Obesity Management in Obesity Surgery

Obesity has been recognised as a worldwide epidemic for the last few decades. A Body Mass Index (BMI) of 25 has been pegged as the landmark, above which is the definition of being overweight. A BMI of above 35 has been classified as being morbidly obese. The obesity societies of Asia has redefined the BMI criteria for Asians as 32.5. 

There are many diseases associated with obesity. The long list includes metabolic diseases like Diabetes Mellitus, Hypertension and Hyperlipidemia (and all the complications associated with these diseases), cancers like breast cancer and colorectal cancer, chronic joint diseases like chronic back pain, osteoarthritis of the spine, hips, knees and ankles and other illnesses like skin infections, pancreatitis and much more. There is evidence that those with morbid obesity are more likely to be depressed and have a shortened life-span.

Diet and exercise have been the mainstay of obesity management. However, the chance of weight loss of more than 10% together with keeping that weight down over a sustained period of time, is less than 2% for the morbidly obese. All these statistics, coupled with the complications of obesity that is a huge financial burden to the family and the state, has stimulated the development of obesity management and surgery (Bariatric surgery).

Over the last 40 years, obesity surgery is proven to be the best method to reduce the weight of morbidly obese patients quickly and, more importantly, to sustain that weight loss. In general, there are two main categories of obesity surgery. The restrictive surgeries like the Laparoscopic Adjustable Gastric Band (LAGB) and the Laparoscopic Sleeve Gastrectomy (LSG) have about 80% success in helping the patient lose about 60% of their excess weight within a year or two and this has been shown to be maintained and improved upon for at least 5 to 10 years. The second category is the malabsorptive group of surgeries which is typified by the Laparoscopic Roux en Y Gastric Bypass (LRYGB). This procedure has been shown to not only have a better weight loss profile, but it maintains the weight loss a longer time. With these procedures there is also a reduction or resolution of the complications of obesity by at least 80%.

These procedures, as the name suggests, are done laparoscopically (or keyhole surgery) and there are many advantages of this technique which would include less wound pain and complications, lesser respiratory complications, lesser hospital stay and faster recovery and time to work. The procedures have become very safe as compared to the surgeries done 40 years ago and the current perioperative complications are minimal due to the fact that the surgical techniques used are standard and the anaesthesia care has improved by leaps and bounds.

There will be a group of patients who are below the BMI criteria for Obesity surgery or are too ill to undergo surgery. These patients can be offered the Intragastric Balloon that is inserted into the stomach via gastroscopy under sedation. The balloon insertion is safe and there will be no scars on the abdominal wall. It will then be removed after 6 months and the projected weight loss is about 10%.

This article was contributed to Tab A Doctor by,
Dr Ganesh Ramalingam, Consultant General Surgeon, Panasia Surgery

Breathing Better

“Respiratory illnesses account for more than 50 per cent of clinic consultations and about 35 per cent of hospital admissions. It is also one of the leading causes of death in children under the age of 5 years in Malaysia, along with infectious diseases, injuries, congenital disorders and neurological problems,” says Dr Salehuddin Samsudin, Consultant Paediatrician and Neonatologist at the Sime Darby Medical Centre ParkCity. 

The most vulnerable are children less than 6 months old, premature infants and the immune compromised. According to Dr Salehuddin, asthma and upper and lower respiratory tract infections are the main respiratory diseases that are seen in paediatrics. Asthma affects about 10 to 15 per cent of children and is the commonest chronic respiratory illness in childhood. Although asthma may present at a very early age, it is very difficult to make an accurate diagnosis in children under the age of 5 years. This is because there are many other respiratory illnesses that can mimic asthma in this age group such as bronchiolitis, viral pneumonia or mycoplasma pneumonia. A strong family history of allergies, eczema and asthma makes the diagnosis more likely. Children with asthma have recurrent reversible narrowing of their lower airways. They usually have sudden breathlessness, coughing or wheeze, which is often worse at night or with exercise.

Dr Salehuddin says that asthma is often treated with bronchodilators (medications that relax the bronchial muscles) in the more severe episodes but in many recurrent cases a good preventive strategy is to use inhaled steroids. “Compliance with treatment and regular contact with your paediatrician is important to ensure the symptoms remain under control. It is also essential to avoid any known triggers such as house dust mites, pollen and cigarette smoke.”

The most important intervention is for the parent to stop smoking. He adds that even if parents smoke outside the house, there will be enough smoke particles on them and their clothing to trigger an attack in susceptible children. “Upper respiratory tract infections such as middle ear infection, tonsillitis and pharyngitis (throat infections) are mostly caused by viral infections.

However, there are bacterial organisms such as streptococcus that normally live in one’s nose and throat, which could also invade and cause ear and throat infections. Other more virulent organisms can also be passed on from one person to another via direct contact or droplets,” explains Dr Salehuddin.

Lower respiratory (usually below the trachea) or chest infections on the other hand, can be severe but are less common than upper respiratory tract infections. The same organisms that cause upper respiratory tract infections can also cause lower respiratory tract infections. Pneumonia, bronchiolitis and whooping cough are sometimes preventable by taking the necessary vaccinations.

“Parents should look out for symptoms of high fever, productive or wet cough with fast and increased work of breathing which usually accompanies chest infections,” advises Dr Salehuddin.

A careful clinical examination will usually show that the child has rapid breathing with increased respiratory effort, a crackling noise when listened with a stethoscope or reduced air entry, which could be a sign of fluid collection or a collapsed lung. A chest X-ray would be able to confirm the diagnosis safely even in very small babies. 

“Treatment is usually with oral or intravenous antibiotics and oxygen or respiratory support in more severe cases. There is no evidence that cough medications can alter the natural progression of the disease although it is often used to improve the coughing symptoms,” he says.

Although respiratory illnesses in children can get severe at times, identifying signs and symptoms early on and seeking immediate treatment will help keep the illnesses at bay.

This article was contributed to Tab A Doctor by,
Dr Salehuddin Samsudin, Consultant Paediatrician and Neonatologist, Ramsay Sime Darby Health Care, ParkCity Medical Centre

Colposcopy - What is it?

When your cervical screening test has shown evidence of abnormal cells, you will be referred to a Gynae for a colposcopy examination. An abnormal result usually means that small changes have been found in the cells on the cervix (the neck of the womb). These changes act as early warning signals that cervical cancer might develop in the future. However, it is important to remember that it is very rare indeed for these abnormalities to be cancer.

Colposcopy is a screening and simple examination that allows the Gynae to see the type and site of the abnormality on your cervix.

During the examination, you will be asked to undress from waist downwards (though a full skirt need not be removed). A nurse will hep you to position yourself on a special type of couch. The couch has padded supports on  which you rest your legs.

When you are lying comfortably, the Gynae will gently insert a speculum into your vagina, just as when you had your cervical screening test. The Gynae will look at your cervix using a colposcope. The colposcope is specially adapted type of microscope. It is just a large magnifying glass with light source attached. It looks like a large pair of binoculars on a stand. It does not touch you or go inside you.

The Gynae will then dab different liquids onto your cervix to help identify and highlight any areas of abnormal cells. The abnormal areas will appear white. If any abnormal area is identified, a small sample of tissue (a biopsy) will be taken from the surface of the cervix. A biopsy is about the size of a pinhead. You may feel slight stinging but it should not be painful. The procedure will take about 15 minutes.

It will take about a few days before you get the results of the biopsy. The Gynae then will tell you what is wrong and what treatment, if any, is needed.

This article was contributed to Tab A Doctor by,
By Assunta Hospital, Malaysia

Breast Cancer Stages, Associated Risks and Treatment Options

Stage 0 breast cancer usually refers to a condition known as ductal carcinoma-in-situ (DCIS). This is a precancerous condition. Given time, this condition if untreated may progress to form a frankly cancerous tumour which is described as invasive breast cancer. With the further passage of time, it will progress from a small cancer (stage 1) to a larger cancer with spread to the surrounding lymph nodes (stage 2 and 3) and eventually spread to other organs such as the lungs, liver, bones and brain through the blood stream (stage 4).


All stages of invasive breast cancer, from stage 1 to 4, has the ability to travel to other parts of the body outside the confines of the breast, take root and lie dormant, eventually to reactivate and grow in those areas causing a relapse. That is why in most cases of breast cancer relapse, the disease does not recur in the breast but in other organs. In such situations, the cancer is considered advanced and incurable.

 

Fortunately, in the pre-cancerous stage of DCIS (as is the case under consideration), the tumour cells have yet to acquire the ability to travel and spread through the blood stream. Thus, there is no possibility of the disease relapsing in other organs in future causing death. In other words, the long term survival form DCIS (stage 0 breast cancer) is practically 100%. The long term outlook of your relative is therefore very optimistic.


While the risk of the disease spreading and causing a relapse in other organs is absent, there is still a significant risk of a new breast cancer developing in the opposite breast. A new breast cancer, if it does form, may either be of the same stage 0 or it could develop as a higher stage cancer. This is particularly true of your relative who has both a personal as well as a family history of breast cancer.


Women are at much higher risk of developing breast cancer compared with men because the female hormones in women has a stimulatory effect on the transformation of normal breast cells into breast cancer cells. This may potentially be the underlying cause of breast cancer development in your relative. A laboratory test may be performed on the breast cancer tissue that was removed 3 years ago to see if the cancer cells respond to the stimulation of female hormones. This test may still be performed even though the surgery was performed 3 years ago as local hospitals have a practice of preserving and storing all tumour tissue removed during surgery for 5 or more years.


If the test shows that the cancer cells are responsive to female hormones, you relative may consider taking an anti-hormonal treatment to reduce the stimulatory effect of the body's female hormone on the opposite breast thereby reducing the risk of a new cancer forming in that breast. Studies have shown that such a proactive treatment may reduce the risk of a future breast cancer by 50-70%.


If your relative has any female siblings, they are at high risk of developing breast cancer as they now have 2 first degree relatives (mother and sister) with breast cancer. They should consider consulting an oncologist to discuss preventive treatment as I have described.


An active lifestyle with regular exercise and a healthy diet may reduce the risk of future breast cancer relapse. The probable explanation is that such a lifestyle is associated with a lower rate of obesity. As the fat tissue in a woman's body is capable of converting substances in the blood into female hormones, this may lead to a greater stimulatory effect on the transformation of normal breast tissue into breast cancer. Avoiding obesity, in this case, is therefore particularly important.


Surgical removal of a cancerous breast lump while conserving the breast is usually the preferred treatment if such a surgery can be performed with a reasonable cosmetic outcome. Such a breast conserving surgery is usually followed by radiotherapy to the affected breast. The long term survival from breast cancer in such an approach is similar to total removal of the breast (mastectomy) and is better for the patient's self-image and psychological health.

This article was contributed to Tab A Doctor by,

By Dr Wong Seng Weng, Medical Director, The Cancer Centre, a subsidiary of the Singapore Medical Group

Parents warned against giving paracetamol and ibuprofen for mild fever

Parents should not give children with a mild fever regular spoonfuls of paracetamol and ibuprofen, doctors advise today, as they warn that doing so could extend their illness or put their health at risk.

A misplaced “fever phobia” in society means parents too frequently use both medicines to bring down even slight temperatures, say a group of American paediatricians, who warn that children can receive accidental overdoses as a result.

As many as half of parents are giving their children the wrong dosage, according to a study carried out by the doctors.

In new guidance, the American Academy of Pediatrics advises that a high temperature is often the body’s way of fighting an infection, and warns parents that to bring it down with drugs could actually lengthen a child’s illness.

Family doctors too readily advise parents to use the medicines, known collectively as “antipyretics”, according to the authors of the guidance.

GPs also often tell parents to give their children alternate doses of paracetamol and ibuprofen – known as combination therapy – believing the risk of side effects to be minimal.

In its official guidance, the National Institute for Health and Clinical Excellence (Nice) says the use of the drugs “should be considered in children with fever who appear distressed or unwell”.

Although Nice says that both drugs should not “routinely” be given to children with a fever, it states that this approach “may be considered” if the child does not respond to being given just one of them.

Children’s paracetamol solutions such as Calpol and ibuprofen solutions such as Nurofen for Children are sold over the counter in chemists. Recommended dosage quantities vary by age.

There is a range of solutions for different age groups, meaning it is possible for parents with children of different ages to mix up which they are giving.

According to the British National Formulary, which GPs consult when prescribing or advising on medication, children should receive no more than four doses of the right amount of paracetamol in a 24-hour period, and no more than four doses of ibuprofen a day.

In its guidance today, however, theAmerican Academy of Pediatrics notes that both medications have potential side effects and says the risks should be taken seriously.

Doctors, the authors write, should begin “by helping parents understand that fever, in and of itself, is not known to endanger a generally healthy child”. “It should be emphasised that fever is not an illness but is, in fact, a physiological mechanism that has beneficial effects in fighting infection.”

Despite this, the academy says, many parents administer paracetamol or ibuprofen even though there is only a minimal fever, or none at all.

“Unfortunately, as many as half of all parents administer incorrect doses,” the authors say. A frequent error is giving children adult-sized doses, while children who are small for their age can also receive doses that are too high even if their parents follow the instructions correctly.

Paracetamol has been linked to asthma, while there have been reports of ibuprofen causing stomach ulcers and bleeding, and leading to kidney problems.

“Questions remain regarding the safety” of combination therapy, say the authors, led by Dr Janice Sullivan, of the University of Louisville Pediatric Pharmacology Research Unit, and Dr Henry Farrar, of the University of Arkansas.

Dr Clare Gerada, the chairman of the Royal College of GPs, said: “In my experience of 20 years as a GP, parents are usually pretty careful.

“I think the most important thing to be worried about is keeping medicines out of the reach of children, because some taste quite nice.”

This article was originally published on telegraph.co.uk

Your Guide To Assisted Conception

Sometimes nature needs a helping hand. Your doctor would be able to recommend the most suitable method of assisted conception after running some tests. The approach recommended is dependent on several factors, namely the age of the female partner, the duration and cause of infertility and the preference of the couple. The following is an overview of the current treatment available for treating infertility. 

Ovulation Induction
This is the most basic of all infertility treatment. For women who do not ovulate regularly, fertility tablets (sometimes injections) are given to stimulate the ovaries to produce eggs. The doctor then scans the ovaries to try to pinpoint the best time for intercourse. Alternatively, the woman may wish to time the intercourse by performing self-urine LH test.
 
Laparoscopic Keyhole Surgery
This is a surgery where tiny “keyhole” cuts are made on the tummy and special laparoscopic instruments are inserted. The aim of the surgery is to diagnose the cause of infertility (diagnostic laparoscopy) as well as to treat infertility (therapeutic laparoscopy). Surgery may be advised if you have blockage or adhesions of the Fallopian tubes, endometriosis, ovarian cysts and certain uterine fibroids. In general, the chance of falling pregnant is doubled after this surgery. 

Intrauterine insemination (IUI)
IUI is often used when the woman is not ovulating regularly and has at least one open Fallopian tube or the husband has sperms that have low quality. This treatment is also useful for couples who cannot have intercourse adequately due to erectile dysfunction or vagisnismus (painful intercourse). The semen is washed and treated. A small plastic tube is inserted into the woman’s womb and the processed semen is inseminated close to the eggs, at the time she is most fertile. This usually takes place in conjunction with stimulation of the ovaries with medications. 

In-vitro fertilization (IVF)
IVF is usually considered if the woman has damaged Fallopian tubes which are not amenable to surgical correction, or the husband has borderline low sperm count or quality, or when there are antibodies in the sperm. IVF is also sometimes considered if the couple has unexplained infertility. The woman undergoes a series of injections to stimulate the ovaries and when the eggs are matured they are collected. This is done using ultrasound and a fine hollow needle. Once the woman is sedated, a small probe is placed into the vagina to guide the needle to the ovaries, and the eggs are sucked up. The eggs are then mixed with the sperms in a flat, glass petri dish and kept in culture in the incubator for at least two days. The fertilized eggs (embryos) are then transferred back into the womb using a fine plastic tube. 

Intracytoplasmic Sperm Injection (ICSI)
ICSI is used if the male partner has extremely low sperm count or quality. It is also useful for couples who have had IVF cycles where very little or no fertilization occurred. Eggs are collected as for IVF. Mature eggs are chosen and each one is held on a tiny pipette while a single sperm is injected directly into the centre of the egg using microinjection equipment. Fertilization occurs in about 70% of the time and the fertilized eggs are subsequently transferred back into the womb. 

In-vitro Maturation (IVM)
In-vitro maturation (IVM) involves retrieving immature eggs from an unstimulated or partly stimulated ovary, and maturing these eggs in the incubator. Subsequently, these matured eggs are fertilized using ICSI. This is an attractive alternative to conventional IVF as it minimizes the discomfort and risks of ovarian stimulation as well as there is a significant reduction in costs. IVM is particularly useful in women who have polycystic ovaries, as the risk of Ovarian Hyper-stimulation Syndrome (OHSS) is high. 

Preimplantation Genetic Diagnosis (PGD)
Following IVF, one or two cells are removed from a fertilized egg (embryo) using very specialized techniques. These cells are then tested for specific genetic disorders such as thalassemia and/or the correct numbers of chromosomes to exclude conditions such as Down Syndrome. Only healthy embryos are then transferred back into the womb. Despite earlier reports, PGD has not been shown to improve pregnancy rates. 

Laser Assisted Hatching (LAH)
For a pregnancy to result from IVF or ICSI, the embryo must successfully implant into the uterus following the embryo transfer. Using a precision laser, an opening is made in the zona pellucida (the shell surrounding the fertilized egg) to weaken the wall of the embryo. The opening made by laser hatching helps the embryo hatch from zona pellucida and implant correctly. This procedure is recommended for women undergoing Frozen Embryo Replacement (FET) and women with recurrent IVF failure. 

Sperm or Egg Banking
For certain individuals, there is a need to preserve their sperm or eggs for use at a later stage. This may include men or women who may need to undergo surgery to remove their reproductive organs due to a cancerous condition, or undergo chemotherapy which may render them sterile. It is now possible to freeze adequate amounts of sperms and eggs in cryobank for future use. There are also women who want to freeze their eggs before they reach the end of their reproductive life as they have not found the right life partners yet.

This article was contributed to Tab A Doctor by,
Dr Wong Pak Seng, Obstetrics and Gynaecologist, Sunway Medical Centre

Breast Cancer – What are the choices?

Introduction 

Breast cancer is the most common cancer among women in Singapore. Worldwide, it is also the most common cancer among women. Breast cancer cases have increased because of the aging population (chances of getting breast cancer increases with age) and more women are now aware and are going for regular breast checks.

Risk factors 

The risk factors for breast cancer are:
• Women over the age of 40 years (but can occur at any age)
• Personal history of breast cancer in the same breast or contralateral breast
• Family history of breast, ovarian, uterine cancer or colon cancer
• Genetic predisposition (defects in BRCA 1 or BRCA 2 genes)
• Radiation exposure (treatment) to the chest during childhood or adolescence or young women
• Early onset of menses(before age 12) or late menopause(after age 55)

Fig. 1

• Use of combined hormone replacement therapy
• Use of birth control pills
• Never had children or had children after age of 30
• Excessive alcohol intake

• Obesity

Signs and symptoms (Fig.1 and 2)

The signs and symptoms of breast cancer are:
• Persistent lump in the breast or axilla
• Change in breast skin colour or appearance such as redness, puckering or dimpling

Fig. 2

• Change in breast size or shape

• Discharge from the nipple especially if it is bloody

• Change in the nipple or areola, such as scaling, persistent rash, or nipple retraction

Diagnosis and Staging Tests

Tests used to diagnose and monitor patients with breast cancer may include:

• Breast ultrasound to show whether the lump is solid or fluid-filled. (Fig.3) 

Fig. 3

• Mammography to screen for breast cancer or help identify the breast lump (Fig. 4 and 5) 

Fig. 4

Fig. 5

• Breast MRI to help better identify the breast lump or evaluate an abnormal change on a mammogram

• Breast biopsy, using methods such as needle aspiration, ultrasound-guided, stereotactic, or open (Fig.6)

• CT(computed tomography) scan to check if the cancer has spread

• PET(positron emission tomography) scan to check if the cancer has spread 

Fig. 6

Staging

Stage 0 (Ductal / Lobular carcinoma in situ or DCIS / LCIS ) (5 year survival 95%)

The cancer cells are found in the milk ducts or lobules of the breast. The cancer cells have not spread out of the milk ducts or lobules of the breast. 

Stage I (5 year survival 90%)

The breast tumour is less than 20mm in size. No spread to lymph nodes

Stage II (5 year survival 75%)

There is breast tumour 20mm in size or smaller and breast cancer cells are found in 1 to 3 axillary lymph nodes or,

There is breast tumour more than 20mm in size without any breast cancer cells in the lymph nodes.

Stage III (5 year survival 55%)

There is breast tumour of any size with breast cancer cells in 4 or more axillary lymph nodes or lymph nodes near the breastbone; or

The breast tumour is more than 50mm in size with breast cancer cells in 1 to 3 axillary lymph nodes or lymph nodes near the breastbone.

Stage IV (5 year survival 15%)

The breast cancer cells have spread to other organs of the body like lungs, bone, liver and brain.

Treatment 

Treatment for breast cancer includes surgery, chemotherapy,  radiotherapy and hormone therapy.

In breast cancer surgery, there is breast-conserving surgery (BCS) and there is mastectomy.(fig.7)

Fig. 7

Breast-conserving surgery (BCS) involves only the removal of the tumour or lump including the surrounding normal tissue (called lumpectomy) or a segment of the breast (segmental mastectomy). In BCS, if the margins of the tissues removed is found to have cancer cells a wider excision should be done to make sure that the margins are clear of cancer cells.

Mastectomy involves removal of the whole breast. In simple mastectomy, the entire breast is removed including the nipple. In skin-sparing mastectomy, the entire breast tissue is removed sparing the skin over it as breast reconstruction can be done. This procedure cannot be done if the breast tumour is too large or the skin of the breast is affected by cancer. In nipple-sparing mastectomy, the entire breast tissue is removed excluding the nipple and skin of the breast. This procedure cannot be done if the nipple or the skin near the nipple is affected by cancer. In modified radical mastectomy, the entire breast is removed including the nipple and the axillary lymph nodes. 

Choosing between Breast Conservation Surgery and Mastectomy (Table 1)

When choosing between BCS and mastectomy, the patient and the doctor should consider 

• the size and number of tumours, 

• location of the tumour in the breast,

• if the cancer cells have spread to surrounding areas, 

• the size of the breast, 

• family history

• patient’s wish

Table 1

Factors to consider	Breast Conservation suitable	Mastectomy advised
Size of cancer	Small	Large esp >5cm
Number of cancers	Only one	Multiple
Location of cancer	Away from nipple	Near the nipple
Involvement of skin or muscles	None	Skin or deep muscles involved
Size of breast	Good size	Small breasts
Family history	Low risk	Strong family history
Pros and Cons	After Breast Conservation Surgery	After Mastectomy
Need for adjuvant radiotherapy	Required treatment to the remaining breast tissue	May not need if margins are clear and muscles not involved
Need for chemotherapy	Depends on stage	Depends on stage
Need for hormone therapy	Depends on hormone receptor status of the cancer	Depends on hormone receptor status of the cancer
Follow up	Close follow up on remaining breast tissue and contralateral breast	Focus mainly on contralateral breast
Survival rate	Same in early stages (together with radiotherapy) as mastectomy

In radiotherapy, x-rays are used to kill the cancer cells before or after surgery. Possible side effects of radiotherapy are diarrhoea, bleeding and fatigue.

In chemotherapy, a drug is used to kill the cancer cells before or after surgery. Possible side effects of chemotherapy are nausea and vomiting, loss of appetite, fatigue, hair loss and diarrhoea. 

In hormone therapy, anti-estrogen or aromatase inhibitors are used to stop the action of estrogen or stop the production of estrogen as breast cancer cells require estrogen to grow and multiply.

Risk reduction

Breast cancer prevention lowers the chance of one person getting breast cancer but it does not guarantee that you will not get breast cancer. 

You can reduce risk by:

• avoiding use of combined hormone replacement therapy

• avoiding use of birth control pills 

• avoiding excessive alcohol intake

• maintaining normal body weight

• having children before age 30

• breastfeeding your children

• knowing your family history and seeking advice if there is a strong family history of cancer

• going for breast screening

Women at high risk of breast cancer may also undergo preventive mastectomy or prophylactic mastectomy. These women are those with personal history of breast cancer, strong family history of breast cancer, women who are genetically predispose to develop breast cancer (women who have defects in their BRCA 1 or BRCA 2 genes like Ms Angelina Jolie) or young women who had radiation exposure (treatment) to the chest.

Screening recommendations

The recommended screening for breast cancer are:

 

• breast self-exam once a month. If you detect or notice any breast lump, please consult your doctor.

• clinical breast exam by a doctor once every year from 40 years and above

• mammogram once a year from 40 to 49 years and every 2 years from 50 years onwards. 

• we also recommend breast ultrasound together with the mammogram to improve detection rate. 

• if mammogram and breast ultrasound results are not clear, CT scan or MRI of the breasts can also be performed.

This article was contributed to Tab A Doctor by,

By Dr Kum Cheng Kiong, Senior Consultant Surgeon, Center of Screening and Surgery

6 Surprising Sleep Wreckers

Do you wake up in the morning feeling more tired than you did when you went to bed? If so, something is disturbing your sleep. But do you know what it is?

Some reasons for sleep loss are obvious -- espresso nightcaps, wailing newborns, and insensitive neighbors playing the drums. But the causes of sleep loss aren't always so clear.

"People often don't have any idea what's disturbing their sleep," says Thomas Roth, PhD, director of the Sleep Disorders Center at Henry Ford Hospital in Detroit. "There's a lot of mis-attribution. They assume it's one thing, but it's actually something else entirely."

Why such confusion? “People often wake up in the night without realizing it," Roth tells. "You can be awake one or two minutes at a time in the night and you won't remember it the next day."

While some of these unremembered wake-ups are normal, too many will leave you chronically exhausted. And many common causes of sleep loss result in just this sort of brief, hard-to-catch awakening -- making it even harder to sort out the cause.

Here are six surprising causes of disturbed sleep.

Sleep Wrecker 1: Pets in Bed

While lots of people let their pets snuggle in bed with them for comfort, evidence suggests that animals in bed make it harder to sleep.

According to a survey by the Mayo Clinic Sleep Disorders Center, 53% of people who sleep with pets say that their animals disturb their sleep. Animals just don't have the same sleep and wake cycles that we do. So 3 a.m. to your cat might seem like an excellent time to start pouncing on your feet. Even more subtle disturbances -- the clanking of the tags on your animal's collar as it shuffles around -- can wake you up.

If you're feeling chronically exhausted, take a break from the interspecies slumber parties to see if it makes a difference with your disturbed sleep.

"Really, there are other places for your dog to sleep besides your bed," says Jodi A. Mindell, PhD, professor of psychology at St. Joseph's University in Philadelphia and author of Sleep Deprived No More. If you can't bear to kick your pets out of the bedroom, which is the ideal, at least set up a new spot for them on the floor.


Sleep Wrecker 2: Alcohol and Nightcaps

As a cause of sleep loss, this is often a surprise to people. Doesn't drinking make you drowsy? Isn't that why people have nightcaps? Isn't that why college parties always end with everyone passed out on the floor?

But the body's response to alcohol is more complicated than you might think. "Alcohol affects the rhythm of sleep," says Mindell. "It acts as a sedative at first, but then a few hours later when blood alcohol level drops, it will wake you up again."

To prevent your glass of wine from waking you up later, stop drinking two to three hours before bedtime.


Sleep Wrecker 3: Undiagnosed GERD

People who have GERD -- gastroesophageal reflux disorder -- often find the nights difficult. Once they're lying down, the acid can back into the esophagus, causing heartburn and pain. Some try to sleep propped up on pillows to cope.

"Acid reflux is a biggie when it comes to disturbed sleep," says Ronald Kramer, MD, a spokesperson for the American Academy of Sleep Medicine and specialist at the Colorado Sleep Disorders Center in Englewood, Colo. "Whenever I see a person with sleep problems, I always screen for it."

What you might not know is that GERD doesn't always cause such dramatic symptoms. Some people might only have one constant symptom: disturbed sleep.

"Even if you rarely have pain, the acid can still be waking you up at night," says Kramer. GERD can cause other nondescript symptoms too, like chronic cough. If you have GERD that’s interrupting your sleep, getting treated for it is important. Not only will treatment help you sleep, but it will reduce the risk of serious health problems later.

Sleep Wrecker 4: Medicine, Vitamins, and Supplements

Some of the most common causes of disturbed sleep are in your medicine cabinet, but you might not suspect them at all. Common drugs, like steroids for asthma and beta-blockers for high blood pressure or heart problems, can keep you up at night.

Despite being called "narcotics," so can opioid drugs for pain. While they relieve pain quickly -- and can make you feel drowsy in the process -- they can also lead to sleep apnea.

Botanical supplements can cause sleep loss, too. Supplements like ginseng and guarana are stimulants. Even vitamins aren't free of risk.

"Vitamins B6 or B12 can give people vivid dreams, and that can wake people up," says Mindell. "It's much better to use those in the morning."

If you're having chronic sleep problems, go to your doctor with a list of all the medicines, vitamins, and supplements that you use. Ask if any of them could be causing your sleep problems.

Sleep Wrecker 5: Pain -- Even Mild Pain

Just about any painful condition can cause disrupted sleep. Headaches, back pain, arthritis, fibromyalgia, and menstrual pain are all common causes.

What you might not realize is that the pain doesn't even have to be particularly severe to cause sleep loss. In fact, it doesn't even have to wake you up.

Pain signals sent out by your body can fragment your sleep, reducing the amount of time you spend in deep, restorative sleep. You might not wake up, but your sleep will be less restful.

"People with chronic pain often wake up feeling more tired than they were when they went to bed," says Roth.

Even if you have only mild chronic pain, it's worth checking it out with a doctor.


Sleep Wrecker 6: Being Exhausted -- as Opposed to Sleepy

Here's a common scenario. You come home from a long day at work, completely exhausted. You stumble into the bedroom, fully expecting that as soon as your head hits the pillow, you'll be out.

But somehow, that's not what happens. 45 minutes later, you're still staring at the ceiling. What's gone wrong?

"Contrary to what people think, being exhausted doesn't necessarily make people sleep better," says Roth. "There's actually a big difference between being exhausted and being sleepy." Roth points out that if you ran 50 miles and then dropped down in bed, you would unquestionably be exhausted. However, your body might be far too revved up to sleep.

Regardless of how worn out you feel, always take some time to unwind. "Don't rush to bed after a stressful day," says Roth. Instead, spend some time sitting quietly first. It could save you lots of tossing and turning later.


Or Is It a Sleep Disorder?

Of course, you could also have an undiagnosed sleep disorder, one of the common but hardly surprising wreckers. About 40 million people in the U.S. suffer from sleep disorders, conditions that can seriously interfere with the quality of your rest.

For instance, periodic limb movement disorder (PLMD) causes your legs to jerk rhythmically while you're asleep, disturbing restful sleep. Sleep apnea causes snoring and brief interruptions in your breathing, which can also wake you from deep sleep.

Since these conditions only manifest themselves when you're asleep, you might not know you have the symptoms. Many people have sleep disorders for years before they're diagnosed.

Or your partner may have the sleep disorder -- disturbing your sleep as well.

"If your spouse is snoring and kicking in the night, neither of you are going to sleep well," says Mindell.

There are plenty of other causes of disturbed sleep -- a bedroom that is too hot or too cold, shades that don't block enough light, noises that can be muffled by a sound machine, hot flashes during menopause. Figuring out what might help can take some trial and error.

The important thing is to take action. If you're having trouble sorting out what could be causing your disrupted sleep, ask your doctor or schedule an appointment at a sleep clinic.

You should also take time to think more seriously about sleep and how much you're getting. Do you need four or five cups of coffee to get through a typical day? Do you always have to sleep in on the weekends? Do you tend to fall asleep immediately as soon as you get into bed? Those are typical signs of sleep deprivation, says Roth.

"People learn about nutrition and exercise in grade school, but nobody teaches us anything about the importance of sleep," says Roth. "As a society, we need to accept that better sleep has to be a priority."

This article was originally published on webmd.com

Quitting Smoking - Planning Your Strategy to Quit

When it comes to quitting smoking, some people find it helpful to plan ahead. Others don't. Do what works for you.

If you prefer to plan ahead, start by asking yourself some questions. Are you a goal-setter? How confident do you feel that you will succeed at giving up smoking? Asking yourself these questions is one way to prepare yourself for quitting.

Know your reasons. Your reason for wanting to quit is important. Maybe you want to protect your heart and your health and live longer. Or maybe you want to spend your money on something besides cigarettes. If your reason comes from you-and not someone else-it will be easier for you to try to quit for good.

After you know your reasons for wanting to quit, use these five keys to quitting: get ready, get support, learn new skills and behaviors, get and use medicine, and be prepared for relapse.

1. Get ready

Contact your doctor or local health department to learn about medicines and to find out what kinds of help are available in your area for people who want to quit smoking. Telephone helplines operated by your state can also help you find information and support for quitting smoking.

Here are some other ways to get ready to quit smoking:

Set your goals. To achieve a long-term goal like quitting smoking, you may find it helpful to break the task into smaller goals. Every time you reach a goal, you feel a sense of pride along the path to becoming tobacco-free. Use this personal action plan to help you reach your goals.

Set your goals clearly. Write down your goals, or tell someone what you are trying to do. Goals should include "by when" or "how long" as well as "what." For example: "I will keep a smoking journal for 1 week, starting tomorrow."

Set a quit date, and stick to it. This is an important step. Choosing a good time to quit can greatly improve your chances of success. Avoid setting your quit date on high-stress days, such as holidays.

Reward yourself for meeting your goals. Quitting smoking is a difficult process, and each small success deserves credit. If you don't meet a goal, don't punish yourself. Instead, hold back on a reward until you achieve your goal. For example, give yourself something special if you succeed at stopping for longer than you have before.

Pace yourself. You may want or need to quit slowly by reducing the number of cigarettes you smoke each day over the course of several weeks. Set a comfortable pace. Certain activities won't be temptation-free for many months after you quit.

Be realistic. You may feel very excited and positive about your plan for change. Be sure to set realistic goals-including a timeline for quitting-that you can meet. For example, your goal could be to cut back from 20 cigarettes a day to 10.

Make some changes. Get rid of all cigarettes, ashtrays, and lighters after your last cigarette. Throw away pipes or cans of snuff. Also, get rid of the smell of smoke and other reminders of smoking by cleaning your clothes and your house, including curtains, upholstery, and walls. Don't let people smoke in your home. Take the lighter out of your car. Try some methods to reduce smoking before your official quit date. Use a smoking journal to keep track of what triggers urge you to use tobacco. This gives you important information on when it's toughest for you to resist.

If you have tried to quit in the past, review those past attempts. Think of the things that helped in those attempts, and plan to use those strategies again this time. Think of things that hindered your success, and plan ways to deal with or avoid them.

2. Get support

You will have a better chance of quitting successfully if you have help and support from your family, friends, and coworkers. Others sources of support include:

Your doctor. He or she can help you put together a plan of medicines and nicotine replacement therapy (NRT) that works for you. This could be the nicotine patch, or maybe the nicotine patch with gum for those times you need something more.

Phone support. Telephone counselors can help you with practical ideas. Often they are people who have quit smoking themselves.

You can also find online and phone support along with quit-smoking programs that you can attend. People who use telephone, group, or one-on-one counseling are much more likely to stop smoking than people who try to quit on their own.


3. Learn new skills and behaviors

Since you won't be smoking, decide what you are going to do instead. Make a plan to:

Identify and think about ways you can avoid those things that make you reach for a cigarette (smoking triggers), at least at first. Try to change your smoking habits and rituals. Think about situations in which you will be at greatest risk for smoking. Make a plan for how you will deal with each situation.

Change your daily routine. Take a different route to work, or eat a meal in a different place. Every day, do something that you enjoy.

Cut down on stress. Calm yourself or release tension by reading a book, taking a hot bath, or digging in your garden.

Spend time with nonsmokers and people who have stopped smoking.

Start seeing yourself as a person who is making healthy choices.


4. Get and use medicine

You will double your chances of quitting even if medicine is the only treatment you use to quit. Your odds get even better when you combine medicine and other quit strategies, such as counseling.

You won't have to take medicines forever-just for as long as it takes to help you quit. And remember that no matter how much it costs to buy medicines to help you stop smoking, it's still less than the cost of smoking.


5. Be prepared for relapse

Most people are not successful the first few times they try to quit smoking. If you start smoking again, don't feel bad about yourself. A slip or relapse is just a sign that you need to change your approach to quitting. Make a list of things you learned. And think about when you want to try again, such as next week, next month, or next spring. Or you don't have to wait. If you're still motivated to quit, you can try again as soon as you want.

If you slip or smoke a little, don't give up. Talk to someone who has quit smoking, or to a counselor, to get ideas of what to do. If you are taking medicine or using nicotine replacement, keep doing so unless you go back to regular smoking.

Quitting smoking is hard, but it can be done. To stay motivated, keep reminding yourself why you want to quit smoking. Make a list of your reasons to quit and the benefits you expect from quitting. Put your list of reasons on your bedroom dresser, in your wallet, or on the refrigerator. Review it whenever you are struggling with the quitting process. Add to your list whenever another reason or benefit occurs to you.

If you have tried to quit smoking before, remember that most people try to quit many times before they are successful. Don't give up.

This article was originally published on webmd.com

Colon and Rectum Cancer – What you should know and How to reduce your risks

Introduction – The incidence is rising!

Colorectal cancer is the number one cancer diagnosed for males in Singapore and number two cancer diagnosed for females in Singapore (Singapore Cancer Registry, Interim Annual Registry Report, Trends in Cancer Incidence in Singapore, 2006-2010). Colorectal cancer cases have increased because of the aging population (chance of getting colorectal cancer increases with age) and also more people are going for screening.

Screening for colorectal cancer is effective because it almost always starts as a small benign growth, known as polyp, in the wall of the colon or rectum and, over a few years grows bigger to become a cancer. (Fig.1)

Fig. 1

Who is at risk?

The risk factors for colorectal cancer are:
• Age over 50 years (but can occur at any age)
• Personal history of colorectal polyps or colorectal cancer
• Personal history of ulcerative colitis or Crohn's disease
• Family history of colorectal cancer
• Genetic syndrome, Hereditary Non-Polyposis Colorectal Cancer (HPNCC) and Familial Adenomatous Polyposis (FAP)
• Physical inactivity
• Low-fibre and high-fat diet
• Obesity
• Excessive alcohol drinking
• Smoking

What are the signs and symptoms of colorectal cancer?

Usually, people with early stages of colorectal cancer may not experience any symptoms. Thus it is important to go for screening even if there are no symptoms. The common symptoms of colorectal cancer are:
• Blood in the stool
• Unexplained weight loss
• Change in bowel habits (diarrhoea or constipation)
• Bloating and feeling of fullness
• Stools that are narrower than normal
• Nausea and vomiting
• Persistent abdominal pain

How is the diagnosis made?

The diagnosis is usually confirmed with a colonoscopy and biopsy of the cancer. 

Fig. 2

Colonoscopy is an outpatient procedure using a flexible endoscope to examine the inner walls of the colon and rectum. The procedure takes about 20 to 30 minutes under sedation and should be done in a hospital by

a trained doctor. If a polyp or growth is seen during colonoscopy, the some tissues are taken out and send to the laboratory to check if it is benign or cancerous. Fig. 2 shows colon cancer as seen during colonoscopy.

Once diagnosis is confirmed, special scans such as CT or PET scans may be ordered by the doctor to study the extent of the disease.

Stage and Prognosis (Fig. 3)

Stage I (5 year survival rate more than 90%)
Cancer cells are found in the mucosa (innermost layer) and submucosa of the colon wall and may also be found to have spread up to the muscle layer of the colon wall.

Stage II (5 year survival rate 60-75%)
Cancer cells are found to have spread through the muscle layer to the serosa (outermost layer) of the colon wall or nearby organs.

Stage III (5 year survival rate 40%)
Cancer cells have spread nearby lymph nodes

Stage IV (5 year survival rate very low))
Cancer cells have spread to organs like lungs, liver and ovary or a distant lymph node.

Fig. 3

How is colorectal cancer treated?

Treatment for colorectal cancer includes surgery, chemotherapy and radiotherapy which may be used alone or in combination.

In surgery, part of the colon or rectum where the cancer is noted will be removed.(Fig.4) After surgery, most patients can lead an active lifestyle and defecate through their anus like normal individuals.

Fig. 4

In chemotherapy, a drug is used to kill the cancer cells before or after surgery. Possible side effects of chemotherapy are nausea and vomiting, loss of appetite, fatigue, hair loss and diarrhoea.

In radiotherapy, x-rays are used to kill the cancer cells before or after surgery. Possible side effects of radiotherapy are diarrhoea, bleeding and fatigue.

How do I reduce my risk of colorectal cancer?

Family history risks, genetic predisposition and risk associated with age cannot be modified except by going for screening. (see screening recommendations below). 

There are however some modifiable factors we can control:

• Avoid or stop smoking

• Exercise regularly

• Maintain a normal body weight (body mass index <25)

• Eat a high fibre, low fat diet

• Avoid excessive alcohol

• Go for screening 

Screening recommendations

Colorectal cancer is curable if detected early. 

Go for colorectal screening if you are 50 years and above even with no symptoms. If you have a history of colorectal polyp or colorectal cancer do not forget to have regular follow-up with your doctor. If you have a family history of colorectal cancer, you should go for screening at least 10 years earlier than the age when your relative was diagnosed with colorectal cancer. 

The recommended screening tests for colorectal cancer are fecal occult blood test and colonoscopy which should begin at the age of 50 years for people with no symptoms and no family history. If you have symptoms described above, consult your doctor early. 

Fecal occult blood test screens for blood in stool that cannot be detected by the naked eye. It is easy and painless as the person just need to submit a stool sample to the laboratory.

The best method is colonoscopy. It is an outpatient procedure using a flexible endoscope to examine the inner walls of the colon and rectum.

This article was contributed to Tab A Doctor by,

By Dr Kum Cheng Kiong, General Surgeon, Center of Screening and Surgery

 

25 Amazing Nutrition And Health Benefits Of Bananas

Today let us embark on a journey towards discovering one of the fruits that most of us love, but don’t know much about. I am talking about a Banana; don’t most of us just love this delicious fruit? You bet!

However, there are some weight watchers who will raise their eyebrows if I tell them that this fruit should be part of their diet. They will soon know why this awesome fruit deserves to be loved and eaten. And for all those people who are NOT inspired to eat this soft, rich creamy, delicious, beneficial fruit packed with nutrients and essential vitamins, the following should induce you to so.

First let us look at the nutritional value of bananas. Bananas are loaded with several nutrients.
Natural sugars: glucose, fructose and sucrose,

Vitamins and minerals: vitamin B6, vitamin C, Vitamin A, potassium, dietary fibre, biotin, carbohydrates, magnesium, riboflavin and manganese.

Here is a more detailed nutritive value table on Banana

Principle	Nutrient Value	Percentage of RDA
Energy	90 Kcal	4.5%
Carbohydrates	22.84 g	18%
Protein	1.09g	2%
Total Fat	0.33 g	1%
Dietary Fiber	2.60 g	7%
Vitamins
Folates	20 µg	5%
Niacin	0.665 mg	4%
Pantothenic acid	0.334 mg	7%
Pyridoxine	0.367 mg	28%
Riboflavin	0.073 mg	5%
Thiamin	0.031 mg	2%
Vitamin A	64 IU	2%
Vitamin C	8.7 mg	15%
Vitamin E	0.10 mg	1%
Vitamin K	0.5 µg	1%
Electrolytes
Sodium	1 mg	0%
Potassium	358 mg	8%
Minerals
Calcium	5 mg	0.5%
Copper	0.078 mg	8%
Iron	0.26 mg	2%
Magnesium	27 mg	7%
Manganese	0.270 mg	13%
Phosphorus	22 mg	3%
Selenium	1.0 µg	2%
Zinc	0.15 mg	1%
Phyto-nutrients
Carotene-α	25 µg	–
Carotene-ß	26 µg	–
Lutein-zeaxanthin	22 µg	–

Health Benefits of Bananas

Now let’s take a quick look at the banana health benefits:

1. It gives instant surge of energy:
It does this by converting the natural sugars into energy instantly and this is one of the reasons sportsmen consume it during intervals. Bananas are an excellent breakfast for kids and adults as it provides required energy throughout the day. This probably the most popular health benefit of banana.


2. It helps keep blood pressure under control:
Research indicates that potassium keeps blood pressure under control and improved consumption of calcium, potassium and magnesium can also help decrease high blood pressure. Bananas are rich in potassium, calcium & magnesium, so it is a healthy option for keeping blood pressure in check.


3. It helps lower cholesterol:
It is said that Pectin which is a soluble fibre in banana helps to lower Cholesterol levels. According to researchers, fibres that are water soluble such as pectin, psyllium, beta-glucan etc., lower the LDL Cholesterol without disturbing the HDL cholesterol.


4. It supports renal health:
Bananas being a rich source of potassium, if consumed regularly in moderation, promote renal health. The International Journal of Cancer states that Bananas being a rich source of antioxidant phenolic compounds, if consumed together with cabbage and root vegetables protect renal health.


5. Banana improves nerve function and enhances brain power:
Banana is a rich source of B vitamins and therefore perks up nerve function. Potassium, in banana keeps the mental faculties vigilant and boosts learning abilities.


6. It decreases the risk of stroke:
Studies indicate that regular intake of bananas in daily diet helps reduce the occurrence of stroke and this is due to the high amount of potassium.


7. Bananas Reduce the Risk of Cancer:
Rich in antioxidants and dietary fibre, consumption of bananas reduce risk of various types of cancer especially bowel cancer.


8. It helps build healthy bones:
Probiotic bacteria present in bananas is said to have astonishing ability to absorb calcium in the body. Hence, consuming bananas help in building better bones.


9. Banana enhances digestive ability:
It is very rich in the substance known as fructooligosaccharide which acts as a probiotic (friendly bacteria). It stimulates the growth and activity of probiotics in the colon and produces enzymes that enable absorption of nutrients thus enhancing the digestive ability and preventing unfriendly bacteria from harming the body.


10. Bananas helps combat stomach ulcers:
Certain substances in bananas stimulate the cells which make up the stomach lining, this enables production of a thicker protective mucus barrier against stomach acids. Also the substance known as protease inhibitors in banana, help getting rid of bacteria in the stomach that produces stomach ulcers, thus protecting against damage of stomach and ulcer.


11. Bananas help in Diarrhoea treatment:
Raw bananas are astringent in nature and are effective in treatment for diarrhoea. They also regulate fluid balance.


12. Bananas relieve from constipation:
Pectin found in Bananas, help to alleviate constipation and improves bowel function.


13. Bananas help in curing piles:
Since bananas help regulate bowel movement they help cure piles.


14. Bananas help regulate anaemia:
Bananas are good for Anaemic patients as they contain high levels of iron which help regulate the haemoglobin levels in the body.


15. Bananas help alleviate heartburn:
The antacid substance in banana gives immense relief from heartburn


16. Bananas prevents allergies:
The presence of benign amino acids in banana helps combat allergies.


17. Bananas help withdraw smoking urge:
Vitamins B6 and B12 along with magnesium and Potassium in Bananas helps recover from nicotine addiction


18. Bananas help recover from hangover:
Bananas when blended with honey and yoghurt cures hangover.


19. Bananas enhance weight Gain:
The combination of milk and bananas enhances weight gain. Bananas provide the body with necessary natural sugars and milk provides protein.


20. Bananas Benefits for Weight Loss:
Bananas contain loads of fibre and low amounts of fat and they are also easily digestible. A banana of 100 grams contains approx. 90 calories. And taking into consideration all its benefits it will not hurt including it into your diet. So dear weight watchers don’t eliminate banana from your diet completely.


21. Bananas Prevent Insomnia:
Bananas are rich in amino acids known as Tryptophan. This substance triggers production of melatonin (sleep hormone) which induces sleep. Eating banana a few hours before bedtime ensures a peaceful night’s sleep.


22. Bananas promotes healthy skin:
Bananas contain vitamin C a potent antioxidant which helps produce collagen, a protein found in the skin. This protein keeps skin soft and supple and eliminates fine lines and wrinkles, and protects the body from attack of free radicals which cause premature ageing. Additionally, bananas contain vitamin B6 known as pyridoxine which promotes healthy skin.


23. Bananas promote healthy scalp and hair:
Bananas contain potassium, natural oils, carbohydrates, vitamins and help in softening hair, protecting its natural elasticity, prevents split ends and breakage. Additionally, they enhance shine, growth, and help in controlling dandruff.


24. Bananas reduces mosquito bite:
Itching and swelling caused by mosquito bites can be reduced by rubbing the inside of a banana on it.


25. Other benefits of bananas:
Bananas curbs morning sickness. Snacking on bananas at regular intervals helps preventing it.
Vitamin B6, serotonin, tryptophan, dopamine, etc., in bananas help combat symptoms of PMS, erratic mood swings, and depression.

We should say a banana a day keeps the doctor away, shouldn’t we?

This article was originally written for stylecraze.com