Hope it will be of benefit to you & others.

Please note that another name for Lady Finger (Bhindi ) is " OKRA ".

Last month in one of TV program I learnt of a treatment of Sugar
(Diabetes). Since I am diabetic, I tried it and it was very useful and my Sugar is in control now. In fact I have already reduced my medicine.

Take two pieces of Lady Finger (Bhindi) and remove/cut both ends of each piece. Also put a small cut in the middle and put these two pieces in glass of water. Cover the glass and keep it at room temperature during
night. Early morning, before breakfast simply remove two pieces of lady finger (bhindi) from the glass and drink that water.

Keep doing it on daily basis.

Within two weeks, you will see remarkable results in reduction of your SUGAR.

My sister has got rid of her diabetes. She was on Insulin for a few years, but after taking the lady fingers every morning for a few months, she has stopped Insulin but continues to take the lady fingers every day. But she chops the lady fingers into fine pieces in the night, adds

the water and drinks it all up the next morning. Please. try it as it
will not do you any harm even if it does not do much good to you, but U have to keep taking it for a few months before U see results, as most cases might be chronic.

Forwarded email from my friend...

believe it or not??

no harm to try it...

Easy bruising needs to be evaluated carefully as some cases may have serious underlying problems.

A BRUISE or ecchymosis is caused by bleeding underneath the skin and leakage of red blood cells out of injured blood vessels. This is a common complaint and a good majority of them turn out to have nothing sinister or serious.

Nevertheless, easy bruising needs to be evaluated carefully because a few of these cases may have serious underlying disorders.

Some of the important factors for doctors to sort out whether this is something trivial or a serious problem include the duration of the symptom, local or generalised bruising (if there is bleeding from other sites) and accompanying symptoms such as fever, weight loss, joint pain and so on.

All patients with easy bruising need careful history and thorough physical examination followed by laboratory tests, which are guided by clinical impression.

Anatomy of a stable clot

The fear of patients presenting with easy bruising is the likelihood of a defect or defects in the clotting mechanism causing “excessive bleeding”. The formation of a stable clot would need:

1. An intact coagulation system with adequate coagulation factors.

2. Adequate platelet count with normal platelet function.

3. Normal blood vessels which constrict locally to decrease blood flow in time of injury.

Patients with low coagulation factors such as in liver dysfunctions can bruise/bleed excessively.

Patients with low platelet count (thrombocytopenia) can develop spontaneous bruising and similarly those with impaired platelet function can have bleeding problems.

Vascular or blood vessel abnormalities rarely cause significant bleeding.

Some patients can have multiple clotting or haemostatic failures such as in disseminated intravascular coagulation (DIC) where there is consumption of both clotting factors and platelets due to activation by procoagulants or substances that promote clotting.

History is essential

Easy bruising at different age groups can have some unique causes. For instance, the commonest cause of easy bruising in childhood in tropical countries like Malaysia is a condition called acquired platelet dysfunction with eosinophilia (APDE).

This is an interesting disorder (poorly documented by Western authors!) resulting from the overactive or hyperimmune response to parasitic infestations and the resultant immune complexes “coat” the platelets, causing defective platelet function and hence the bleeding tendency.

Amongst the elderly, easy bruising is fairly common. The so-called senile purpura is likely due to capillary fragility and weakened collagen tissue with ageing and is entirely innocuous.

Easy bruising is a far commoner complaint amongst females. If the bruises occur for the first time excessively over a short period, she needs to be evaluated urgently.

Patients who have bruises for years generally do not have blood clotting or serious blood disorders. A common problem is the “easy bruising syndrome”, which typically occurs in females of reproductive age. The underlying cause is unknown and has been linked to fragile blood vessels, antibody problems or hormonal disturbance. The laboratory tests on coagulation studies are typically normal. The bottom line is that there is no bleeding tendency even when they are challenged with surgical procedures/operations or when they sustain injuries.

Family history is important because some bleeding disorders are inherited, with the well known examples being haemophilia A (Factor VIII deficiency) and B (Factor IX deficiency) and Von Willebrand’s disease.

Drug history is crucial in clinical practice. Aspirin, non-steroidal anti-inflammatory drugs (NSAID), steroids and warfarin are capable of causing bleeding problems.

Some “health foods” such as ginseng, spirulina and gingko can result i

n bleeding due to their anti-platelet actions.

Unexplained bruises in unusual locations such as around the eye or face should raise the possibility of domestic violence or abuse.

Past medical history of bleeding episodes are illuminating to the underlying cause. Patients who could go through surgical procedures such as dental extractions without bleeding problems are unlikely to have serious congenital bleeding disorders. Patients with liver disease, renal failure and bone marrow failure (e.g. aplasia or leukaemia) can have bleeding tendency.

Some of the more definitive symptoms indicative of serious disorder include bleeding from multiple sites, for instance nose bleed, gum bleed, gastrointestinal bleed with black stool or melaena, bleeding in the urine (haematuria) , menorrhagia (excessive menstrual bleed) or prolonged bleeding during or after surgery/tooth extraction.

Other symptoms such as persistent fever, painful joints and bone pain would need further evaluation.

Physical findings such as bleeding in the eyes and wet purpura in the mucous membranes are indicators of serious haemostatic or clotting failure. Severe pallor would indicate anaemia and hence the severity of the bleed.

Wet purpura in the buccal mucosa (mouth) is likely to be associated with severe thrombocytopenia.

Thrombocytopenia or platelet dysfunctions are associated with petechiel haemorrhage (small little bleeding spots) and mucosal bleeds such as gum or nose bleed.

Bleeding into joints and muscles are indicative of coagulation problems such as haemophilia or liver diseases. Acute leukaemic patients can present with pallor, enlarged lymph nodes, swollen gum and spleen. They would need immediate laboratory assessment.

Blood tests for easy bruising

Basically, we want to make sure that the blood cells, especially platelet counts, are in the normal range, and also whether the clotting mechanisms (dependent on platelet number and function, clotting factors and vessel wall interactions) are intact.

The screening blood tests ordered consist of full blood picture and coagulation profile. It is important that the tests are done in good time and abnormal results are acted promptly as delay in diagnosis and treatment impact adversely on the immediate outlook of the disease.

Preliminary diagnosis of acute leukaemia can be made in the blood film if there are circulating leukaemic cells €“ this is especially important in acute leukaemia to avoid onset of life threatening bleeding and associated infective complications.

More specialised tests such as bone marrow examination or detailed coagulation tests e.g. factor assay, need to be performed quickly in those with abnormal screening tests. These tests may only be available at tertiary medical centres and urgent referral needs to be organised.

In dealing with cases of suspected of leukaemia, the patients should be assessed quickly by the attending specialist within a day or two. Circulating inhibitors/antibodies, especially to factor VIII, can cause almost intractable serious haemorrhage and needs urgent specialist care.

What are the treatment options?

Treatment depends solely on the underlying cause. Some patients just need reassurance while others need immediate supportive treatment as well as definitive treatment, for instance blood component transfusions and induction chemotherapy for acute leukaemia.

The supportive care for bleeding complications has improved with the used of blood component therapy. For instance, haemophilia patients are given factor concentrates while thrombocytopenic patients are given platelet transfusion, while patients with coagulopathy or multiple factors deficiency are given fresh frozen plasma (FFP) to replace the missing/deficient component.

Component therapy is certainly more effective than traditional whole blood transfusion and carries less risk of overloading patients.

The definitive treatment depends on the diagnosis. Acute leukaemia patients would need chemotherapy, and later, in some cases, bone marrow transplant to achieve the possibility of cure.

Aplastic anaemia patients would need anti-thymocyte globulin or bone marrow transplant if they have severe disease.

Immune thrombocytopenic patients are treated with steroids, immunosuppressive drugs such as azathioprine, or splenectomy in some cases.

Patients with congenital factor deficiency such as haemophilia need life-long supportive care.

Those with disseminated intravascular coagulation (DIC) need treatment of their triggering cause quickly (for instance, severe infection, shock, hypoxia) to have any chance of survival.

n This article is contributed by The Star Health & Ageing Panel, which comprises a group of panellists who are not just opinion leaders in their respective fields of medical expertise, but have wide experience in medical health education for the public.

The members of the panel include: Datuk Prof Dr Tan Hui Meng, consultant urologist; Dr Yap Piang Kian, consultant endocrinologist; Datuk Dr Azhari Rosman, consultant cardiologist; A/Prof Dr Philip Poi, consultant geriatrician; Dr Hew Fen Lee, consultant endocrinologist; Prof Dr Low Wah Yun, psychologist; Datuk Dr Nor Ashikin Mokhtar, consultant obstetrician and gynaecologist; Dr Lee Moon Keen, consultant neurologist; Dr Ting Hoon Chin, consultant dermatologist; Prof Khoo Ee Ming, primary care physician; Dr Ng Soo Chin, consultant haematologist. For more information, e-mail starhealth@thestar.com.my.

The Star Health & Ageing Advisory Panel provides this information for educational and communication purposes only and it should not be construed as personal medical advice. Information published in this article is not intended to replace, supplant or augment a consultation with a health professional regarding the reader’s own medical care.

The Star Health & Ageing Advisory Panel disclaims any and all liability for injury or other damages that could result from use of the information obtained from this article.

This is the first of a two-part series on how to space your pregnancies.

NEWLY-wed couples have a lot to think about after the blissful glow of the honeymoon has faded. One very important aspect of married life to consider is family planning.

Careful family planning helps you to space your pregnancies so that your body can recover and heal from the previous pregnancy. It also helps you to plan your family’s financial resources so that you can comfortably welcome the new addition to your family.

You can practise family planning by using contraceptive methods. There are two kinds of contraceptives: non-hormonal and hormonal methods.

Non-hormonal methods

Family planning with non-hormonal methods include the use of natural methods, or devices and procedures that do not involve hormones.

Natural family planning method €“ This is a contraceptive method that relies on Mother Nature. With this method, a woman has to keep track of her fertile period through her menstrual cycle.

A woman usually ovulates about two weeks before her cycle begins. This will be the start of her fertile period and when she should avoid sexual intercourse.

The method of counting days is not very reliable, because not all women are as regular as a clock. A more effective method of charting ovulation is the basal body temperature (BBT) method, which involves charting the temperature of the vagina every day. Just as a woman is about to begin ovulating, her body temperature will rise and her cervical mucous will increase, and become clear in colour and “stretchy”. You can check this with a basal body thermometer - different from a normal thermometer - every day.

A new development in this method is the ovulation predictor, which tests the urine for oestrogen metabolites (which marks the start of the fertile phase) and the LH surge that takes place 36 hours before the end of the fertile phase.

While this method is entirely natural and does not use any chemicals or devices, it is not always suitable for every woman, especially those who have irregular cycles, are often ill, work irregular hours or are unable to keep records. It requires so much constant monitoring and abstinence from sex for more than one week every month that it may cause stress and tension between a couple.

If you are not confident in using this method correctly, it could have a high failure rate.

Barrier methods - These are probably the most common contraceptive methods. They include latex condoms, diaphragms and caps, as well as spermicides.

They work by putting up a physical barrier that prevents the sperm from being able to reach the egg inside the woman’s body. An added benefit is that they also protect against sexually transmitted infections, while other contraceptive methods don’t.

While barrier methods are easy to use and relatively cheap, they should always be used in combination with another contraceptive method. After all, condoms have been known to break, or one may forget to put in the diaphragm in the “heat of the moment”.

Lactational amenorrhoea method (LAM) - LAM is really just a fancy name for a form of contraceptive that occurs when you are breastfeeding. When you are breastfeeding, your body undergoes hormonal changes that suppress ovulation and menstruation. This method offers 98% protection from pregnancy.

However, your breastfeeding routine must follow strict guidelines. You must practise exclusive breastfeeding (only giving baby breast milk) on demand. If you do give supplemental foods, such as other liquids or solid foods, they must not exceed 5-10% of the baby’s total daily diet.

The intervals between feeding must not exceed four hours (in the daytime) or six hours (in the night).

The contraceptive effects of breastfeeding are an added benefit of breastfeeding, but they are not foolproof. When your baby reaches the age of six months, or if you begin menstruating, you should use another family planning method.

Intrauterine devices (IUDs) - Intrauterine devices are suitable for monogamous women in stable relationships who want a reliable, long-term, non-hormonal method of contraception.

An IUD is a T-shaped copper device inserted in the uterus to inhibit fertilisation of the egg by the sperm. It is highly effective (94-99% success rates), lasts for five to 10 years, can be reversed easily, and best of all, allows for sexual spontaneity without having to worry about taking a pill or putting on a condom.

While IUDs have few side-effects, they can cause heavy menstrual bleeding, or spotting between periods. In rare cases, the IUD may be pushed out of the uterus into the vagina, or perforate the wall of the uterus.

There is also a type of IUD that works by releasing hormones into the body. Ask your doctor about the benefits and drawbacks of each type, and whether it is suitable for you.

Sterilisation - Finally, there are couples who may want a permanent method of birth control - meaning they are not planning to have any more children.

There are sterilisation methods for both men and women. For women, the procedure is called “tubal ligation”, which involves cutting, sealing or blocking the fallopian tubes (the tubes between the ovaries and the uterus, through which eggs travel). This prevents the eggs from reaching the sperm and becoming fertilised.

For men, sterilisation involves a vasectomy. This is a small operation to cut the vas deferens (the tube that takes sperm from the testes to the penis). Once the vas deferens is cut, sperm can no longer get into the semen that is ejaculated during sex.

You and your partner have to be absolutely sure that you no longer want children before you agree to undergo either of these procedures. Although they are reversible, you will have much lower chances of being fertile after that.

Ultimately, the family planning method you choose is a decision best left up to you and your partner. In my next article, I will describe the hormonal methods of contraception and the considerations that should guide your choice.

Datuk Dr Nor Ashikin Mokhtar is a consultant obstetrician & gynaecologist (FRCOG, UK). For further information, visit www.primanora.com. The information provided is for educational and communication purposes only and it should not be construed as personal medical advice. Information published in this article is not intended to replace, supplant or augment a consultation with a health professional regarding the reader’s own medical care. The Star does not give any warranty on accuracy, completeness, functionality, usefulness or other assurances as to the content appearing in this column. The Star disclaims all responsibility for any losses, damage to property or personal injury suffered directly or indirectly from reliance on such information.

There are many conditions that can affect our eyes. It’s wise to get eye problems checked early, just in case.

ACCORDING to the International Agency for the Prevention of Blindness (IAPB), approximately 45 million people worldwide live with blindness, of which 80% or 36 million are over the age of 50.

With the world’s ageing population growing as a result of improved life expectancy, this represents a significant problem as the prevalence of eye diseases such as cataract, glaucoma and age-related macular disorder rise significantly with age.

In a time and age where our older generation should be enjoying the fruits of their labour, they are instead at risk of losing their sight.

World Sight Day

World Sight Day, commemorated annually on the second Thursday of October, is championed by VISION 2020, a global initiative supported by the World Health Organisation (WHO) and the International Agency for the Prevention of Blindness (IAPB). Its objectives are:

·Raise public awareness of blindness & vision impairment as major international public health issues.

·Influence governments/Ministers of Health to participate in and designate funds for national blindness prevention programmes.

·Educate target audiences about blindness prevention, about VISION 2020 and its activities, and to generate support for VISION 2020 programme activities.

In Malaysia

The National Eye Survey conducted in 1996 recorded the prevalence of blindness in Malaysia at 0.29%, with cataract and retinal diseases forming the majority of cases.

Prof Dr Muhaya Hj Mohamad, Chairperson of the Malaysian Medical Association (MMA) Ophthalmological Society, says: “Among those afflicted by blindness, the majority are above 50 years of age because the eye diseases that cause blindness take many years to develop. This is both a blessing and a tragedy €“ a blessing because it can be detected early enough for treatment, and a tragedy for those who never knew that blindness can often be avoided.

“Preserving our sight for as long we possibly can is not as straightforward as it might seem,” she adds.

“Although some cases can be protected and preserved through interventions like corrective glasses, some chronic conditions, such as diabetes, can contribute to blindness as well. So there is no one-stop solution of just seeing an ophthalmologist and getting the problem solved.”

Avoidable blindness

Avoidable blindness is defined as blindness which could be either treated or prevented by known, cost-effective means. Although there are many causes of vision impairment, VISION 2020 is targeting the main causes of avoidable blindness, in order to have the greatest possible impact on vision loss worldwide. These target disease areas are:

Age-related macular degeneration €“ Age-related macular degeneration (AMD) is the most common cause of blindness in industrialised countries, and mainly affects those over 50 years of age. Its prevalence is likely to increase as a consequence of population ageing.

AMD presents in two forms, “wet” and “dry”. In most populations, the dry form is the more frequent, but it is less likely to lead to severe bilateral visual loss.

The wet form is characterised by the development of abnormal new blood vessels deep to the sensory retina, which can leak or bleed, leading to marked loss of central vision; if bilateral, this can be very disabling.

Each year, after the onset of wet age-related macular degeneration in one eye, 15% of persons develop the wet form in their second eye. Current options for prevention are limited, but new treatments are being developed to preserve or restore vision in some patients with the wet form.

Cataract €“ Cataract is defined as the clouding of the lens of the eye, which impedes the passage of light. Although most cases of cataract are related to the ageing process, occasionally children can be born with the condition, or a cataract may develop after eye injuries, inflammation, and some other eye diseases.

Childhood blindness - In low-income countries, high proportions of children are blind from preventable causes, which require community-based interventions. In all regions, children with treatable diseases, principally cataract, can have their sight restored.

Childrens’ eyes cannot, however, be considered smaller versions of adults’ eyes, and specific expertise and equipment are required. Unlike adults, children require long-term follow-up after surgery to manage complications and to prevent amblyopia (“lazy eyes”). The understanding and involvement of parents is critical.

Diabetic retinopathy €“ Diabetic retinopathy is a complication of diabetes mellitus. Well-conducted clinical trials have shown that good control of diabetes and hypertension significantly reduces the risk for diabetic retinopathy, and there is evidence from studies spanning more than 30 years that treatment of established retinopathy can reduce the risk for visual loss by more than 90%.

Screening programmes for detecting diabetic retinopathy at an early stage at which treatment can prevent visual loss and health education programmes are the main means of prevention of blindness due to this condition.

Glaucoma - Glaucoma is a group of conditions characterised by damage to the optic nerve and loss of the field of vision. The two main types are primary open-angle glaucoma (POAG) and primary angle-closure glaucoma (PACG).

POAG is more frequent in whites and Afro-Caribbeans, while PACG is more common in South-East Asia. Glaucoma is uncommon among persons under the age of 40, but the prevalence increases with age.

Other risk factors include raised pressure inside the eye (intraocular pressure), a positive family history and belonging to a susceptible ethnic group.

As the early stages of both types of glaucoma are often asymptomatic, patients often present late, particularly in developing countries. Once vision has been lost, regardless of the type of glaucoma, it cannot be restored.

Low vision - Low vision is currently defined as “visual acuity of less than 6/18 down to and including 3/60 in the better eye”, from all causes. Many such persons require cataract extraction or refraction services. Low-vision services are aimed at people who have residual vision that can be used and enhanced by specific aids.

Onchocerciasis - Onchocerciasis is caused by an infection which is transmitted by the blackfly species. The vast majority of the 37 million infected people live in West, Central and East Africa.

This infection also causes a range of skin diseases and other systemic conditions. The WHO Onchocerciasis Control Programme, which operated between 1974 and 2002, covered 11 countries in West Africa and was highly successful, and it is no longer a public health concern in most of the affected areas.

Refractive errors - Refractive errors (myopia, hypermetropia, astigmatism, presbyopia) result in an unfocused image falling on the retina. The resulting vision impairment often result in lost education and employment opportunities, lower productivity and impaired quality of life.

Assessment of individuals who have refractive errors, particularly those aged 50 years or above, provides an opportunity for identifying other potentially “blinding” conditions before they cause visual loss (such as glaucoma and diabetic retinopathy).

Trachoma - Trachoma, which is the most common infectious cause of blindness, is caused by Chlamydia trachomatis. Children who have the active stages of the disease are the reservoir of infection, while blindness, which occurs after repeated episodes of infection, usually affects adults. Boys and girls are equally affected by active infection, while blindness is more common in women.

Trachoma affects communities that have poor water supplies, sanitation and/or poor health services.

The organism is transmitted from person to person through direct and indirect contact and by flies. Blindness can be prevented by surgery while the infection and its transmission can be reduced with surgery, antibiotics, facial cleanliness and environmental change.

Preserving sight for the future

According to global statistics, as much as 75% of blindness is avoidable through early prevention and diagnosis.

“One of the worst mistakes to make, especially in an ageing person, is to assume that loss of vision is supposed to happen as we grow older,” asserts Prof Dr Muhaya. “This is absolutely untrue. Any change or loss of vision should be investigated because this is our eyesight that we are trying to preserve. Ignoring vision loss is like ignoring chest pain. Just because loss of vision is not fatal doesn’t mean that it’s less important.”

Suggestions for good eye health include the following:

·Visit an ophthalmologist every other year for an eye screening if you are below 40 years old. An annual check-up is recommended for people above 40 years old, have a family history of eye conditions like glaucoma, cataracts or diabetic.

·See a doctor immediately if you have any acute or prolonged episodes like blurred vision, flashes of light, blind spots or any other symptom that affects your vision.

Contact lens users

For those who use contact lenses, there are steps to take to reduce the risk of infections. These include:

• Wash your hands before handling contact lenses
• Follow directions for cleaning and storing contact lenses
• Clean the lens case after each use
• Follow the recommended lens replacement schedule
• Avoid sleeping and swimming in lenses or wearing them longer than recommended
• Maintain better control of blood sugar levels to slow the onset and progression of diabetic retinopathy.

Spotlight on AREDS

The Age-Related Eye Disease Study (AREDS) was conducted by the US National Eye Institute to determine the role, if any, of antioxidant supplements in reducing the rate of progression from intermediate age-related macular degeneration (AMD) to advanced AMD.

This is based on the assumption that the antioxidants can prevent cellular damage in the retina by eliminating free radicals and harmful oxidants that are generated by the eye’s absorption of light and other normal metabolic processes.

The composition of antioxidants and minerals used in AREDS were:

• Vitamin C, 500mg
• Vitamin E, 400 IU
• Beta carotene, 15mg (equivalent to Vitamin A, 25,000 IU)
• Zinc (as zinc oxide), 80mg
• Copper (as cupric oxide), 2mg

This combination, taken daily, was effective in reducing the risk of developing advanced AMD by 25% in patients with intermediate AMD in one or both eyes, and in patients with advanced AMD in one eye only, or vision loss due to AMD in one eye.

AREDS was conducted among 4,757 men and women aged 50 to 80 years, with five years of follow-up. Researchers also cited no significant adverse effects, although individuals who smoke or are exposed to asbestos are not advised to consume high levels of betacarotene.

References:

1. American Academy of Ophthalmology, www.aao.org

2. National Eye Institute, US National Institutes of Health, www.nei.nih.gov

3. National Eye Survey 1996

4. WebMD Eye Health Centre, www.webMD.com

5. Vision 2020, www.v2020.org

Osteoarthritis may seem to be just a symptom of ageing, but like any medical condition, it needs medical attention.

IF you have known or lived with men and women nearing their retirement age or beyond, you will find many who have experienced the agony of muscle and joint pain.

Their complaints are strikingly similar. Common grouses include pain in their elbows after lifting heavy objects, pain in their knees after a day on their feet and inability to bend down or squat. Some even have difficulty in bending their fingers or reaching for things on higher shelves.

Unlike chest pain, pain in the muscle and joints is often accepted as part and parcel of ageing. It does not create the urgency for those who experience them to consult a doctor immediately – at least not until the pain becomes unbearable and their daily lives are affected.

However, if you are above 50 and have joint pains, the bad news is that you may have some form of arthritis (arthro: joint; itis: inflammation). The good news is, you don’t have to worry about joint replacements yet if you get appropriate treatment early.

“Osteoarthritis (OA) is one of the major causes of disability around the globe that is affecting mankind physically, mentally, socially and financially,” said consultant orthopaedic surgeon Dr Saket Jati.

While rheumatoid arthritis are mostly seen in people about 12 to 40 years of age, people who have osteoarthritis are mostly above 35, said Dr Jati.

In Malaysia, an estimated 60% of the population will have some form of arthritis by the age of 60, particularly osteoarthritis (more than 20%). Rheumatoid arthritis (RA), on the other hand, affects 1% of our population and can affect all age groups.

As there is no cure for osteoarthritis yet, conventional treatments are aimed at giving patients the means to achieve pain-control, increase mobility and maintain a good quality of life. Early diagnosis is the first step in ensuring appropriate treatment.

Osteoarthritis

The joints are essentially two bones with cartilage and fluid in between held together by connective tissue to allow movement and provide support to our body.

Cartilage at the ends of bones and (synovial) fluids in between them act as shock absorbers and lubricants to ensure the bones move in tandem smoothly.

When you have OA, you are experiencing a gradual loss of cartilage from your joints as your cartilage loses its ability to repair itself normally. The smooth surface of cartilage becomes rough and causes irritation to your joint. And with less “cushion” in between, bones eventually rub against each other when you move or carry weight, causing pain and difficulty.

There are two types of OA – primary or idiopathic OA and secondary OA. Idiopathic OA has no identifiable cause while secondary OA can be caused by specific underlying conditions – including previous joint injuries, joint conditions that are present at birth and joint conditions that occur during growth.

Regardless of type, OA is a chronic condition that can gradually worsen over time. Common symptoms of OA are:

• Pain in a joint during or after use, or after a period of inactivity
• Tenderness in the joint when you apply light pressure
• Stiffness in a joint that may be most noticeable when you wake up in the morning or after a period of inactivity
• Loss of flexibility may make it difficult to use the joint
• Grating sensation (crepitus) when you use the joint
• Bone spurs, which appear as hard lumps, may form around the affected joint
• Swelling (effusion) in the affected joints in some cases

Any joint can be affected by OA, but the most commonly affected ones are joints in the hands,

hips, knees and spine.

The pattern of joint involvement varies between individuals, but unlike rheumatoid arthritis (RA), it often affects joints on one side of the body differently than the other side. There may also be enlargement of finger joints in some OA patients.

Not just an old people’s disease

According to a review paper published by the American Academy of Family Physicians, the exact etiology (cause) of osteoarthritis is unknown. Although OA is strongly associated with the wear and tear of joints through the course of life, it is no longer considered a normal part of ageing, wrote Dr Kenneth C. Kalunian in his osteoarthritis patient information sheet found at clinical information resource website, UpToDate. “Studies suggest that the risk of OA is also influenced by other factors, including heredity, obesity and occupation,” Dr Kalunian explained.

In the same write-up, Dr Kalunian noted that most people with OA have one or more of the following risk factors.

Age. While statistics show that at least 80% of people over age 55 have some x-ray evidence of OA, advancing age remains one of the strongest risk factors of the disorder. Nevertheless, despite an abnormal x-ray, many people have no joint pain or impaired function.

Gender. For unknown reasons, the chances of women developing OA are between two and three times more than men. However, according to the Arthritis Foundation of Malaysia, more than half of men over 65 also developed osteoarthritis.

Obesity. Although the association between obesity and the risk of OA varies for different joints, studies have found that the risk of developing OA is decreased in women who lost weight. Obesity also appears to increase the risk of pain and disabilities to those with OA.

Other risk factors include previous joint injury, higher bone mass, muscle weakness, occupations that require frequent squatting or kneeling and other activities that require heavy lifting, prolonged standing or walking several miles a day.

Sports could also predispose some to the risk of developing OA. According to Dr Kalunian, the risk of developing OA in people involved in certain sports such as wrestling, boxing, cycling, gymnastics and ballet dancing is increased.

But you do not need to hang up your ballet shoes just yet. The risk of developing OA in these sports depend on the initial health of your knee joints and the type of activity (low-impact or high impact).

Repetitive low-impact activity (activities that do not impose high-impact forces on the joints) like cycling is associated with an increased risk of OA in people who have pre-existing knee abnormalities, but not in those who have healthy knees [2].

In contrast, repetitive high-impact activities like wrestling and boxing is associated with an increased risk in both people with or without pre-existing knee abnormalities.

Diagnosing osteoarthritis

It is difficult to identify a definitive diagnostic test because the signs and symptoms could be caused by various kinds of diseases.

Therefore, the diagnosis of OA is based on a consideration of several factors, which include the evaluation of signs and symptoms, results of laboratory tests and x-rays.

Laboratory tests indirectly aid the diagnosis of OA by helping to rule out conditions with similar symptoms. Common tests are the erythrocyte sedimentation rate (ESR) test, rheumatoid factor, and synovial fluid analysis (examination of the fluid in the joints).

Blood tests like the ESR and rheumatoid factor can help doctors distinguish whether your arthritis is a case of OA or RA.

“OA usually do not show blood abnormality,” said President of the Arthritis Foundation of Malaysia and consultant rheumatologist Dr Chow Sook Khuan.

She also added that a synovial fluid analysis will only be performed to exclude other associated conditions like septic arthritis and co-existing inflammatory arthritis. X-rays are helpful for determining the severity of OA in advanced cases, but it is not routinely done for people without symptoms because changes may not be present on x-rays in the early stages of OA.

Treatment and practical solutions

To find out the nature and extent of muskuloskeletal (muscle and bone) pain in Malaysia, consultant rheumatologist Dr Kiran Veerapan, along with Richard Wigley and Hans Valkenburg embarked on a COPCORD (Community Oriented Programme for the Control of Rheumatic Diseases) survey in year 1988.

The survey results, published in the Journal of Rheumatology in the year 2007, showed that 58.8% of those who have rheumatic pain in the study self-medicate with over-the-counter analgesics or other medications that they acquired without prescription.

But is self-medication advisable? According to Dr Chow, although mild analgesics like paracetamol is allowed to relieve pain, if a person has persistent joint pain, especially with signs such as joint swelling, significant morning joint stiffness (more than 30 -60 minutes from awake in morning), loss of joint function (regardless of one or more joints affected), this person must seek medical advice as all those signs and symptoms imply more serious arthritis.

“Early treatment of a serious arthritis can prevent structural damage of the affected joint,” Dr Chow said.

If you are diagnosed with OA, make sure you are well informed about the natural course of osteoarthritis. You can learn about ways to manage your condition and have realistic expectations of the treatments your doctors can offer.

For mild OA pain that is bothersome, but not enough to affect your daily activities, your doctor may prescribe rest, exercise, losing weight, using heat and cold to manage the pain, physiotherapy, over-the-counter pain creams and braces or shoe inserts [1].

While applying heat is often the common method used for pain relief in our community, cold packs can also do the trick. However, if you have poor circulation or numbness, do not use cold treatments. Heat treatment should also be warm, not hot [1].

If the pain persists despite initial treatment, you may require medications for pain-control or to slow down cartilage degradation. “Medicines are used to provide a pain-free, more mobile, efficient and effective lifestyle,” said Dr Jati, adding that analgesics (painkillers) and anti-inflammatory agents should be used with caution as they have possible side-effects.

While there are no proven disease modifying agents for OA, glucosamine, chondroitin sulfate, diacerin and esterified fatty acids may ease pain in some individuals and slow down cartilage degradation in some early cases if they combine the use of medication with non-drug measures, says Dr Chow.

According to Dr Chow, intra-articular steroid injections (injecting small amounts of steroid to the affected joint) can also be used to treat the inflammatory flare-ups associated with knee OA, but it must be done by a trained doctor in accordance to certain guidelines.

However, studies show that the injections are effective only for the short term.

“Early treatment in the form of knee strengthening through exercises is useful. Drug therapy does not halt OA, but since exacerbation prevent people from exercising, pain relief is important,” says Dr Kiran, who is a consultant rheumatologist now based in Canada.

Surgery may be an option for severe OA that is not relieved by other treatments. Joint replacement and debridement (removing loose pieces of cartilage and bone from around your joint) are among the surgical options available [1].

Although medical advances have provided physicians means to help you relieve or lessen the pain caused by OA, a major component of OA treatment lies in your attitude towards the condition.

A positive attitude will go a long way to help you cope with OA. More importantly, it determines how much impact OA will have on your everyday life, despite the pain and disability.

For more information about osteoarthritis, you can visit the Arthritis Foundation of Malaysia website www.afm.org.my.

References:

1. Osteoarthritis, by Mayoclinic.com; http://www.mayoclinic.com/health/osteoarthritis/DS00019

2. Patient information: Features and diagnosis of osteoarthritis, by Kenneth C Kalunian, M.D.; http://www.uptodate.com/patients/content/topic.do?topicKey=arth_rhe/2266

3. Osteoarthritis: Diagnosis and therapeutic considerations, by Ralph Hinton et al., American Academy of Family Physicians; http://www.aafp.org/afp/20020301/841.html

4. Musculoskeletal Pain in Malaysia: A COPCORD Survey, by Dr Kiran Veerapen, Richard D Wigley, and Hans Valkenburg, The Journal of Rheumatology. http://www.jrheum.com/abstracts/abstracts07/207.html

An overgrowth of yeast in the vagina.

A VAGINAL yeast infection is one of the most irritating yet common conditions that affect women.

In fact, it is so common that about 75% of women will have a yeast infection at some point in their lives. Of these, almost half will have recurrent infections, meaning two or more infections later on in life.

This week, I will share some basic facts about this condition, and also answer some burning questions about the link between yeast infections and sex.

What is a yeast infection?

Yeast infection is also called candidiasis, and is due to the fungus Candida albicans that infects the vagina.

You must be wondering why yeast would grow in the vagina. In fact, it is natural to find small amounts of yeast living in the vagina under normal conditions. However, the natural acidity of the vagina can be unbalanced, causing the yeast to overgrow and cause an infection.

The infection will then cause irritation of the vagina and the vulva (the area around the vagina). This may cause you to suffer extreme itchiness in and around the vagina. This may be accompanied by a thick, white, odourless vaginal discharge that has the texture of cottage cheese.

You may also notice other symptoms like burning, redness and swelling of the vagina and vulva, pain upon urinating, and pain or discomfort during sex.

What causes it?

Vaginal yeast infections are usually caused by a weakened immune system that can lead to changes in the acidity of the vagina. The various conditions that can lower a woman’s immune defences are stress, lack of sleep, sickness, poor diet, extreme intake of sugary foods, pregnancy, menstruation and disease such as poorly-controlled diabetes and HIV infection.

You may also find that taking certain medications can increase your risk of getting a yeast infection, such as birth control pills, antibiotics and steroid medicines.

What about sex? Some women believe that they can get yeast infections through sexual intercourse with their partners. However, this is actually very rare.

A woman could be at higher risk if she has unprotected intercourse with a partner who has a yeast infection, but this condition is rare in men. There is a slightly higher risk following oral sex given by men who carry yeast organisms in their mouth.

Nonetheless, yeast infections are not likely to be transmitted from partner to partner. Having said that, however, other infections can be contracted sexually, and women should always practise safe sex with their partners.

Don’t be shy – see a doctor

It can be embarrassing to admit that you have symptoms of a vaginal infection. However, it is important that you overcome your shyness and see your GP or gynaecologist.

Sometimes, the signs of a yeast infection are similar to that of sexually transmitted diseases, such as chlamydia and gonorrhoea. Getting a medical check-up could help you determine whether you have a yeast infection or something more serious.

A yeast infection is easily diagnosed. Your doctor will examine you to look for swelling and discharge. He or she may also take a sample from your vagina and examine that under the microscope to look for yeast organisms.

Treatment is often in the form of antifungal creams, tablets, ointments or suppositories (inserted into the vagina).

Do not attempt to treat the infection yourself – always get your doctor’s advice, even if you want to use over-the-counter medicines. Taking antifungal medications when you don’t have a yeast infection could make your condition worse and increase your risk of getting a resistant strain of infection in the future.

Avoiding repeat infections

It is very common for women to develop recurrent yeast infections, even several in one year. Here are some tips to prevent another yeast infection from occurring:

·Don’t use douches.

·Avoid scented hygiene products like bubble bath, sprays, pads and tampons.

·Change tampons and pads frequently when you are menstruating.

·Don’t wear clothing or underwear that are tight in the crotch.

·Wear cotton underwear or pantyhose with a cotton crotch.

·Change out of wet swimsuits and exercise clothes as soon as possible.

·Keep your vaginal area clean.

·After a shower or bath, dry the vaginal area completely before getting dressed.

·After using the toilet, always wipe from front to back.

·Avoid sharing towels with others.

·Don’t take antibiotics unless prescribed by your doctor.

·Eat a diet high in vegetables, protein and grains, and avoid processed foods, sugars and alcohol.

·Abstain from sex while undergoing treatment for a yeast infection.

·If you are experiencing chronic yeast infections and are using birth control pills, consider changing your birth control method.

Finally, see your doctor for more advice about avoiding repeat yeast infections. Ignoring it won’t make it go away.

Datuk Dr Nor Ashikin Mokhtar is a consultant obstetrician & gynaecologist (FRCOG, UK). For further information, e-mail www.primanora.com. The information provided is for educational and communication purposes only and it should not be construed as personal medical advice. Information published in this article is not intended to replace, supplant or augment a consultation with a health professional regarding the reader’s own medical care. The Star does not give any warranty on accuracy, completeness, functionality, usefulness or other assurances as to the content appearing in this column. The Star disclaims all responsibility for any losses, damage to property or personal injury suffered directly or indirectly from reliance on such information.

IT is no secret that breastfeeding is the gold standard of infant feeding. Nevertheless, when medical officer Dr Seri Suniza Sufian was pregnant with her first baby, she wondered what kind of milk would she give to her child.

“I actually had the cheek to think of what milk I was going to give this baby inside my womb,” said Dr Seri, who is now a mother of four fully breastfed children and a consultant in obstetrics and gynaecology.

Speaking on breastfeeding and women’s reproductive health at the Working Women and Breastfeeding forum recently, she recounted her meeting with Breastfeeding Information Bureau President Norjinah Moin, who asked her point blank: “Why do you want to give your child powdered milk or formula?”

Since then Dr Seri never looked back because she knew the answer: that it was only natural and beneficial to both mother and child if she were to breastfeed.

Research has shown babies who are breastfed to be less likely to be infected by a wide range of infectious diseases, including bacterial meningitis (infection of membranes in the brain), diarrhoea, respiratory tract infection and urinary tract infection.

Some studies even suggest breastfeeding may enhance your child’s learning abilities and reduces the rates of sudden infant death syndrome (SIDS) in the first year of life and type 1 and 2 diabetes mellitus later in life.

“Another benefit of breastfeeding that is not often highlighted is it promotes the normal pattern of swallowing and breathing,” said orthodontist Prof Dr Zamri Radzi. By “exercising” the mouth and facial muscles, sucking on the mother’s breast promotes the child’s orofacial (mouth and face) development.

While a lot of emphasis is placed on the benefits infants can get out of breast milk, mothers benefit too from the act of nursing. A mother who breastfeeds may decrease her chances of experiencing postpartum (after-delivery) bleeding and developing hormone-dependent cancers, like ovarian or breast cancer, if she does not have any other risk factors.

Other benefits include weight loss, uterus contraction to its original size and natural contraception during the first six months of exclusive breastfeeding (baby is fed with breast milk alone).

Besides providing health benefits, breastfeeding is also cost-efficient!

Imagine your baby having to consume a tin of infant formula per week that costs about RM50 to RM60 for one or even two years (in a move to promote breastfeeding, infant formula is not a controlled item in Malaysia). You can save at least RM2,600 per year, not to mention the extra healthcare costs saved with reduced trips to the local doctor – your child tends to fall sick less often due to the antibodies passed down from your milk.

On a larger scale, the potential economic benefits are great. In his review and analysis of the economic benefits of breastfeeding, US Department of Agriculture researcher Jon Weiner reported that a minimum US$3.6bil (RM11bil) of healthcare cost would be saved every year if breastfeeding were increased from current levels in the US (64% in-hospital, 29% at six months) to those recommended by the US Surgeon General (75% and 50%).

Although it is intuitive that similar findings would be found in Malaysia, studies like these have yet to be done locally.

Looking at the common misconceptions that surround breastfeeding.

HEARING the first cry of her first child, a new mother heaves a sigh of relief. She waits in anticipation to welcome her bundle of joy into her arms.

In the periphery of her vision, she sees the midwife walking towards her with her baby wrapped snugly in a white cotton towel.

Being previously immersed in prenatal preparation, she frantically searches her memory for some inkling of what to do next. Of course, breastfeed!

Suddenly, bucketloads of advice – from well-meaning relatives, friends, the mother-in-law and the last parenting book she read – enters her blissful state of mind as she tries to decide on the best way to feed her baby.

Studies have found that breastfeeding actually promotes better bone remineralisation in the mother. -APphoto

To clear some of the confusion, the following are the common misconceptions about breastfeeding.

Myth: I can’t breastfeed because I am too thin/malnourished.

Fact: Malnourished women typically do not have trouble breastfeeding. Breast milk production remains largely unaffected by malnourishment, and is produced in a non-exhaustive supply, making it readily available at all times for newborns. Only in severely malnourished women can breastfeeding be a problem.

Myth: I don’t have enough milk.

Fact: When a baby starts suckling on your breast, the stimulation will induce the release of oxytocin in your body, which stimulates the let-down reflex (milk ejection reflex) when your are relaxed. During the first few days of breastfeeding, your milk may be a watery, clear and yellowish fluid. This is actually colostrum (also known as beestings or first milk), which is high in carbohydrates, protein and antibodies and low in fat.

Although your baby may become hungry often, it may be because babies have small digestive systems and need frequent feeding with small amounts of milk at any one time. Or, your baby may not have latched on properly onto your breast.

Myth: I can’t breastfeed because I am sick.

Fact: With very few exceptions, the baby will be protected by continued breastfeeding. By the time the mother has fever (or cough, vomiting, diarrhoea, rash, etc) she has already given the baby the infection, since she has been infectious for several days before she even knew she was sick. The baby’s best protection against getting the infection is for the mother to continue breastfeeding.

If the baby does get sick, he will be less sick if the mother continues breastfeeding. In Malaysia, mothers who have been tested HIV-positive are not recommended to breastfeed their child; but in some countries where the babies are more likely to die from infections from the unsafe preparation of replacement foods (e.g. lack of clean water supply to prepare infant formula), mothers can still breastfeed.3

However, nursing mothers should always check with their physicians if they are ill or if they have started on any medications or treatments.

Myth: Breastfeeding ties the mother down.

Fact: It depends on how you look at it. A baby can be nursed anywhere, any time, and thus breastfeeding is liberating for the mother. No need to drag around bottles or formula. No need to worry about where to warm up the milk. No need to worry about sterility. No need to worry about how your baby is, because he is with you.3

Myth: As I have a breast implant, it may be dangerous for me to breastfeed.

Fact: Most do very well. There is no evidence that breastfeeding with silicone implants is harmful to the baby. Occasionally this operation is done through the areola. These women do have problems with milk supply, as does any woman who has an incision around the areolar line.3

Myth: My baby is born premature. My milk is not ready for a baby to feed on.

Fact: In pregnancy, there is an increased level of the prolactin hormone in your body. Therefore, the mammary (breast) glands are ready to produce milk as the pregnancy progresses. If you delivered prematurely, the breast milk is well designed and more suitable for the baby at that gestation. You may be encouraged to express breast milk even though the baby is not suckling well.

Breast milk production starts very early and it is suited to the baby’s needs at any stage of gestation.

Myth: If my baby is drinking my milk, I might get brittle bones and develop osteoperosis when I am old.

Fact: Studies have found that breastfeeding actually promotes better bone remineralisation. That means, a lot more bone formation takes place when a woman is breastfeeding.

On another note, supplements are usually not needed every day if you are eating a normal diet unless its use is indicated by your health professional. If not practised prudently, excessive supplementation may result in weight gain.

Usually, nursing mothers need more iron to prevent anaemia, but they only need about 200 more calories (about two slices of bread) daily compared to women who are not breastfeeding.

References:

1. Dr Seri Suniza Sufian, consultant obstetrician and gynaecologist

2. Breastfeeding and the Use of Human Milk, American Academy of Pediatrics Policy statement (Organisational Principles to Guide and Define the Child Health Care System and/or Improve the Health of All Children).

3. Breastfeeding Myths, Jack Newman M.D., http://www.breastfeeding.com/all_about/all_about_myths1.html#M1_1, (13 Aug 2008)

4. Maternal Health and Well-Being: A Cornerstone of the Millennium Development Goals, United National Association of USA; http://www.unausa.org/site/pp.asp?c=fvKRI8MPJpF&b=1733129

For more information about breastfeeding, you can visit the Malaysian Breastfeeding Information Bureau website at bibmalaysia.org. You can also contact the Breastfeeding Information Bureau at 03-4107 3678 or breasted@bibmalaysia.org for further assistance.

A brain scientist stumbled upon a great opportunity to study her own brain - she had a stroke.
IF AIDS and cancer are the worst diseases that could befall any human being, I would say that a stroke is a close third.
Stroke survivors either recover completely, or they may lose some of their abilities to function or think like they did before.
Having a brother with schizophrenia motivated Jill Bolte Taylor to dedicate her life to research in brain science, specialising in the post-mortem investigation of the human brain. - Photo by Katherine Domingo, My Stroke of Insight.

With so much at stake, I never would have described the experience of surviving a stroke as anything other than a narrow escape from death.
But when neuroanatomist Jill Bolte Taylor realised that she was having a stroke, her first thought was “Wow, this is so cool!” And it turned out to be just the experience she was looking for after years of studying the human brain - the first-person account of mental deterioration, inside out.
My Stroke of Insight is Taylor’s compelling story, from brain scientist to stroke survivor and back.
Having an older brother who experienced symptoms of schizophrenia since young, Taylor’s fascination with the human brain stemmed from her desire to understand how she and her brother could walk away from the same experience with different interpretations about what had just happened.
It was this curiosity that led her to dedicate her life to research in brain science, specialising in the post-mortem investigation of the human brain.
By the age of 37, Taylor had completed two post-doctoral research fellowships in Harvard Medical School, served on the US National Alliance of Mental Illnesses (NAMI) for two years and was travelling extensively around the United States as the “Singin’ Scientist” who sings to encourage people to donate their brains for research when they no longer have use for it.

Life was good for Taylor. She was at the height of her career, living her passion and enjoying herself, until she woke up on December 12 ,1996, to a piercing headache that would change her life forever.
“Within four brief hours, I watched my mind completely deteriorate in its ability to process all stimulation coming in through my senses,” she wrote.
Taylor had what scientists and doctors would call an arteriovenous malformation (AVM) - a congenital disorder that predisposes people born with it to strokes during their prime years of life.
As one of the first documented accounts of stroke by a brain scientist, My Stroke of Insight is a unique blend of scientific knowledge and spiritual insights.
In 20 chapters, Taylor provides a detailed account of her stroke, her orchestration of her own rescue, her surgery, and her recovery - physiologically, psychologically and emotionally.
With as little jargon as possible, she translates the experiences of a stroke patient into physiological changes that occurs in the brain, making her story an educational one. And if brain science is too daunting to understand in words, Taylor had also provided anatomically accurate drawings to help illustrate her explanation.
What makes this book unique, however, was the spiritual insights found in Taylor’s description of the partial loss of her “thinking” left brain.
Disconnected from the internal chatter created by the left brain (which controls her line of thought, speech and action), Taylor was free to experience the bliss of being in the present moment.
In fact, the ability to be in the present moment was so blissful that Taylor had to convince herself to try to regain the functions of her left brain in order to be “normal” again.
As she slowly regained her ability to reconnect to her left brain, she soon found out that she could choose to tune out negative internal chatter and experience inner peace just by thinking positive thoughts.
As she put it, “Nirvana is just a thought away”.
In recovery, Taylor describes the conditions of which she was most responsive to treatment and rehabilitation, the role people around her played in her recovery and the shortcomings of conventional medicine, which often treats the disease, and not the person.
She also addresses the importance of moral support - something which is often overlooked or neglected by friends and family of stroke survivors in their desperation to nurse their loved ones back to health.
“Recovery, however you define it, is not something you do alone, and my recovery was completely influenced by everyone around me. I desperately needed people to treat me as though I would recover completely,” wrote Taylor.
One step at a time, Taylor put her left brain back online with the support of her mother.
While stroke survivors can relate to Taylor’s story and understand more about their condition, medical professionals can understand better the psychological and emotional needs of a stroke survivor in rehabilitation. There are also tips on how to recognise a stroke and recommendations for recovery that caters for everyone.
It is always a pleasure to meet or read about someone who can always see the silver lining in the clouds, because they bring hope in the gloomiest of days. Taylor is definitely one of them.

My Stroke of Insight is available at Kinokuniya bookstores at Suria KLCC and retails for RM 87.95. Interviews with Jill Bolte Taylor, including one with Oprah Winfrey, can be accessed at her website, drjilltaylor.com through the “In the world” link.

The ultrasound has to be used at the right time, for the right reasons.
REMEMBER in 2005 when Tom Cruise bought an ultrasound machine for his home, so that he could monitor his wife Katie Holmes’ unborn baby?
Medical experts in the US were alarmed and outraged that this could occur. The ultrasound examination is not a game, but a medical procedure that is performed by trained experts as an important part of prenatal checkups.
An ultrasound can give important information about whether the baby has any abnormalities.

What exactly do doctors look for in an ultrasound? How will this information help expecting mothers? Are there any risks involved? I will discuss these points in this article.
Ultrasound is the technology of using high-frequency sound waves to create an image. These sound waves are directed at the foetus using the “transducer”, which is the gadget that is run gently over the stomach. The sound waves are then bounced back to produce a picture on the screen.
This “picture” tells the proud parents-to-be whether their baby will be a boy or a girl, or whether there is more than one baby!
An ultrasound should routinely be done for all pregnancies during the first trimester. During this ultrasound, the doctor will look for a number of things, such as to confirm whether the pregnancy is in the uterus, the viability of the foetus (is the heart beating?), the number of foetuses and the size of the foetus to look for whether it corresponds to the period of the pregnancy.
The cervix, that is the mouth to the womb, the uterus, as well as the ovaries are also scanned for any abnormalities
In the second trimester, the ultrasound is performed to look for any anatomic or structural abnormalities - where the placenta is implanted, and how the fluid around the baby looks. If any abnormalities are found, the doctor will continue to evaluate them in the third trimester. The final ultrasound will also be done to monitor the foetus’ growth and size.
The third trimester ultrasound is not done routinely, and only if there is a need to follow up on a significant problem found in the earlier ultrasound such as if the foetus is not growing as expected or there is concern regarding the well-being of the foetus.
An ultrasound can give important information about whether the baby has any abnormalities. Firstly, the obstetrician will look at whether the placenta is normal. For instance, is it implanted too low in the uterus, which might cause bleeding during pregnancy? Or is it implanted in a location that will interfere with a vaginal delivery?
The ultrasound will also show whether any organs, such as the kidneys or brain, are missing or not developing well. Structural abnormalities, such as a hole in the heart, abnormal spine formation and other congenital problems, may also be spotted.
The doctor will also use the ultrasound image to measure the bones and the size of the head, in order to check the growth of the foetus.
The ultrasound is also important for mothers who have problems before or during pregnancy, such as hypertension, diabetes or certain infections.
If the mother has a high risk pregnancy, then tests such as chorioinic villous sampling can be done as early as eight weeks onwards.
Other tests include amniocentesis, placental biopsy and umbilical cord sampling, all of which are used to analyse abnormalities in the baby’s chromosomes. Some of these tests can be invasive and relatively riskier than others, so you should discuss every option with your doctor before making a decision.
Of course, every parent-to-be will hope and pray that the ultrasound does not show any abnormalities in the first place. However, it is important to remember that the ultrasound is not a fool-proof test. It cannot pick up every single detail about the foetus, so there may be abnormalities that cannot be found in an ultrasound, or there may be instances where it is difficult to determine the sex of the baby.
Because an ultrasound uses sound waves, and not radiation, an ultrasound will not harm your unborn baby.
However, it is still unwise to overuse or abuse this technology. You cannot have an ultrasound done whenever you wish just because you feel like “having a look” at the baby, or you want to see how much it weighs.
The ultrasound has to be used at the right time, for the right reasons. If a mother does not have any risk factors, further ultrasounds – other than the basic one or two – are not necessary.
It is also important that the ultrasound be performed by the appropriate expert - the foetal medicine specialists - when looking for foetal anomalies and in assessing high risk pregnancies so that they know what to look for. An untrained eye looking at the picture could miss some crucial information or problems with the baby.
Datuk Dr Nor Ashikin Mokhtar is a consultant obstetrician & gynaecologist (FRCOG, UK). For further visit www.primanora.com. The information provided is for educational and communication purposes only and it should not be construed as personal medical advice. Information published in this article is not intended to replace, supplant or augment a consultation with a health professional regarding the reader’s own medical care. The Star does not give any warranty on accuracy, completeness, functionality, usefulness or other assurances as to the content appearing in this column. The Star disclaims all responsibility for any losses, damage to property or personal injury suffered directly or indirectly from reliance on such information.

Choose shoes and in-soles with the right fit to prevent foot ailments.
WEARING tight-fitting shoes or footwear without sufficient support may result in more than just minor discomfort. In the long run, foot problems that develop can range from corns and calluses to painful conditions called metatarsalgia or heel spurs.
Foot problems are commonly experienced but many people do not do something about them before they worsen.
Daniel Berkemeier, managing director of Schein Orthopaedics, said an estimated 80% to 90% of Malaysian adults suffer from some form of foot problem.
Daniel Berkemeier: ‘Most foot, knee and back problems are related to our feet.’ He is holding a shoe designed for diabetics.

“Most foot, knee and back problems are related to our feet. Foot problems include serious conditions such as diabetic foot syndrome or rheumatism to those caused by ill-fitting footwear,” he said.
Schein specialises in custom-made orthopaedic shoes and in-soles for people with foot, knee and back problems.
The company recently brought in their master craftsman, Guido Fahrentrapp, an orthotist and prosthetist, to give advice and solutions to people with such problems. The German is an expert in designing and custom-making special footwear, in-soles and artificial legs. He will be in Malaysia through August.
Fahrentrapp, who has 27 years’ experience in this field, said wrong footwear is a common cause of foot problems.
“Many people wear shoes that are too tight or too small. Pointed shoes for women are also not advisable because they really hurt the feet as toes may cross over each other. In addition, the big toe and fifth toe may also develop bunions,” he said.
A bunion is a bony bump on the joint at the base of the big toe. This causes the big toe joint to be enlarged, leading to overlapping toes which puts pressure on the big toe joint. Pain in turn will be felt.
Bunions can also form on the joint of the little toe, known as a bunionette. The reasons bunions occur include heredity factors, abnormal walking patterns, arthritis and ill-fitting footwear.
Another common problem is calluses, caused by an accumulation of dead skin cells that harden over an area of the foot. This formation is part of the body’s natural defence mechanism against excessive pressure and friction. Calluses normally occur on the ball of the foot, the heel and the inside of the big toe.
Corn is also caused by accumulation of dead skin cells which can press on the nerves, causing pain. It is developed by wearing tight-fitting footwear or stockings, high heels and having deformed or oversized toes.

Special in-soles for people with foot, knee or back problems by Schein Orthopaedics.

Meanwhile, overpronation or flat foot, is a painful foot problem which occurs while walking. In this situation, the heel bone goes outward and the feet does not form a normal arch (or arch collapse).
This leads to extreme stress or inflammation on the plantar fascia, potentially leading to severe discomfort and other foot problems. (Plantar fascia is the tendon at the bottom of the foot that connects the heel bone to the toes.)
Flat foot condition can be genetic or due to the wrong footwear which does not provide proper arch support.
The heel bone is the largest bone in the foot and absorbs the most pressure and shock.
A heel spur, another painful foot problem, occurs when calcium deposits form as a result of the plantar fascia pulling away from the heel bone, causing a bony protrusion or heel spur to develop. Usually, heel spurs develop due to a high arch or flat foot condition.
“Spurs look like a hook which penetrate the fatty tissue and through the muscle. Having heel spurs is very painful, especially when one first stands up,” said Fahrentrapp.
Another common foot problem is metatarsalgia or spread foot, a painful condition in the metatarsal region of the foot, more commonly known as the ball of the foot. It is caused by improper and restrictive footwear, resulting in forefoot joints becoming painful or inflamed due to excessive pressure.
To prevent foot problems in children, Fahrentrapp advised parents to look out for signs of flat feet in their young children when they start walking.

Sandals designed to fit special in-soles.

“(When they are standing) check that their heels are straight (viewed from the back). If there is a flat foot condition, parents should support their arch with shoes that are high-arched and have cup heel in-soles.
“This helps the feet grow back to the normal position through walking because children’s foot cartilage is still soft,” he explained.
Children also frequently suffer from adducted foot condition where both the forefoot goes inwards towards each other.
“In this situation, special shoes with a very stable heel cup can correct the problem,” said Fahrentrapp.
People suffering from diabetics need to take extra care of their feet as the disease can destroy foot nerves and wounds take longer to heal.
“Special footwear can prevent ulceration in 80% of patients,” said Berkemeier, adding that the features of such footwear include a high toe box, a higher heel area and perforated, soft in-soles.
“The in-soles of these shoes are softer in the forefront but harder at the back. They have strong heel cups and outer soles to give foot better guidance as diabetics have less sensation on their feet,” he said.
Berkemeier does not recommend women wearing high heels for long periods of time.
“Heels more than 1.5 inches (4cm) are not encouraged. In normal walking, we do not put pressure on the three middle bones on our foot, only on the outer bones and the heel. With high heels, the normal arch of the fore foot is distorted,” he said.
Besides wearing sensible heels, the right shoe size is often something people get wrong. Berkemeier said the right shoes should have 1.3cm (half an inch) of space in front of the toes, not at the back of your heel as commonly thought.
“For sports shoes, you can take out the in-sole to check for this space. Children’s shoes must also be very flexible unless they have foot problems.
“For women, if you must wear pointed shoes, make sure all your toes have enough space to lie out straight in front and not cross over each other,” he said

Custom-made insoles may ease certain foot pain.
CUSTOM-fit insoles may help ease foot pain caused by high arches, rheumatoid arthritis and certain other conditions, a research review suggests.
Australian researchers found that in 11 clinical trials, custom-designed orthotic devices for the shoes helped ease certain forms of foot pain.
One study, for instance, showed that within three months, the shoe inserts improved pain in adults with abnormally high arches.
Another study, of 209 adults younger than 60, found that custom orthoses eased pain from bunions — though they did not appear to be as effective as surgery in the long run.
Custom orthoses are shoe inserts that are prescribed by a doctor and designed based on an impression taken of the patient’s feet. They are widely used, but few well-designed clinical trials have been done to confirm that the devices work.
The bottom line is that for a few forms of foot pain, custom orthoses are better than no treatment at all, said Fiona Hawke of the University of Newcastle, the lead researcher of the review.
“It is, however, difficult to confidently recommend custom-made foot orthoses over other interventions, as very little research has been performed,” she said. Hawke and her colleagues reported their findings in the Cochrane Library, a publication of the Cochrane Collaboration, an international organisation that evaluates medical research.
Besides showing promise for painful high arches and bunions, the researchers found that custom orthoses may ease foot pain from juvenile idiopathic arthritis — a form of arthritis that affects children. In these cases, though, it was not clear that custom orthotics were any more effective than “off-the-shelf” shoe inserts.
A few studies have also examined custom orthotic devices for foot pain caused by rheumatoid arthritis. They have generally shown that the devices may diminish pain in the back of the foot, at least in the short term.
When it comes to plantar fasciitis, a common cause of heel pain, custom orthoses have shown limited benefits. They did, however, seem to ease patients’ pain when combined with splints worn at night to keep the sole of the foot in a lengthened position.
The evidence is strongest for using the shoe inserts to treat pain caused by high arches, according to Hawke.
She noted, though, that “strong” in this case means that the evidence came from a high-quality study — and not that people with high arches will necessarily get substantial pain relief.
It’s also not known, Hawke added, how custom-made orthoses measure up with off-the-shelf versions. — Reuters

The use of traditional and complementary medicine is becoming more widespread. There needs to be clear regulations to address the many issues surrounding such practices.
TRADITIONAL and complementary medicine (T/CM) is used by many people throughout the world. Its use varies between countries, with about 60% of the Hong Kong population reporting its use and 10% in the United Kingdom, 20% in Canada and 76% in Singapore.
In countries like Vietnam and China where T/CM is an integral part of the healthcare system, about a third of patients receive traditional medicine.
Traditional medicine has maintained its popularity in the developing world and its use is rapidly spreading in developed countries. It is estimated that more than 50% of the population in Europe and North America have used complementary and/or alternative medicine at least once.
The global market for herbal medicines is estimated to be US$60bil (RM192bil) annually and is growing steadily. Traditional herbal preparations account for 30% to 50% of the total medicines consumed in China.
Popular interest
There are several reasons for the increasing popularity of T/CM. The middle- and high-income groups of the population are more health conscious and have adopted a proactive approach to their own health by seeking out different forms of self-care. Aggressive marketing, particularly with the tagline that T/CM products are “natural”, have generated its use.
The lower income group has resorted to T/CM for different reasons i.e. availability, relatively lower costs, cultural and peer influences. A major reason is that modern medicine has generated expectations that cannot be delivered consistently.
The global market for herbal medicines is estimated to be RM192bil annually and is growing steadily. - Reuters photo
There is very limited global data on the number of T/CM practitioners. In some countries like South Africa, they exceed significantly the number of doctors. The number of practitioners is comparable to that of doctors in some countries like China and India, while they are a minority in Europe and North America.
Data from a survey conducted by the Malaysian Health Ministry in 2005 revealed that 69.4% of respondents had used T/CM in their whole life and 55.6% in the preceding 12 months. Of those who used T/CM products for health problems, the modalities used were viz:
·Biologically-based therapy e.g. herbs, vitamins supplement - 88.9%
·Manipulative and body-based e.g. massage, reflexology, chiropractic - 27.0%
·Mind-body medicine e.g. hypnosis, prayer, meditation, yoga, taichi - 11.1%
·Whole medical system e.g. acupuncture, ayurveda, homeopathy, Chinese medicine - 1.9%
The Health Ministry’s Drug Control Authority reported that, as at December 31, 2007, the cumulative number of registered products comprised 18,200 traditional medicines (46.5%) compared to 11,805 prescription medicines (30.2%) and 9,098 over-the-counter medicines (23.3%).
The National Health and Morbidity Survey in 2006 provide additional information. It reported that the out-of-pocket expenditure for those above 18 years of age in 2006 was RM3.76bil, of which a whopping RM2.97bil (79%) was for health promotion, as compared to RM0.54bil (14.4%) for ambulatory care and RM0.17 bil(4.5%) for hospitalisation. Of the expenditures, 88.1% were spent at private facilities, 8.5% at government facilities and 3.4% at both.
Terminologies
The terminologies used to describe conventional (or Western) medicine and traditional and complementary medicine (T/CM) is variable. Some terms have additional meanings depending on whether they are used by the proponents or critics of T/CM.
The terms “traditional medicine” and “complementary medicine” are relatively recent terminologies for a range of healing practices that have been practised for hundreds of years, in some instances. Such practices were previously referred to as “primitive medicine” and “fringe” or “marginal medicine”.
The World Health Organization (WHO) has defined traditional medicine “as including diverse health practices, approaches, knowledge and beliefs incorporating plant, animal, and/or mineral based medicines, spiritual therapies, manual techniques and exercises applied singularly or in combination to maintain well-being, as well as to treat, diagnose or prevent illness.
“The terms complementary/alternative/non-conventional medicine are used interchangeably with traditional medicine in some countries.”
The term “complementary and alternative medicine” (CAM), which refers to the use of treatments as an adjunct to, or supplementary to, conventional medicine, is widely used. It has been defined by WHO as “a broad set of healthcare practices that are not part of that country’s own tradition and are not integrated into the dominant healthcare system.”
Some CAM practices are adaptations of traditional medicine. As CAM is a relative concept, its knowledge and practices vary between countries and are time-specific.
The Health Ministry defined T/CM (in 2001) as a form of health-related practice that excludes the medical or dental practices utilised by registered medical or dental practitioners.
The T/CM practices in Malaysia include acupuncture, aromatherapy, ayurveda, chiropractic, homeopathy, Malay medicine, naturopathy, reflexology, traditional Chinese medicine, traditional Indian medicine and yoga.
Efficacy and safety issues
Without evidence of efficacy, it is hard to judge the safety of any practice that impacts on health. This is simply because the risk of an adverse effect, which might be acceptable for an effective treatment, will be unacceptable for an ineffective treatment.
About 25% of medicines are made from plants that were initially used traditionally. Herbal medicines which have demonstrable efficacy like morphine, which is used for pain relief, and vincristine, which is used in cancer chemotherapy, are important in conventional medicine. Their use illustrates the principle that “natural” is not synonymous with innocuous, as their safety margins are narrow.
In general, the evidence of the efficacy of T/CM is limited, as most therapeutic claims remain unsubstantiated. The scientific evidence from randomised clinical trials is only persuasive for many uses of acupuncture, some herbal medicines and some of the manual therapies.
Acupuncture has been proven to be effective in relieving postoperative pain, nausea during pregnancy, nausea and vomiting due to cancer chemotherapy, and dental pain, with very few side effects.
More research is needed to determine the efficacy and safety of several other T/CM practices and products.
The unregulated or inappropriate use of T/CM products and practices has resulted in negative or dangerous effects. For instance, the herb “Ma Huang” (ephedra), which is traditionally used in China to treat respiratory conditions, and was marketed as a dietary aid in the United States, resulted in at least a dozen deaths, heart attacks and strokes.
Interactions with prescription and over-the-counter medicines have also been reported with untoward effects for the user.
The quality of manufacturing may also pose serious problems. If plants are used, the precise chemical content would depend on the variety and the growing conditions, processing, and storage. The concentrations of compounds in T/CM products may vary considerably. Although commercially grown plants can be reliably identified, plants gathered in the wild may not be. Toxic species may be substituted for innocuous ones.
Another risk is the adulteration of T/CM products with prescription medicines e.g. corticosteroids and toxic substances e.g. heavy metals like lead, mercury and arsenic.
The Health Ministry’s Drug Regulatory Control Authority (DCA), as part of its post-market surveillance programme to ensure continued compliance to safety, efficacy and quality, subjects samples of registered products to testing.
A total of 2,538 registered products were sampled in 2007. Six product batches were recalled within 72 hours and 138 product batches were recalled within 30 days, due to quality defects. The recalls involved 17 prescription medicines (12.8%), 13 over-the-counter medicines (9.8%) and 103 traditional medicines (77.4%). It is noteworthy that the recall rate for traditional medicines is disproportionate to its segment of the products registered (46.5%) by the DCA.

The scientific evidence from randomised clinical trials is only persuasive for many uses of acupuncture, some herbal medicines and some of the manual therapies. - AFP photo

Regulation
Unlike T/CM, conventional medicine is heavily regulated. There are more than 40 health laws that doctors and health administrators have to be conversant with, depending on their practice situations.
One of the reasons for this is historical, as Malaysia inherited the common law from the United Kingdom. The common law right to choose one’s own treatment for illness has hardly been controlled by statutory law. As long as one does not claim to be a doctor or practise protected disciplines like dentistry, pharmacy and midwifery, or supply prescription medicines, any one could set themselves up as a practitioner in any aspect of healthcare.
This situation is unlike that in Europe or the United States where there are few healthcare activities that are permitted without authorisation by the state.
Because T/CM practitioners do not have to submit themselves to authority, it has led to a situation where T/CM is practised without recognisable training, qualification, professional standards or indemnity coverage. In short, there is little or no accountability with T/CM products and practices, until very recently.
The Health Ministry being cognisant of the need for a stronger evidence base on the safety, efficacy and quality of the T/CM products and practices, and the need to promote therapeutically sound use of T/CM by providers and consumers, established a Standing Committee on T/CM in 1998 and launched its national policy on T/CM in 2001. The Drug Control Authority also started to register T/CM products to address safety issues.
The much publicised T/CM Bill is eagerly awaited by many doctors and health administrators. One aspect that is of interest is whether the penalties for non-compliance are similar to that in the Private Health Care Facilities and Services Act.
T/CM products
T/CM products have recently come under the purview of the Control of Drug and Cosmetic Regulations 1984, Poison Act 1952, Sale of Drug Act 1952, Advertisement and Sale Act 1956 and Protection of Wild Life Act 1972.
T/CM products registered in Malaysia have to comply with the safety requirements of the Health Ministry’s Drug Control Authority. However, almost all T/CM products are registered as food supplements or vitamins, which registration requirements are much less stringent than that of prescription or over-the-counter medicines.
Whilst registration of T/CM products has ensured that they do not contain scheduled poisons and contaminants, efficacy issues have yet to be addressed. This question needs to be addressed, particularly when health promotion takes up about 79% of out-of-pocket health expenditure.
How effective are T/CM products? Are claims reflected in the reality of the situation in which the T/CM products are used? Are consumers getting value for their money? This is of particular relevance when the economic circumstances demand that there be belt-tightening.
Educational standards, registration and licensing
It is a fact that there are many T/CM practitioners who practise without qualifications or without adequate training. Of those who are trained, the length of training and the qualifications obtained vary widely. Some continue learning as apprentices or through short courses or correspondence courses.
There is a need for regulators to establish objectives of training and define core competencies in T/CM. Although many T/CM practitioners are not likely to face critical diagnostic issues or interact seriously with conventional medicine, others may have patients who choose not to consult a doctor, with some T/CM practitioners encouraging such an approach.
This issue needs to be clarified. If T/CM practitioners claim therapeutic autonomy, then they should have the benefit of a full medical education to equip them to work independently of doctors.
Some T/CM disciplines like osteopathy and chiropractic have developed and moved along the path of self-regulation in some countries, e.g. the United Kingdom and Australia. There are university degree courses in these disciplines with acts of parliament that protect their titles and provide orthodox regulation of their activities.
There are currently no formal accredited courses in T/CM offered by any institution of higher learning in Malaysia. However, there is progress in that the National Accreditation Board of the Ministry of Higher Education, in collaboration with the Health Ministry, has drafted standards and criteria for the offering of such courses. The standards recommended practices that are in tandem with internationally recognised good practices.
There were 7,154 T/CM practitioners registered with the Health Ministry as at December 2007. The criteria and implications of their registration have not found its way into the public domain yet.
Some countries require T/CM practitioners to be registered or to possess a licence to practise. Eligibility is usually determined by evidence of qualification and/or safe practice. Some countries automatically register a practitioner with a recognised qualification while others require the passing of a licensing examination. A robust and independent accreditation system is needed for automatic registration.
T/CM practice
Many T/CM practitioners practise in multiple therapeutic areas. It is important to address the issue of whether the regulations apply to the practice of a single therapy or recognise a varied range of therapies.
Standards of practice and conduct are usually spelt out in a code of conduct. The responsibility for setting standards is usually left to the professional body. The problem arises if the standards are set too low, for various reasons.
The public should be given the opportunity to pursue complaints against T/CM practitioners with the provision of codes of conduct, disciplinary procedures and sanctions. Although this is currently absent, it is the responsibility of regulators to ensure its implementation as soon as possible.
When there is an adverse event in conventional medicine, the patient and/or his representative can complain to the Health Ministry and/or Malaysian Medical Council and/or commence legal proceedings. What is the recourse for the patient and/or his representative when there is an adverse event following treatment by a T/CM practitioner? Worse still, what is the recourse if the adverse event occurred after treatment by a doctor as well as a T/CM practitioner?
The practice of T/CM by doctors is a question that some doctors have raised. The Code of Professional Conduct of the Malaysian Medical Council (MMC) prohibits doctors from employing or associating with persons who are not qualified or not registered under the Medical Act.
Any doctor who uses a T/CM product or practice has to ensure that it is evidence based and that they have been trained in the practice. Involvement in questionable practices may expose a patient to risks, and even danger, and the doctor to disciplinary proceedings by the MMC.
With increasing societal expectations for greater professional accountability in the medical profession, T/CM practitioners will need to do the same by increasing public scrutiny of their affairs.
Conclusions
Many people consult T/CM practitioners at the same time they consult their doctors. However, many do not inform their doctor for a variety of reasons. As there are efficacy and safety issues with many T/CM products and practices, it is in the interest of the patient for communication between doctors and T/CM practitioners to be enhanced.
There are many aspects to be addressed in the regulation of T/CM which have, to date, flourished without any accountability. It is hoped that the regulation of T/CM will enable the Health Ministry to achieve its objective of ensuring quality and safe use of T/CM practices and products to attain optimal potential in healthcare delivery.
Dr Milton Lum is Chairperson of the Commonwealth Medical Trust. 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. The views expressed are those of the writer and readers are advised to always consult expert advice before undertaking any changes to their lifestyles. The Star does not give any warranty on accuracy, completeness, functionality, usefulness or other assurances as to the content appearing in this column. The Star disclaims all responsibility for any losses, damage to property or personal injury suffered directly or indirectly from reliance on such information.