There is no cure for diabetes

For diabetics who can’t control glucose levels with lifestyle measures, drugs are required. sugar-973899_640THERE is no cure for diabetes. The objective of its management is to maintain blood glucose levels within normal limits to prevent the development of health problems, for example, heart disease, kidney disease or stroke, in later life. The initial treatment of mild type 2 diabetes is lifestyle measures, which is all that is necessary sometimes. However, medicines to control blood glucose levels are necessary when lifestyle measures are no longer effective in mild diabetes and in moderate to severe diabetes. The initial medicines will be tablets. Later, it may include insulin, which is injected, and/or other medicines as well.

If you are suffering from Type 1 & 2 diabetes, please consult a Physician for the available options.

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Carpal Tunnel Syndrome

Carpal tunnel syndrome is a disorder of the hand caused by pressure of the nerve that run through the wrist. Symptoms include numbness, pins and needles, and pain around the fingers. These sensations are often more pronounced at night and can awaken people from sleep.

Chronic carpal tunnel syndrome can also lead to wasting (atrophy) of the hand muscles and frequent dropping of objects from the hand due to reduced in grip strength.

For more information about other hand conditions, please refer to www.alphahandcentre.com or visit our Consultant Orthopaedic & Trauma Surgeon, Dr. Terence Tay at

Alpha Hand Surgery Centre
25 Jalan PJU 5/6, Kota Damansara,
47810 Petaling Jaya,
Selangor, Malaysia

Tel: +60 3-6142 1087 /+60 3-6141 8533

Breast Lumps

1. What are breast lumps?
Breast lumps are swellings felt within the breasts. They may be single or multiple.

2. How are breast lumps detected?
Breast lumps are usually discovered by the patient herself. This may be on self-examination or during unrelated activity e.g. during a shower. They can also be detected by a doctor during a health check-up. Breast lumps are reliably detected on screening by breast imaging, either with ultrasound or mammogram.

3. What are the related symptoms?
Most breast lumps are painless. Pain is found in a rapidly growing lump or if there is infection (abscess). Pain is not a feature in breast cancer.

Your doctor will ask relevant questions when you present with a breast lump. These include whether you had a previous history, how long it was there, fluid discharge from the nipple, the number of children you have, taking oral contraceptives (the ‘Pill’), whether you still have periods or if you are menopausal, and whether you have a family history of breast cancer. These questions aid in diagnosing the nature of the breast lump.

4. What are the types of breast lump?
Breast lumps are either cystic (liquid-filled) or solid. Cysts are almost entirely benign. Solid lumps can be either benign or malignant (cancerous). Benign lumps are mostly fibroadenomas (firm white lumps containing the protein collagen). Other benign lumps include haematoma (old blood clots), galactocoele (collection of breast milk), mastitis (inflammation), abscess (infection) and granuloma (chronic infections including tuberculosis).

5. What are the tests required?
The ultrsound scan will distinguish between cystic and solid masses. Mammography (‘Mammo’) is useful in detecting changes in the breast pattern (architecture) on plain x-ray films; some of these changes may indicate early cancer even before a ump is detected. Mammograms are usually recommended after the age of 40. Because these tests provide different kinds of information, a combination of both is often used. In cystic swellings, the fluid may be aspirated (drawn out) and sent for cytology, which is a microscope test to look for cancer cells. Solid lumps can also be studied by this method, namely fine needle aspiration cytology (FNAC). The accuracy of this test is over 90%.

6. What is the treatment?
Cysts should mostly be left alone. They can be aspirated if large and/or cause symptoms, such as discomfort. Should a solid lump be left alone of removed? Based on the history, physical examination, and ultrasound and/or mammogram, your surgeon will advise on the best treatment plan for you. If there is any suspicion of cancer, urgent FNAC and/or excision is vital.

7. Surgery for breast lumps
Excision is done under general anaesthesia. This is not a major surgery and can be performed in a day-care setting; i.e. you do not require overnight hospital stay. It is a short procedure (about 30 minutes). The scar will match the size of the lump. If absorbable sub-cuticular (under the skin) sutures are used, they do not have to removed and scarring is much less. All excised lumps are sent to the laboratory for histological examination (HPE)to determine their exact nature. Needless to say, early surgery offers the best chance of cure in breast cancer.


 

Disclaimer: Nothing on this blog should be considered or used as a substitute for medical advice, diagnosis or treatment. Blog visitors with personal health or medical questions should consult their health care provider.

Heartburn or acid reflux

Acid reflux is also known as heartburn or acid indigestion. It creates a burning pain in the lower chest area and often after eating. Acid reflux is often associated with our lifestyle and eating habits.  Eating frequent but smaller meals can help reduce your risk of heartburn and acid reflux diseases. Reduced consumption of carbonated drinks and alcohol along with exercise may help to reduce the symptoms.

Symptoms to note:

  • Hard to swallow food down your throat
  • Indigestion for 3 weeks or more
  • Sudden weight loss
  • Frequent burping or trapped wind
  • Nausea or vomiting
  • Pain in the upper stomach area

 

People who suffer from persistent heartburn for more than 3 weeks should seek help from doctor or a Gastroenterologist as it may lead to stomach and oesophageal cancers or other medical conditions.

A cautionary sign

Transient ischaemic attack is a warning sign that a stroke may just be around the corner.

A TRANSIENT ischaemic attack (TIA) is due to a temporary interruption of the blood supply to part of the brain, leading to a “mini-stroke”. Its features are similar to that of a stroke, but the duration is about a few minutes. The TIA is usually resolved within 24 hours.

TIAs provide a warning that further TIAs or a stroke is on the way. Its incidence is not well known as many people who have TIA do not seek medical attention. However, strokes are the third most common cause of death in Malaysia. It is estimated that there are about 52,000 strokes per annum, i.e. strokes occur in six persons every hour.

It has been estimated that without treatment, the likelihood is one in 10 that a stroke will occur within a month after a TIA. As strokes lead to disability and even death in some instances, TIAs should be treated as seriously as strokes. Its early investigation and treatment will markedly reduce the risk of another TIA or stroke.

Anatomy of a TIA

The brain receives its blood supply primarily from the carotid arteries in the front of the neck and secondarily from the vertebral arteries in front of the backbone. These arteries branch into smaller vessels that supply blood to all parts of the brain.

One of these smaller blood vessels gets blocked off during a TIA. This blockage is temporary, lasting a few minutes, and the blood supply is restored soon after, unlike a stroke, in which the blockage lasts a longer period of time. The lack of a constant supply of oxygen-rich blood leads to damage, and later, death of the brain cells.

The blockage is due either to a narrowing of the arteries or as a result of a blood clot formed elsewhere in the body getting into the brain’s arteries to reach a blood vessel small enough to block its passage.

The brain’s arteries are narrowed or blocked by cholesterol deposits (plaques) on its inner lining due to atherosclerosis. Everyone’s arteries get narrower with age, but the process is hastened by factors like high blood pressure, poorly controlled diabetes, raised blood cholesterol, obesity, smoking, excessive alcohol intake, obesity, and a family history of diabetes or heart disease.

TIAs can also result from blood conditions like leukaemia, abnormally thickened blood (polycythaemia), or overproduction of platelets (thrombocythemia).

A TIA can result from blood clots formed in an artery (from elsewhere in the body), which gets “thrown” off (emboli) and eventually blocks the brain’s blood supply. This may be due to irregular heartbeats, the causes of which include high blood pressure, coronary artery disease, disease of the heart’s mitral valve, overactive thyroid gland and excessive alcohol intake.

It is rare that a brain haemorrhage causes a TIA.

TIAs, like strokes, are preventable as lifestyle changes can reduce many of the risk factors. However, there are some risk factors that are not preventable. They include:

  • Age – The risks are increased in the older person, although TIAs can occur at any age, including the young.
  • Gender – Men are more likely to have TIAs than pre-menopausal women. However, the likelihood of TIA and stroke increases in postmenopausal women. Although the reason for this is not well elucidated, it is believed that the female hormones, oestrogen and progesterone, affect the elasticity of the body’s ateries.
  • Ethnicity – The risks are increased in Indians and Malays because the incidence of diabetes and hypertension are higher in these groups.
  • Medical history – The risks are increased if one has had a heart attack, stroke or TIA.
  • Family history – The risks are increased if a close relative has had a TIA or stroke.

There are several other factors (preventable) that increase the risks of TIAs and strokes. They include:

  • High blood pressure (hypertension) is the single most important risk factor. The hypertension leads to extra strain on the arteries, causing them to narrow or be easily blocked.
  • Diet – Atherosclerosis is more likely to develop with a diet high in saturated fats and excessive salt intake.
  • Diabetes increases the likelihood of TIA because of the increased risk of atherosclerosis.
  • Smoking doubles the likelihood of TIA or stroke because the chemicals in the cigarette smoke cause thickening of the arteries, thereby increasing the likelihood of clotting.

Features of TIA

The features vary depending on the part of the brain that is affected and the extent to which it is affected.

The common features of TIAs and strokes are:

  • Face – There may be an inability to smile, open the mouth or the face or eye may hang downwards.
  • Arms – There may be an inability to lift one or both arms due to numbness or weakness.
  • Legs – There may be an inability to move one or both legs due to numbness or weakness.
  • Speech – There may be slurring of speech or an inability to talk at all although awake.

Other features may include sudden vision loss, dizziness, difficulty talking and understanding what others say, difficulty swallowing, balancing problems, sudden headache, and blacking out.

Diagnosis

Immediate medical attention should be sought if one has or knows another person who has features of a TIA. This will reduce the likelihood of another TIA or stroke.

The diagnosis of a TIA is made by history taking and physical examination even if one thinks that the symptoms have gone. The objective is to check the patient’s neurological status and to rule out other conditions which may have caused the symptoms.

If a TIA is suspected, a referral will be made to a physician, geriatrician or neurologist for further evaluation. This should be done within a week of the occurrence of a TIA and immediately if there is more than one TIA in a period of seven days.

There are several investigations that are carried out after a TIA to check for the underlying conditions that may have caused it. They include:

  • Blood tests like clotting factors, glucose, cholesterol
  • Electrocardiogram to detect any abnormal heart rhythms
  • Chest x-ray may be done to exclude other medical conditions
  • Imaging

The common methods of brain imaging are computerised tomography (CT) scan and magnetic resonance imaging (MRI).

The CT scan involves multiple x-ray imaging to produce detailed three dimensional images of the brain and will provide information about factors that may have caused the TIA, e.g. haemorrhage or tumour. The MRI involves use of magnetic and radio waves to produce detailed images of the brain.

Both the CT scan and MRI are used to take images of the brain’s blood vessels as well the blood vessels in the neck that connect the heart and the brain’s blood vessels. This procedure, called a CT or MR angiogram, involves injecting a dye into a vein in the arm.

The brain imaging modality used depends on the availability of CT scan and/or MRI.

Other investigations of the cardiovascular system will be carried out to determine the cause of the TIA. It includes ultrasound examination of the heart (echocardiogram) or carotid artery in the neck (Doppler scan). It can also include injecting dye into the carotid or vertebral arteries (arteriography) to enable a detailed examination of the arteries in the brain.

The management of TIA will be discussed in a subsequent article.


 

Dr Milton Lum is a member of the board of Medical Defence Malaysia. This article is not intended to replace, dictate or define evaluation by a qualified doctor. The views expressed do not represent that of any organisation the writer is associated with

Brain attacks

When blood supply to the brain is compromised, it can lead to damage, and possibly death, of the brain cells, a condition called stroke.

THE human brain has been compared to a supercomputer. But the brain is much more complicated than that, a fact that is confirmed with each new discovery about its capabilities, which is still largely unknown.

This single organ controls all the body’s functions, which include heartbeat, breathing, sexual function, thinking, speech, memory, emotions, movement, and sleep. It influences the immune system’s response to ill health, and determines, to some extent, how a person responds to medical treatment.

In short, the brain makes us human and separates us from other living creatures on planet Earth.

The brain, which is encased in the bony skull, is divided into two sides (hemispheres), each controlling the opposite side of the body.

Different parts of the brain have different functions. The frontal lobe is responsible for the highest intellectual functions like thinking and problem-solving. The parietal lobe is responsible for sensory and motor function. The hippocampus is involved in memory. The thalamus is the relay station for almost all of the information coming into the brain, and the hypothalamus, the relay stations for the systems regulating the body’s functions.

The midbrain has cells that relay specific sensory information from the sense organs to the brain. The hindbrain comprises the pons and medulla oblongata, which control breathing and heart functions, and the cerebellum, which controls movement and cognitive processes that require precise timing.

The brain’s functions depend on a constant blood supply for the oxygen and nutrients needed by its cells. The restriction or stoppage of this supply leads to damage, and possibly death, of the brain cells. This is called a stroke.

A stroke, also called a cerebrovascular accident (CVA), is a condition whereby the blood supply to a part of the brain is cut off. It is a medical emergency, and the earlier treatment is provided, the less severe it will be.

Strokes are the third most common cause of death in Malaysia. It is estimated that there are about 52,000 strokes per annum, i.e. strokes occur in six persons every hour.

Different types

There are two main types of strokes.

Ischaemic strokes, which comprise the majority of stroke cases, occur when the blood supply to the brain stops because the vessel is blocked by a blood clot. This may be due to thrombosis, in which a blood clot forms in one of the brain’s arteries, or to an embolism, in which a blood clot formed elsewhere in the body gets into the brain’s arteries to reach a blood vessel small enough to block its passage.

Haemorrhagic strokes occur when bleeding results from a burst blood vessel supplying the brain because of weakness in its wall. The blood collection compresses the brain, causing damage and loss of function.

A related condition is transient ischaemic attack (TIA) in which there is temporary interruption of the blood supply to part of the brain, leading to a “mini-stroke”. As TIAs provide a warning that a stroke is on the way, they should be treated seriously.

Causes of stroke

Strokes are preventable as lifestyle changes can reduce many of the risk factors. However, there are some risk factors that are not preventable. They include:

·Age – The risks are increased in the older person, although about a quarter of strokes occur in the young.

·Ethnicity – The risks are increased in Indians and Malays because the incidence of diabetes and hypertension are higher in these groups.

·Medical history – The risks are increased if one has had a heart attack, stroke, or TIA.

·Family history – The risks are increased if a close relative has had a stroke.

Ischaemic strokes occur when the brain’s blood supply is blocked by clots formed where the arteries are narrowed or blocked by cholesterol deposits due to atherosclerosis.

Everyone’s arteries get narrower with age, but the process is hastened by factors like high blood pressure, poorly controlled diabetes, raised blood cholesterol, smoking, excessive alcohol intake, obesity and a family history of diabetes or heart disease.

An irregular heartbeat leads to blood clots being thrown off to block the brain’s blood supply. The causes of irregular heartbeats include high blood pressure, coronary artery disease, disease of the heart’s mitral valve, overactive thyroid gland and excessive alcohol intake.

Haemorrhagic strokes occur when a blood vessel of the brain bursts, resulting in bleeding into the brain itself (intracerebral haemorrhage). Sometimes, the bleeding is on the brain surface (subarachnoid haemorrhage).

The primary cause of haemorrhagic stroke is high blood pressure, the risk factors of which include smoking, overweight or obesity, lack of exercise, excessive alcohol intake and stress.

Blood-thinning medicines can also cause haemorrhagic strokes, which can also occur from blood vessel malformations in the brain or an aneurysm, which is a balloon-like swelling of a blood vessel.

Trauma can also cause bleeding in the brain. Although the cause is usually apparent, bleeding into the brain’s lining (subdural haematoma) may occur without signs of trauma.

A rare cause of stroke is blood clot formation in the brain’s veins, which is usually due to clotting abnormalities.

Signs and symptoms

The features vary depending on the part of the brain that is affected and the extent to which it is affected. Strokes usually occur suddenly.

The common features are:

·Face – There may be an inability to smile, open the mouth or the face or eye may hang downwards.

·Arms – There may be an inability to lift one or both arms due to numbness or weakness.

·Legs – There may be an inability to move one or both legs due to numbness or weakness.

·Speech – There may be slurring of speech or an inability to talk at all.

Other features may include sudden vision loss, dizziness, difficulty talking and understanding what others say, difficulty swallowing, balancing problems, sudden and severe headache, and blacking out.

Awareness of the above features is crucial, particularly for those at increased risk of a stroke, and their caregivers.

The complications of stroke include swallowing problems (dysphagia), which affect about a third of stroke patients. This leads to small food particles entering the respiratory tract causing lung infection (pneumonia).

Stroke can also lead to excess cerebrospinal fluid (CSF) in the brain’s ventricles (hydrocephalus) in about 10% of haemorrhagic strokes. CSF, which is produced by the brain, is continuously drained away and absorbed by the body. When its drainage is stopped following a haemorrhagic stroke, the excess CSF causes headaches, loss of balance, nausea and vomiting.

A small percentage of stroke victims who have lost some or all movement in their legs will have blood clot formation in their legs. The features of this deep vein thrombosis (DVT) include swelling, pain, tenderness, warmth and redness, especially in the calf. Urgent diagnosis and treatment is necessary to avoid the clot moving to the lungs, causing pulmonary embolism, which is potentially fatal.

Diagnosing stroke

The diagnosis of a stroke is made by history taking and physical examination. However, imaging of the brain is essential to determine if it is an ischaemic or haemorrhagic stroke, the part of the brain that is affected, and the severity of the stroke.

As the treatments of the different types of stroke vary, a speedy diagnosis will facilitate its management.

The common methods of brain imaging are computerised tomography (CT) scans and magnetic resonance imaging (MRI).

The CT scan involves multiple x-ray imaging to produce detailed three-dimensional images of the brain. MRI involves the use of magnetic and radio waves to produce detailed images of the brain.

Both the CT scan and MRI are used to take images of the brain’s blood vessels, as well as the blood vessels in the neck that connect the heart and the brain’s blood vessels. This procedure, called a CT or MR angiogram. involves injecting a dye into a vein in the arm.

The brain imaging modality used depends on the availability of a CT scan and/or MRI. A CT scan provides enough information if the suspected stroke is major. The MRI is useful if there are complex symptoms, the extent or location of the affected area is unknown, and in patients who have recovered from a TIA.

Brain imaging should be done early; in some patients, within an hour of admission.

A swallow test is usually done for all stroke patients because of the risk of aspiration pneumonia due to dysphagia. This involves giving a few teaspoons of water to the patient and if there is no choking or coughing, to be followed by half a glass of water.

Other investigations of the cardiovascular system will be carried out to determine the cause of the stroke.

It includes ultrasound examination of the heart (echocardiogram) or carotid artery in the neck (Doppler scan). It can also include injecting dye into the carotid or vertebral arteries (arteriography) to enable a detailed examination of the arteries in the brain.

The management of stroke will be discussed in a subsequent article.


 

Dr Milton Lum is a member of the board of Medical Defence Malaysia. This article is not intended to replace, dictate or define evaluation by a qualified doctor. The views expressed do not represent that of any organisation the writer is associated with.

I’m gonna jump

The are several factors that increase the risk of a person committing suicide.

EVERYONE’S life has its ups and downs, with feelings and emotions accompanying many of these situations. Most people adapt and cope with the downs. However, there are some who are so overcome with these emotions that they take their own life.

Suicide is an individual’s intentional act of ending his or her life.

Many suicide attempts are preceded by a history of self-harm, in which there is deliberate injury that a person inflicts on his or her body. This does not mean that the person who self-harms wants to commit suicide, but is an effort by the person to cope with intense emotions.

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However, self-harm is an indication that the person needs immediate assistance.

Suicide is a common cause of death in young people worldwide. According to the National Health and Morbidity Survey 2006, there was a 6.3% rate of acute suicidal ideation, and 25.8% of chronic suicidal ideation. The highest prevalence rate of suicidal ideation of 11% was found in those aged between 16 and 24 years.

The National Suicide Registry Malaysia (NSRM) 2008 report stated there were 290 suicides in that year, of which 219 were men and 71 women, with Chinese comprising 53.5%, Indians 27.3%, and Malays 13.9%.

The youngest suicide victim was 12 years, while the oldest was 83 years. The NSRM estimated that there were 425 suicides between January and August 2010, averaging 60 per month, ie two daily.

It is estimated that the suicide rate is similar to that of the United States.

Although women are more likely to attempt suicide and other self-harm behaviour, it is the men who are more likely to succeed in suicide. The suicide rate in men in many countries is about three times that of women.

Risk factors

The reasons why some people commit suicide while others in similar situations do not, have not been determined. However, there are some factors that increase the risk of suicide.

Genetics is believed to be a risk factor as suicide has been found to be more common in certain families. There are several genetic mutations reported that may alter the chemicals in the brain, increasing the vulnerability to suicidal thoughts and behaviour. However, no specific gene for suicide has been identified.

Mental health conditions are the most significant risk factor, particularly serious and chronic mental health conditions. It has been estimated that about 90% of people who commit or attempt suicide have a mental health condition.

Severe depression is associated with misery and hopelessness – there is a 20-fold increase in the likelihood of attempted suicide than the general population.

Sufferers of bipolar disorder alternate between extreme joy to severe depression. About a third of these sufferers attempt suicide, and about 10% commit suicide.

Patients with schizophrenia are unable to think logically, and have difficulty differentiating between real and unreal experiences, with about 5% committing suicide. The risk is greatest when the diagnosis is made, but with the passage of time, they are better able to cope with their situation.

Anorexia nervosa is a condition in which anxiety about body weight leads to extreme efforts at limiting food consumption. About a fifth of anorexics will attempt suicide.

Patients with borderline personality disorder have altered thinking, unstable emotions, impulsive behaviour and unstable relationships. About half of these sufferers will attempt suicide, with an increased risk in those who were sexually abused in childhood.

It is believed that a combination of other factors increases the risk of suicide. These factors may or may not be significant, depending on the person’s vulnerability at the point in time. They include:

  • History of a recent traumatic experience, eg end of a relationship, bullying, loss of job, bereavement.
  • History of a traumatic experience in childhood, eg sexual or physical abuse, bereavement, parental neglect.
  • A parent with a serious mental health condition, eg severe depression, bipolar disorder, schizophrenia, or who committed suicide.
  • A previous attempt at suicide.
  • Social isolation, with few family members or friends.
  • Misuse or abuse of drugs and alcohol .
  • Unemployment or poor job satisfaction or security.
  • Debt.
  • Occupations which permit access to the means to attempt suicide, eg doctor, nurse, pharmacist, planter.

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Danger signs

There are warning signs that indicate that a person is suicidal. They include talking or writing about death or suicide threats to injure or kill himself or herself, and actively seeking methods of committing suicide, eg stockpiling medicines, particularly sleeping pills, and/or pills used to treat serious mental conditions.

Other warning signs include:

  • Complaints, talk or behaviour that indicate hopelessness or a meaningless life.
  • Loss of interest in personal appearance, eg poor dressing, cessation of use of make-up.
  • Reckless or risky behaviour without concern for the consequences.
  • Sudden mood changes, anxiety, agitation.
  • Increased withdrawal from interactions with family members and friends.
  • Insomnia or sleeping all the time.
  • Abuse or misuse of drugs or alcohol.
  • Putting their affairs in order.

When warning signs are noticed, it would be useful to encourage the affected person to talk about it and to listen attentively. One should listen to what the person has to say to let them know that there is someone who cares about them.

A non-judgemental manner and empathy are essential. One should not influence what is said, but rather, facilitate honest and frank conversation.

Any questions raised by the listener have to be open-ended, and not end the conversation.

At the same time, the person’s doctor or nurse should be contacted. If it is not possible to do so, the accident and emergency department of the nearest hospital should be contacted as to how to get professional help for the affected person. If one assesses that the affected person has a high risk of dying by suicide before the arrival of professional help, one should contact the nearest ambulance service.

At the same time, any possible means of suicide should be removed from the immediate environment of the affected person. This would include medicines, household chemicals, sharp objects, etc.

Providing care to a suicidal person is stressful and distressing, and it can impact upon the carer’s mental health. Professional help may be required to address the carer’s emotions after the event.

Preventing suicide

Mental health is no different from physical health. Measures can be taken to improve mental health so that one is stronger emotionally and better able to cope with the downside of life, thereby reducing the risk of developing mental health conditions like depression.

Exercise is effective in the management of depression. Physical activity reduces stress and anxiety, improves mood, and promotes the release of brain chemicals called endorphins, which makes one “feel good”.

A healthy diet not only provides protection against physical health problems, but may also be vital in maintaining mental health.

Avoidance of social isolation is an important measure as it is a risk factor for suicide. Having friends is beneficial for mental health. If there is individual difficulty in making friends, you should consider joining a local activity group or support group. There is evidence that people involved in providing assistance to others through voluntary or charity organisations are mentally healthier than the general population.

Having a positive attitude is vital as persistent negative thoughts increase the risk of isolation. Cognitive behaviour therapy (CBT) is a type of talking treatment that assists in the management of problems by changing the thoughts and actions of the affected person.

Many people use drugs to help them cope with life’s problems. Their misuse or abuse may lead to more problems and increases the risk of developing serious mental conditions like depression.

Even recreational drugs like marijuana, which is perceived to be less harmful, increase the risk of depression and schizophrenia in some people.

Many people use alcohol to help them cope with life’s problems. Its misuse or abuse may lead to more problems and increases the risk of depression. It would be prudent to avoid exceeding the recommended daily alcohol consumption limits – ie three to four units for men and two to three units for women. A unit is the equivalent of about half a pint of normal strength lager, a small glass of wine, or 25ml of spirits.

A consultation with your regular doctor would be helpful if there are problems with drug usage or alcohol consumption.

However, the evidence is that an effective preventive strategy is to educate doctors on how to recognise and treat depression, and restricting access to lethal methods of suicide. Another promising strategy is to train particular groups of people on how to identify those at risk and refer them for treatment.

Support groups provide counselling and practical advice to people who are depressed, or have suicidal thoughts. The local support group are the Befrienders and their contact details are 95, Jalan Templer, Petaling Jaya 46990 (Telephone: 03 7956 8144 or 03 7956 8145; email: sam@befrienders.org.my)

If you do not like the idea of talking to someone on a helpline, you can talk to a family member, trusted friend, doctor or religious leader. You should also consult your doctor, who can prescribe treatment for mental health conditions.


 

Dr Milton Lum is a member of the board of Medical Defence Malaysia. This article is not intended to replace, dictate or define evaluation by a qualified doctor. The views expressed do not represent that of any organisation the writer is associated with.

Hard to learn

Although dyslexia is considered a learning disorder, there is no relationship between dyslexia and intelligence.

SOME people have a learning disability that leads to difficulty in learning and using certain skills. The skills that are usually affected are reading, writing, listening, speaking, reasoning, and doing mathematics.

The terms used for these disabilities are dyslexia, which refers to difficulties in reading and spelling; dysgraphia, which refers to difficulties in writing; and dyscalculia, which refer to difficulties in doing mathematics.

This article is about dyslexia, which is derived from the Greek works, dys (difficulty), and lexia (use of words). The symptoms range from the very mild to the very severe. People with dyslexia have difficulties with phonemic awareness, verbal memory and verbal memory speed.

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Phonemic (or phonological) awareness is the ability to learn how speech sounds make up words, connecting the sounds to alphabet letters, and learning how to blend the sounds into words. Changes in the sounds lead to different words with different meaning. This ability is believed to be crucial in early reading and spelling development.

Verbal memory is the ability to remember a sequence of verbal information for a short time. Verbal processing speed is the time taken to recognise and process familiar verbal information, e.g. this speed is the time taken to recognise the letters, A, S, E, A and N, process it, and then realise that it refers to the Association of South East Asian Nations. Although dyslexia is considered a learning disorder, there is no relationship between dyslexia and intelligence. Dyslexia has been defined well by Shaywitz, who stated that, “Dyslexia is a reading difficulty in a child or adult who otherwise has good intelligence, strong motivation and adequate schooling … Dyslexia reflects a problem within the language system in the brain.”

Dyslexia is reported to affect about 10% of schoolchildren, with about 4% having severe difficulties that affect their learning ability in school. The incidence in males is estimated to be 1.5 to three times more than that in females. It affects all ethnic groups.

Roots of dyslexia

Dyslexia is a genetic condition. However, there are various theories about the causes.

It occurs in certain families. It is estimated that a child of a dyslexic has a 40% to 60% chance of developing the condition. If an identical twin has the condition, it is very likely that the other twin would also have the condition.

Scientists have detected genes that may lead to dyslexia, but their effects on the brain have yet to be elucidated.

The phonological processing impairment theory is believed by many to explain how dyslexia affects reading and writing. The ability to understand spoken language is an innate capacity of the brain, which recognises a word as a whole and does not register it by the units of sound that constitute a word (phonemes).

However, reading and writing requires the ability to recognise the letters in a word, identify from the letters the phonemes, and then bring them together to form a word. This process, which is termed phonological processing, is believed to be impaired in dyslexics.

There is evidence from magnetic resonance imaging (MRI) that the part of the brain (left hemisphere) involved in producing, analysing and identifying written words demonstrate less activity in dyslexics when they read. This may impact upon phonological processing.

MRI has also shown that the activity in the cerebellum of dyslexics is different from those without the condition. The cerebellum, which is found at the lower back of the brain, is believed to be crucial to the processing of language, coordination and assessment of time. This may explain why dyslexics have difficulties with coordination and time management.

Distinctive features

There is individual variation in the features of dyslexia. Each affected person would have distinctive features.

The features in a pre-school child include delayed speech development when compared to children of the same age; speech problems, like an inability to pronounce long words; problems expressing spoken language, like an inability to remember the right word to use; lack of understanding or appreciation of words that rhyme; or lack of interest in learning the letters of the alphabet.

It is not always possible to detect dyslexia in a pre-school child.

The features in the early school years include problems learning the names and sounds of letters, erratic spelling, problems copying written language, and poor phonological awareness, i.e. the ability to recognise that words are comprised of smaller sound units (phonemes) and new words can be created by altering the phonemes.

The child may also have difficulty in making sense of unfamiliar words by considering smaller words or collection of letters.

The features in the later primary school years include problems with spelling, problems understanding and recognising new words, and slow reading speed.

The features in secondary school include problems with reading fluency, slow writing speed, and problems expressing knowledge in writing.

Some dyslexics reach adulthood without the diagnosis ever being made. Their features include avoidance of reading and writing and hiding these difficulties from others, reliance on memory and verbal skills instead of reading and writing, poor spelling, and poor time management.

Dyslexia is associated with poor numerical skills, poor short term memory, poor concentration, poor time and organisational management as well as problems with physical co-ordination.

The earlier dyslexia is diagnosed, the more likely its management will be effective.

If a child has difficulties with reading and writing, a discussion with the teaching staff and a consultation with the family doctor would be helpful. The latter would exclude health problems which affect the child’s ability to read and write, e.g. vision problems, poor hearing, and other conditions like attention deficit hyperactivity disorder. The former would help in a review of the teaching methodology and provide alternative approaches and support, which is helpful for many children, including those with mild or moderate dyslexia.

If the problem persists despite the above, an assessment by an educational psychologist would be advisable. The latter is a specialist who assists children with problems in their educational progress because of emotional, psychological, cognitive (learning), or behavioural factors. This can be challenging as there are not many educational psychologists available in the country.

Alternatively, assistance can be sought from the Dyslexia Association of Malaysia, which has centres in Peninsular Malaysia. Its contact details are 6, Persiaran Kuantan, Off Jalan Setapak, 53200 Kuala Lumpur (Tel: 03-4025-5109).

The assessment includes an evaluation of the child’s reading and writing abilities as well as other skills like vocabulary, memory, reasoning, language development, processing speed of visual and sound information, organisational skills, and approaches to learning.

A diagnosis of dyslexia is made if the child’s reading and writing skills are poor despite appropriate teaching methodology and the child’s logic and verbal skills are unaffected.

Adults can also have similar assessments done.

Treating dyslexia

There is currently no cure for dyslexia. However, there are many interventions that can assist dyslexics. The degree and type of intervention is determined by the severity of the problems.

Interventions before a child goes to school are effective in achieving long term improvements in the condition. There is evidence that interventions which improve the ability to identify and process sounds (phonological skills) are effective.

These interventions, which are called phonics, concentrate on recognition and identification of sounds in spoken words (phonemic awareness) and instruction on phonics, spelling, writing, vocabulary, comprehension, and fluency.

There is evidence that effective methods of teaching phonics to dyslexics have certain features:

● Teaching is structured, with gradual increase based on what has been learnt previously.

● Use of different senses.

● Reinforcement with regular practice.

● Development of other useful skills.

● Recognition that there are different learning methods and approaches and then selecting the appropriate one for different situations.

● Breaking down the dyslexic’s emotional barriers, like anxiety and frustration, with empathy, encouragement, and promotion of the dyslexic’s self-esteem.

Many older children find the use of educational software applications useful rather than text or exercise books.

Similar approaches are useful in adult dyslexics.

In a nutshell

It is useful to remember that about 95% of dyslexic children respond well to educational interventions, with reasonable to good progress in reading and writing. About 5% continue to experience difficulties and would need more rigorous and long-term support.

It must be emphasised that although dyslexic children encounter daily challenges, even those with severe dyslexia can go on to have full and productive lives.


 

Dr Milton Lum is a member of the board of Medical Defence Malaysia. This article is not intended to replace, dictate or define evaluation by a qualified doctor. The views expressed do not represent that of any organization the writer is associated with.

When sepsis strikes

Sepsis is a potentially life-threatening condition triggered by an infection, and must be detected and treated early.

Everyone suffers from infections from time to time. Various parts of the body can be involved, for example, the respiratory tract, skin and urinary tract.

The organisms are usually bacteria and viruses, but may occasionally be parasites or fungi.

The body’s response to an infection is to limit it to one site. White blood cells travel to the infection site, and a series of reactions occur to fight the infection and prevent its spread.

The process, called inflammation, is aimed at removing the harmful organisms and damaged cells, and start the healing process.

Inflammation can be acute or chronic. The former lasts a few days, though sometimes, a few weeks. The latter can last several months, or even, years, and is due to failure to eliminate the cause of the acute inflammation, or it could be due to a chronic persistent microbe of low intensity. An example of the former is acute upper respiratory tract infection, and the latter, tuberculosis.

When the immune system is weak or the infection is virulent, the infection spreads through the bloodstream to other parts of the body and causes widespread inflammation.

The body’s response injures its own tissues and organs. There may be a marked decrease in blood pressure that affects oxygen transport to vital organs like the heart, kidneys and brain. If untreated or treated inadequately, sepsis leads to multiple organ failure and death.

Infections associated with sepsis are infections of the lung, urinary tract, gallbladder, abdomen, pelvis, skin, and even, flu, in some cases.

The most common infection sites that lead to sepsis are the lungs, urinary tract, abdomen and pelvis.

However, there are instances where the source and cause of the sepsis cannot be identified.

According to the Malaysian Registry of Intensive Care, head injury, sepsis and community-acquired pneumonia were the three most common diagnoses leading to admission to intensive care units (ICU) in Health Ministry hospitals in 2011.

The in-hospital mortality rates of these patients were 25.2%, 58.9% and 40.6% respectively.

Risk factors

Everyone is at risk of sepsis. Some patients with sepsis do not require hospitalisation, although they feel ill. When sepsis is severe, immediate hospitalisation is necessary.

Sepsis is more common in those at risk – the very young and very old; the pregnant; those who have chronic conditions such as diabetes; those who just had surgery, accidental injuries and/or with invasive devices such as drips, catheters and ventilators; those whose immunity are weakened, such as HIV patients or those on treatment that weakens the immunity (long-term steroids, cancer chemotherapy); and those who are hospitalised for some other condition.

Hospital-associated infections are more serious, as many of the bacteria are resistant to many commonly-used antibiotics.

Managing sepsis

The features of sepsis include fever, chills, shivering, tiredness, poor appetite, rapid heart rate and rapid breathing.

The features of severe sepsis, which is life-threatening, include difficulty breathing; abnormal heart function; cold, clammy skin; abrupt change in mental state (confusion, disorientation); slurred speech; loss of consciousness; markedly decreased urine output; and decreased platelets.

The blood pressure in septic shock is very low and does not respond adequately to fluid replacement.

The diagnosis of sepsis is clinical, and the tests include that of blood and body fluids, such as urine, wound secretions, respiratory secretions and stool; imaging, including x-ray, ultrasound, computerized tomography (CT) scan; and kidney, heart and lung function tests.

Early diagnosis is essential to determine the type of infection, its location, and its impact on body functions.

Early treatment is necessary to stop the sepsis from progressing, reduce damage and decrease the risk of death. Treatment is dependent on the site and cause of the initial infection, the organ affected and the damage caused.

Severe sepsis or septic shock can only be treated in a hospital and may require admission to the ICU. This is because the chances of death in severe sepsis and septic shock is about four and six in every 10 affected persons respectively.

The mainstay of treatment for sepsis, severe sepsis or septic shock is antimicrobials upon diagnosis, even before the infectious agent is identified.

Initially, broad-spectrum antimicrobials, which are effective against a variety of organisms, are administered intravenously.

After getting the blood results, the antimicrobials may be changed to one that is more appropriate to the specific cause.

Although antibiotics are not effective against viruses, parasites or fungi, it is likely that they will be started anyway because it would be too dangerous to delay treatment.

Once the specific cause is identified, the appropriate antimicrobial will be given.

Antiviral agents may be given at the outset if there is strong suspicion that it is the cause of the sepsis.

The source of the infection, when identified, will be treated. Collections of pus will be drained. Surgery may be needed to remove pus and infected tissue.

Oxygen is administered through a mask or tubes in the nostrils if blood oxygen levels are low.

Those who have severe difficulty breathing would have a tube inserted into their trachea that is connected to a machine that helps breathing mechanically (i.e. a ventilator).

Medicines called vasopressors are prescribed for low blood pressure to help increase it by stimulating the muscles that pump blood around the body and narrowing or constricting blood vessels.

Extra fluids may also be given intravenously to help increase blood pressure.

Sufficient intake of food and liquids is essential. The former is done by inserting a thin tube up the nose and down into the stomach, or by inserting a drip to provide food and fluids.

Intravenous fluids are usually given in severe sepsis or septic shock to prevent dehydration and kidney failure. A catheter will be inserted into the bladder to monitor urinary output so that renal failure can be detected early.

Painkillers may be needed. Medicines to keep the patient drowsy or asleep may be prescribed to ensure sufficient rest and make the patient more comfortable.

Other treatments that could be instituted include blood transfusion, steroids, insulin and dialysis for impaired kidney function.

The duration of treatment depends on each patient’s individual circumstances.

It is advisable for anyone with features of an infection to seek medical attention, particularly if there are risk factors.

Anyone who develops features of sepsis after surgery, hospitalisation or an infection is advised to seek immediate medical care.

Early diagnosis and treatment will lead to full recovery. Late diagnosis and treatment may lead to disability, and even, death.


Dr Milton Lum is a member of the board of Medical Defence Malaysia. The views expressed do not represent that of any organisation the writer is associated with.

Shingles

Shingles is a result of the same virus that causes chickenpox.

Shingles or herpes zoster (HZ), which is also known as the “snake” in local vernacular, is an infection of a nerve and the surrounding skin by the varicella-zoster virus (VZV), which also causes chickenpox.

After a chickenpox infection, VZV does not disappear but remains inactive in the body. The virus is reactivated when the body’s immunity is weakened, e.g. increasing age, stress, chemotherapy for cancer, HIV/AIDS, recent organ or bone marrow transplant.

HZ cannot be transmitted to adults who have had chickenpox before. However, it is possible for someone who has not had chickenpox previously to get infected from direct contact with fluid from the blisters of a person who has shingles, as they contain live viral particles.

When the blisters have dried and formed scabs, the sufferer is no longer infectious. This usually takes 10 to 14 days.

A shingles attack usually lasts from two to four weeks, with the main symptoms being pain followed by a rash. It can affect any part of the body, with the chest and abdomen the most common areas.

Some may experience early symptoms, which occur a few days before the painful rash. They include a headache; burning, tingling, numbness or itchiness of the skin in the affected area; feeling unwell; and fever.

Eventually, most have a localised band of pain. The affected skin is usually tender to the touch. The pain usually occurs a few days before the rash appears, and can remain for days or weeks after the rash disappears.

The pain is more severe and lasts longer in the elderly.

The rash usually appears on one side of the body on the skin area supplied by an affected nerve. It appears as red blotches initially, and then develops into itchy blisters similar to those in chickenpox.

The blisters then flatten, dry out and turn yellowish. Scabs are formed where the blisters used to be, with slight scarring. Complete healing of the rash takes two to four weeks.

Sometimes, complications occur, especially if the one affected is older or immunity is weakened. The complications involve the nerves, skin, eyes and other organs.

Post-herpetic neuralgia (PHN) is the most common complication. It has been estimated that one in five HZ sufferers above the age of 50 years develop PHN. The pain may be constant or intermittent, burning, aching, throbbing, stabbing or shooting.

PHN sometimes take about three to six months to resolve, and may last for years and become permanent. It is more common and severe in senior citizens.

If the eyes are affected, the complications include ulcers and permanent scarring of its surface (cornea); increased pressure inside the eye (glaucoma); and inflammation of the eye and optic nerve, which connects the eye to the brain.

Ramsay Hunt syndrome, which is due to HZ infection of certain nerves in the head, is rare. It causes earache, hearing loss, dizziness, a feeling that the body or environment is moving (vertigo), hearing sounds from inside the body (tinnitus), loss of taste and facial paralysis.

Other rare complications include infections of the lung (pneumonia), liver (hepatitis), brain (encephalitis), spinal cord (myelitis) or the membranes surrounding the brain and spinal cord (meningitis).

Although HZ is rarely life threatening, it has been estimated that it is fatal in about one in every 1,000 cases in adults above 70 years.

There is no cure for HZ. However, early treatment may reduce its severity and the risk of complications.

Medicines to relieve the pain are usually prescribed.

Antiviral medicines are also prescribed to some patients for seven to 10 days. Although these medicines cannot kill HZ, they stop it from multiplying. This reduces the severity and duration of the attack and prevent complications like PHN.

The medicines are most effective when taken within 72 hours of the rash appearing. They may be taken within a week of the rash appearing in those who are at risk of severe HZ or its complications, i.e. those above 50 years, HZ affecting the eyes, moderate to severe pain or rash, and weakened immunity.

A vaccine against HZ recently become available. Studies have shown that the vaccine reduces the incidence of HZ and PHN; the severity of acute pain; and HZ’s interference with activities of daily living in adults above 50.

The vaccine has been reported to be efficacious for up to 10 years. The incidence of serious side effects is less than 0.1%.

The vaccine has been recommended for adults above 60 years, and may also be prescribed for adults above 50 years.

If you have a HZ rash, avoid swimming, contact sports or sharing towels. This will prevent spread to anyone who has not had chickenpox, which is especially dangerous for the pregnant, infants less than a year, and those with weakened immune system.

If the rash is oozing fluid, it is advisable to avoid work or school.

When the blisters have dried and formed scabs, the sufferer is no longer infectious and does not need to avoid anyone.


Dr Milton Lum is a member of the board of Medical Defence Malaysia. This article is not intended to replace, dictate or define evaluation by a qualified doctor. The views expressed do not represent that of any organisation that the writer is associated with.