Medical Forum No. 228
Discussant: Stephen Wong, M.D.
Dyspepsia refers to a condition of impaired digestion that may include symptoms such as pain on the upper part of the abdomen, feeling of persistent fullness after eating, loss of appetite, belching, nausea, and vomiting.
Dyspepsia may be brought about by organic causes such as intolerance to foods or drugs, peptic ulcer, gastroesophageal reflux disease, gastric and esophageal cancer, or pancreatic and biliary tract disorders. It can also be triggered by other gastrointestinal and systemic disorders or functional causes (no anatomic or organic abnormality).
Diagnostic tests range from the most common upper gastrointestinal endoscopy to tests for Helicobacter pylori—bacteria that can cause stomach cancer, ulcer, and symptoms of dyspepsia, which can can also be done during endoscopy.
Treatments for dyspepsia include Prokinetic drugs, which promote increased movement in the intestines and stomach, propelling down stomach contents and air faster and relieving symptoms such as bloating and belching; Antibiotics, plus acid suppressant drugs, to eradicate bacteria—for Helicobacter Pylori patients; and/or Anti-depressants, with or without psychological intervention (for patients with functional dyspepsia), who can be refractory to acid suppression.
Medical Forum No. 229
Updates on Glaucoma Detection and Treatment
Discussant: Stelson L. Sia, M.D.
Glaucoma is a disease that can only be controlled and not cured. It has no single cause and may produce gradual, progressive, and irreversible damage to the optic nerve.
Most common types of Glaucoma are open angle glaucoma, which occurs when fluid builds up and increases eye pressure even if the anterior chamber angle is not blocked and angle closure glaucoma, which occurs when the anterior chamber angle that drains fluid becomes blocked, therefore causing fluid build-up and increased eye pressure.
Risk factors include genetics, increasing age, smoking, certain medical conditions (e.g. diabetes), increased intraocular pressure.
Unfortunately, most patients do not have any symptoms until the late stage, when the optic nerve has already been severely damaged. Patients may then experience the following: eye pain and redness, photophobia, sudden blurring of vision, headache, vomiting, continuous tearing.
Glaucoma is a lifetime disease which may continually destroy the optic nerve. Loss of vision may occur if the disease is not controlled. The key to glaucoma control is continuous medication and regular eye check-ups. Continuing treatment is the only way to prevent worsening the condition, but this cannot bring back vision.
Medical Forum No. 230
Discussant: Susana Lao, M.D.
Infertility is the inability of a couple to achieve pregnancy, after a period of regular unprotected intercourse. Fertility problems affect one in seven couples. About 85% of women get pregnant within a year, while 93% get pregnant within two years. The effect of age upon men’s fertility is less clear; women become less fertile as they get older.
Today, there is an increasing infertility rate, which may be attributed to later marriages, delayed childbearing, decreased family size, contraception and family planning, women’s increased interest in education or career. Lifestyle and environmental factors also contribute to infertility. These include stress, smoking, wearing tight underwear, alcohol or drug use, occupation, bodyweight, consumption of caffeinated drinks.
Women’s failure to conceive may be traced to ovulation dysfunction, obstruction in fallopian tubes or ductal system, physical problems with the uterus, and abnormalities of sperm production or function.
After one year of unprotected, regular intercourse, or after 6 months under the following conditions, getting help for infertility is recommended: female partner over age 35; two or more miscarriages; endometriosis/painful menstruation; history of pelvic/genital infection; history of sexually transmitted disease; previous abdominal surgery; history of chemotherapy or radiation therapy; irregular or absent periods; excessive acne or hirsutism (body hair) in female; prostate infections; prior use of an intrauterine device (IUD); reversal of surgical sterilization; prior use of the contraceptive and no subsequent menstruation; breast discharge; chronic medical condition (e.g. diabetes, high blood pressure, etc.)
Evaluation includes infertility work-up tests, medical history and physical examination, semen analysis, ovulatory status test.
Treatments available are hormonal therapy, surgery, artificial insemination, and assisted reproductive technologies such as in-vitro fertilization and intracytplasmic injection.
Medical Forum No. 231
Dementia and Memory-Related Disorders
Discussant: Johnny Lokin, M.D.
Dementia is a condition characterized by sustained acquired decline in intellect, which interferes with daily activities. Dementia is a major public health issue and is seen as a factor carrying enormous economic consequences. The World Health Organization (WHO) data show that there is an 8% prevalence among those aged 65 and doubles every five years; 50% of cases are undiagnosed.
As different from dementia, there is a natural Age-Associated Memory Impairment (NOT Dementia) with symptoms including:
Difficulty recalling names, words (improves on cue), recognition memory and non-memory functions intact, insight preserved, and not disabling.
Signs and symptoms of early stage dementia vary from forgetfulness, absent-mindededness (won’t improve with cues), deterioration in judgment & social behaviour, difficulty recalling familiar words, and learning new things, as well as fatigue. The intermediate stage carries loss of logic, memory, motor ability, physical/verbal aggression, paranoia, impatience, restlessness, social skills, speech/verbal, and math skills decline. In its advanced stage, dementia brings hallucinations, emotional deterioration, bladder/bowel control decline, loss of insight, severe motor deterioration, difficulty following simple commands.
Risk factors include advancing age, low level of education, head trauma, hypothyroidism, vascular conditions such as hypertension, diabetes, hyperlipidimia, and heart disease.
There are two major types of dementia. These are Alzheimer’s Disease and Vascular Disease.
Alzheimer’s Disease is a memory change that disrupts daily life and difficulty completing familiar tasks. Symptoms include confusion with time or place, trouble understanding visual images and spatial relationships, decreased or poor judgment, misplacing things and losing ability to retrace steps, withdrawal from work or social activities, challenges in planning or solving problems, new problems in speaking or writing words, and changes in mood and personality.
The second most common type of Dementia is brought about by Vascular Disease which includes occlusion, haemorrhage, hypoperfusion, hypometabolism, lewy body, frontotemporal, and Parkinson’s Disease.
Evaluation to determine presence of Dementia covers shortscreening tests such as MMSE, clock-drawing test, ADAS-Cognitive, Shortblessed, clinical dementia rating (CDR), blood/urine, CBC, ESR, Serum Calcium, B12, Folate, Homocysteine, urinalysis, FBS, Lipid Profile, Liver/Thyroid Functions, CT or MRI of the Brain (Coronal), and ECG, EEG, ApoE4.
There are proven effective treatments and clinical trials essential to prove efficacy and safety. Treatments vary from symptomatic treatment such as acetylcholine in the brain, disease modifying cure or vaccines and for mild to moderate Alzheimer’s Disease and Dementia Donepezil (Aricept) 5mg and 10mg tablet, Rivastigmine, and Memantine.
Medical Forum No. 232
Fractures in the Elderly
Discussant: Nelson T. Lim, M.D.
Most common causes of fractures among the elderly are fall or accidents, osteoporosis, tumor or cancer.
Falls or accidents can be reduced by keeping surroundings clean, uncluttered, and well lighted; wearing sturdy, rubber-soled shoes; exercising to improve strength, balance, coordination, and flexibility; and getting proper medical evaluation and treatment for conditions causing physical changes.
Osteoporosis (brittle bones) can cause bones to become fragile and therefore more likely to break. Often, it develops with no symptoms or discomfort but will eventually cause pain, loss of height, prolonged immobility, psychological distress, or even death.
Osteoporotic fractures typically occur in the hips, spine and wrist. Its causes include aging, heredity and race, nutrition and lifestyle.
Diagnosis is done through skeletal x-rays, complete medical history and physical examination, T-score and bone densitometry or dexa scan.
Treatment may be non-surgical or surgical. The former includes regular exercises, nutrition therapy, estrogen replacement, monoclonal antibody treatment, use of bone forming drugs, estrogen receptor modulators, as well as anti-reroptive and bone forming medications. Also under this category are the use of cast, brace, and traction. The latter, which aims to fix, align, strengthen and stabilize broken bones especially the spine and hips, include hip surgery such as fixation with screws and plates and hip replacement, spinal surgery, and wrist surgery.
Medical Forum No. 233
Frequently Asked Questions about Arthritis
Discussant: Julie Li-Yu, M.D.
Arthritis is one of the most disabling degenerative disorder that causes pain and distress. Its different categories are: Osteoarthritis, which is the most prevalent; Gouty Arthritis, which frequently causes pain and distress to men and postmenopausal women; Osteoporosis, which is a metabolic bone disease that renders bones soft, brittle and fragility to fractures, commonly occurring in the spine, hips and forearms.
Osteoarthritis is detected by x-ray. Its treatment includes pain relievers and pain control coupled with lifestyle intervention.
Attach of gout can be controlled by urate lowering drugs. Long-term therapy is needed to prevent complications.
Preventive measures for both types include eating calcium rich foods, avoiding a sedentary lifestyle, keeping weight in check. Treatment is dependent on the risk profile of patients, including an evaluation of the presence of other chronic diseases.
Risk factors cover postmenopausal women (men at a much later age), hypothryroidism, rheumatoid arthritis, fracture after age 45, prolonged glucocorticoid use, family history of osteoporosis, thin bone frame, and smoking.
Medical Forum No. 234
Discussant: Johnson L. Sy, M.D.
Overactive Bladder (OAB) is a syndrome consisting of the following symptoms: urinary urgency with or without urgency urinary incontinence; frequency; nocturia; no causative infection or pathologic conditions; suggestive of detrusor overactivity.
Causes of OAB are classified Neurogenic and Non-neurogenic. The former covers spinal cord injury, multiple sclerosis, Parkinson’s disease, stroke, dementia, medullary lesions, diabetic neuropathy/cystopathy. The latter classification includes heart failure, edema, drugs such as diuretics, and depression.
Preliminary diagnosis is done through patient history and physical examination with urinalysis.
Treatment goal is to reduce the debilitating symptoms in order to improve quality of life. The patient is provided with informational education to achieve normal urinary tract function with patient and physician agreeing on treatment goal.
Behavioral therapy includes bladder training, pelvic floor muscle exercises such as Kegel’s, fluid management, dietary changes.
Anticholinergic therapy is used to block the muscarinic receptors in the urinary bladder responsible for detrusor muscle overactivity. Side effects include constipation and dry mouth. Contraindication are allergy to anticholinergic drugs and narrow angle glaucoma. Sacral neuromodulation SNS or Percutaneous tibial nerve stimulation PTNS is approved by the FDA, while Intradetrusor onabotulinumtoxin A is not approved by the FDA. For severe cases, an operation is done to augment bladder capacitance(augmentation cystoplasty).