must be cautious. It can occur despite having any obvious stressor or events. He or she might not enjoy what they usually do, e.g. watching television, shopping or walk the dog no longer a joy for them. The people around them will notice that he or she losing weight despite not on any form of diet. They will also not sleeping well at night, requiring sleeping pills at times. In short, those people that have major depressive disorder are at risk of suicide. If the person had committed suicide in the past, he or she is even at a higher risk than usual. Those who had lost their loved ones in recent time are also associated with increased risk of suicide.

Old folks that stay alone, jobless, and financially dependent are especially at higher risk compared to general population to commit suicide. Those who were diagnosed to have schizophrenia are also at risk. Schizophrenia can present in many forms, however the usual theme would be hearing voices, feeling that someone is inflicting harm onto themselves, that they have ‘special ability’ or misinterpret certain common things into unusual experience (the list is not exhaustive). Usually, a schizophrenic patient who will commit suicide are those guided by the voices, for example, hearing someone asking the person to take his/her own life or had underwent major stresses in life due to the disease.

Men or Women: Which Gender is More Lethal?

Men tend to choose the more lethal means of suicide. They are considered to be more impulse driven, straight forward and ‘I-mean-every-word-I-said’ kind of people. Women would choose more peaceful way, less deformity to the body and less pain way to die. Usually, they are more attention-seeking; harming themselves is a mean to attract attention to their current agony.

Treatment

How do we manage a potential suicidal patient? In the situation where a person are trying to take his or her life, we must ask ourselves: Can I help him or her? If the answer is no, then we need to get help from other people or the authorities. All suicidal case has to treated as a serious case. All of them requiring hospital management, the least to be seen by a medical personnel. There is always help available for those who looks for it. I personally do not reject alternative medication. In a multiracial community, the populations tend to attribute certain mental illness with supernatural experiences, thus seeking help from a traditional healers. However, one should not forget the need to treat his/her medical condition. If the person is left untreated for his/her depression, chances are the condition will get worse and the person might deteriorate and end up with suicide. Yet all these condition can be treated easily with medications. So do not deprive yourself from getting the appropriate treatment. Its okay to get other forms of help at the same time.

My mother is a social worker, mostly involved in counseling. She is a professional in doing her job. And most of the time, people can find help from her, emotionally, to unburden the mind and to find someone to talk to. The point is, always find someone to talk to regarding your problem. Find someone you can trust. Do not keep things to yourself too much until it became the last straw on the camel's back. There is always a professional person to help you sail through the troubled sea.

Next, a family members or friend must be supportive to the person. Blaming will only makes the matter worse. All they need is a little bit of love and a listening ears. Listen to their problem, openly discuss the matter. Have more family time together, sharing the joy and pain and the ups and downs.

In a Nut Shell...

I could not stress enough the importance of detecting a suicidal person early. Once detected, there is always a way to treat the problem. Don't be shy, get help. We are not alone in this world.