Saturday June 27th saw BeWell Medical Center host its first hearing assessment clinic, with a team of audiometry specialists from Bangkok and Prachuap Kirikhan. The clinic ran from 1 to 7:30 pm, with 25 patients booking hearing assessments, hearing aid repairs and servicing. We are already taking bookings for the next hearing clinic ~ planned for July, the date yet to be confirmed.
Developments in Heart Failure ( HF ) ~ a review by retired cardiologist, Dr Ben van Zoelen
What is meant by the term heart failure ( HF )?
There are many ways to describe it but HF essentially means that the heart cannot pump enough oxygen-rich blood around the body.
In 1973 I started working as a cardiologist in a private hospital in the Netherlands. Bypass operations for coronary artery disease were in full swing – using stents and balloons to open up narrowed coronary arteries were not yet routine procedures. Our cardiology department had 50 beds, of which 10% were used for heart failure patients. Nowadays more than 60% of the bed capacity is used for heart failure patients. Why is that?
There are two reasons:
i) Today the prognosis of HF is better.
In 1970, 80% of HF patients died within 1 year. Now more than 50% survive for more than 5 years. It’s a pity that it’s still no better than that, but it is improving, year after year.
In the past we thought that we’d be able to treat HF better once we had medication that could be given by mouth to make the heart pump more strongly. Finally we got that medicine. And guess what? More people died when we used it.
This gave us the insight to ‘never lay the whip over an almost dead horse’; better to pamper it, calm down the failing heart and even sometimes give it a good rest by using a mechanical heart for a while.
These days, along with newly developed medicines, we use the good old beta-blocker to slow down the heart. This same group of drugs were absolutely prohibited in the years before which shows how things can turn right around in medical practice…if you just wait long enough.
ii) There are more people with HF
People are generally getting older and aging increases the chances of HF; 10-20% of people in their 80’s and 90’s develop HF.
Also these days there are more survivors of myocardial infarction, many of whom go on to develop HF later.
Better diagnostics using blood tests and ultrasound doppler studies now allow us to diagnose HF patients that would not have been picked up in the past. As we have learned more about HF we’ve also come to recognize that a stiff heart and even a “normal” heart can have HF.
There are now special pacemaker systems for HF patients. Implantation, adjustment and control of these medical devices is complex and so it needs the patient to be in hospital for a while until safely stabilized.
For all of these reasons, we’ve seen an increase in the amount of hospital beds occupied by HF patients since my early years in cardiology. But now steps are being taken to reverse this trend and we’ve developed outpatient polyclinics and remote monitoring of HF patients at home. In fact, we are looking into the possibility of having these two options at the Bewell clinic in the future.
The outlook for HF is very positive – there are thrilling new medications to come in the next few years that we hope will improve the lives of HF patients even further.
~ ~ ~
This article is far from complete. I hope it gives you a better understanding of HF. If you have any comments please let me know. If you find I’ve used too many medical terms you don’t understand please email the clinic and it will be passed on to me.
Ben van Zoelen, retired cardiologist. member of the advisory board of the Bewell clinic.
A Thai Traditional Medicine group visited Be Well Medical Center on Friday 19th June
On Friday, Be Well were delighted to host a visit from a delegation headed by Dr. Khwanchai Visithanon, Director of the Institute of Thai Traditional Medicine at the Ministry of Public Health and Khun Sohnatda Panchee, Deputy Dean for Administrative Affairs at the College of Integrative Medicine at Dhurakij Pundit University in Bangkok.
As part of a government initiative, the group are exploring ways to promote and integrate traditional Thai medicine alongside modern medical practice. Traditional Thai medicine takes the holistic approach to spiritual and physical well-being, incorporating techniques such as herbal medicine, nutrition and physical therapies.
The group were very interested in the Be Well family medicine concept. Following a very informative and productive visit, we look forward to working further with the Ministry of Public Health and with the other parties associated with this initiative.
The Be Well Team
Comedians say that this year there’s been an unprecedented use of the word unprecedented. To show that coronavirus doesn’t have exclusive rights to hyperbole, here’s another unprecedented finding to consider: over the last seven weeks there hasn’t been a single positive case of influenza in Thailand.
This may only be relatively unprecedented (public records don’t go back beyond the start of 2017) but in the last 150+ weeks not once has has there been zero cases of the flu. And now seven weeks in a row without a flu case – in the rainy season too, when typically more respiratory infections are seen than at any other time of the year.
If there’s one thing that the coverage of Covid-19 has taught it’s that any declaration of ‘no positives’ must be viewed in terms of how many tests are being done and this year there have indeed been far fewer flu tests made than in the same period last year (134 vs 510), with zero positives compared to 159 in the same seven weeks last year.
This could mean that there are no cases of influenza to investigate at the moment – not impossible given that the hygiene measures put in place against Covid-19 are likely to be effective against the spread of flu virus also, particularly hand hygiene, distancing and school closures.
On the other hand it may be that there’s just less flu testing this year because so many resources are being directed against Covid-19 instead. Patients who would normally be tested and found positive for flu are those presenting with heavy respiratory symptoms and this year all such cases will come directly under the Covid-19 protocols. Once that condition has been excluded there may be neither the resources nor the appetite to take things any further.
Whatever the reason behind these seven straight zeros, it’s a rare observation and one to keep an unprecedented eye on!
Whether to wear a face mask or not has been a controversial issue throughout this pandemic, with some authorities encouraging universal face mask wearing from the beginning while others have only recently taken the same approach. Inconsistent advice on this has sometimes led to unpleasant incidents, with proponents from one camp seeing the actions of others as highly irresponsible.
Logically, there are two reasons for wearing protective equipment such as face masks: either to protect the wearer or to prevent an infected wearer from passing infection on to anyone else.
Scientific studies into the protection that face masks give to the wearer have been inconclusive and as a result authorities such as the World Health Organization and many of the disease control agencies of Europe and North America did not initially recommend their use by the general public, unless a person had symptoms of respiratory illness.
As our understanding of the Covid-19 pandemic has developed it has become apparent that those who pushed for the use of face masks were probably right, as we now know that many infections (possibly more than half) are contracted from a person without symptoms.
In response, many authorities, though not all, have now changed their recommendations and the wearing of face masks by everyone is becoming standard advice. This approach has received some support from studies showing that droplet spread is indeed reduced if a fabric face mask is worn when coughing or speaking.
Things never stand still for long though and the latest trend is the use of face shields instead of face masks; a common sight on television now and increasingly seen also in restaurants and other commercial venues.
Face shields have for some time been part of the personal protective equipment worn by health workers when dealing with highly infectious patients and were developed as a more comfortable alternative to elasticated eye goggles. They were designed to be used in addition to face masks, not instead of them.
Although face shields have been shown to stop coughed droplets from hitting the wearer’s face when social distancing cannot be maintained (such as when health workers examine and treat infected patients) we are not aware of any scientific studies into their role as a device to prevent onward spread of infection by the wearer and so BeWell does not recommend their use as a replacement for a face mask.
One of the notable things about this pandemic, however, is that the absence of evidence hasn’t necessarily stopped new interventions being taken up and the face shield as a blocker of droplets from the person wearing it has a certain common sense appeal.
Additionally, there are some clear advantages (!) to using a face shield instead of a face mask: they are more comfortable, permit lip reading, and greatly improve face recognition and inter-personal communication (although perhaps not by telephone).
The post-lockdown phase of this pandemic will probably require continued measures against viral infection for a long time to come and it seems likely that people will increasingly push for approaches that are more socially acceptable. Whether proven or not, face shields may well become the look of the future.
The Be Well Team
Many countries are easing lockdown measures now that they’re ‘over the peak’ of Covid-19. In Thailand, we’ve been lucky: our peak was just a small bump compared to the high levels of infection seen elsewhere. But as people return to restaurants and places of work, worship and commerce, what might we expect to happen next?
The optimistic view is that there’s less virus around now and the combination of facemasks, distancing, hand hygiene and contact tracing (and testing) by public health workers will control the situation. A pessimist might counter that if those measures weren’t sufficient the first time around why would they be successful now?
The arrival of a vaccine still seems a long way off, so herd immunity or the sophisticated form of hiding known as ‘lockdown’ are the only options available to us. Herd immunity is a situation where a virus dies out because a lot of people are already immune to it. With this virus it is thought that at least 60% of the population need to have been infected before we have herd immunity.
Calculations suggest that even in the world’s most affected nations less than 10% of the population have had the Covid-19 virus so far, so we are still a long way from safety, even putting aside the question of whether infection will provide immunity against re-infection. On a brighter note, the playing conditions have certainly changed since before the lockdowns began. Nations have now sealed their borders and although human beings have a tendency to ‘find a way’ when their freedom of movement is obstructed, the transfer of virus by people moving from one nation to another is likely to be much less now.
Also, the virus attacked Europe and North America in the cold and dark of winter. In contrast, sunnier countries have seen far fewer cases. With summertime coming to the North the virus may now transmit less easily in those countries, although we should caution that respiratory viruses in Thailand spread most easily during the rainy season…and that’s starting now.
It will be fascinating to see what happens over the next few weeks, both here and around the world, as the biggest medical experiment of all time steps further into the unknown.
Our advice is to remain on high guard (especially if you in a high-risk group), keep your distance from other people – even if you and they are wearing face masks – wash your hands frequently and avoid touching your eyes, nose and mouth with unclean hands.
The Be Well Team Hua Hin 10 May 2020
Teeing off again.
The re-opening of Thailand’s golf courses this weekend makes this the perfect time for a brief look into the medical side of golf.
Simply put, golf has many health benefits. As with other moderate-intensity sports, regular golfing is associated with improved cardiac risk factors such as reduced body weight, better cholesterol profiles and better blood sugar levels. Golf has also been shown to improve muscle co-ordination, balance and strength; factors that play an increasingly important role in injury prevention as a person ages.
Bone strength and bone density are increased in female golfers and caddies, reducing their risk of osteoporosis fractures. Perhaps the greatest gains though, especially in view of the recent homeisolation protocols, are the mental health benefits that come from fresh air, exercise and being out in wide open spaces…or bunkers.
You may know from personal experience, however, that golf’s impact on health is not always so positive. Studies find that between 15% and 40% of amateur golfers are injured playing the game every year, with most injuries affecting the spine, elbow, wrist and shoulders.
Sub-optimal swing mechanics rather than over-use are largely responsible; a problem made worse as mobility and flexibility decrease with age. Bear in mind that after not playing for perhaps a month or so, your own golfing flexibility may have deteriorated since the last time you played.
So what can be done to reduce golf-related injuries? The first step to fixing a problem is to identify it and to this end various self-help tests can be found online that will help you check the range of movement in your spine, neck and hips. Alternatively, you might consider the services of a physiotherapist to assess and advise on suitable flexibility exercises.
It could be said that professionals get fit to play golf and amateurs play golf to get fit. Pre-golfing preparation is not just for the pros though. Strength training has been shown to reduce sporting injuries at all levels. The best exercises to consider for golf are those with elements of power, balance and co-ordination at the same time; ‘body-weight’ exercises are ideal in this regard.
When you arrive at the course, always take several minutes to loosen up your muscles – before any practice swings. Pay particular attention to your shoulders and spine. During the round itself, concentrate on form rather than distance, and remember that lower back injuries are usually caused by doing really simple things badly, such as having poor technique when bending to retrieve or place a ball and when lifting your clubs in and out of the car.
Hopefully your return to golf is a pleasant, successful and painless experience. Stay well and remember to take anti-Covid hygiene measures as you play.
The Be Well Team Hua Hin, 3 May 2020
Last week we mentioned that there is a vaccine for dengue fever but that it’s not recommended for travellers and expats. This probably seems quite strange, so this week we’d like to explain why.
Dengue is a common and at times severe virus infection transmitted by mosquitoes. There were 98,000 cases of dengue in Thailand last year, along with 100 deaths, and yet 3 out of every 4 infections are thought to give no symptoms at all. Like most viral illnesses there is no cure and hospital treatment for severe cases consists of supportive care and hope.
The symptoms of dengue begin a few days after a mosquito bite. Typically, there’s a sudden fever, pain behind the eyes, headache and severe body aches (so bad that in earlier times dengue was known as ‘break bone fever’). In extreme cases there may be bleeding from the eyes, nose and mouth, explaining dengue’s Thai name of ‘khai leuat ork’ (fever blood out).
The Aedes mosquito that transmits dengue has white stripes and is easy to recognise but not so easy to avoid. She bites in the daytime as well as at night and can transmit other similar viruses like Zika, chikungunya and yellow fever virus.
There are 4 distinct strains of dengue virus and the interaction between them and the human immune defence system is key to why vaccination can be dangerous.
Infection with a dengue virus results in long-term immunity to that strain. For a year or two there is cross-over immunity to the other strains also, but this protection is lost as the antibody levels fall, making it possible to catch dengue again. The strains can be caught in any order, with the second infection usually much worse than the first, third or fourth (whichever strain causes it).
This happens because antibody levels from the first infection pass through a ‘danger zone’ as they fall from high to low levels over time. If the second virus comes along when antibodies are in the danger zone then the immune response goes into overdrive, generating an excessive, harmful and sometimes fatal reaction. Levels above or below the danger zone are safe.
This is why we don’t recommend the dengue vaccine – if you’ve never had a dengue infection and you take the vaccine then you will make a high level of antibodies, the same as happens with a first dengue infection. As those antibody levels fall you will for a while be at a much higher risk for severe and possibly fatal dengue than if you’d never been vaccinated at all.
Checking for antibodies before giving the vaccine would avoid this problem but unfortunately the antibody test for dengue is unreliable because there are false positive results from antibodies to similar viruses (chikungunya, yellow fever and Zika). Interestingly, several Covid-19 patients have had false-positive dengue tests also, perhaps indicating a similarity between the antibodies for dengue and Covid-19. The significance of this observation is unknown.
In the absence of a safe vaccination program, the best way to protect yourself against dengue is to
eliminate mosquito breeding sites around the home, ie remove or drain anything that may collect small pools of water during the rainy season. We also recommended wearing long sleeves, long trousers and to use insect repellant at this time of year, even during the daytime.
The Be Well Team Hua Hin, 26 April 2020
This week saw the start of the rainy season, a welcome relief to the heat and drought. But the rains also come with health warnings.
Thailand sees many more infections from respiratory viruses during the rainy season, perhaps because the high humidity allows the virus to survive longer on surfaces, or because human behavioural changes, such as staying indoors together when it’s raining, make it easier for a virus to spread.
In normal years the most dangerous of these infections would be influenza, or ‘flu’. But, of course, this is nothing like a normal year, and we have to hope that the coronavirus doesn’t also spread more easily in the rainy season. At least, social distancing, hand-washing and wearing face-masks will help protect against the flu virus as they do against Covid-19.
One notable difference between these infections is that we already have a vaccine against the flu. Be Well strongly recommends that you do what you can to protect yourself from flu, especially if you are a person at higher risk of serious complications, ie over 60 years of age or someone of any age with a long-term medical condition. Contact us if you are unsure.
The rainy season’s health warning doesn’t only apply to respiratory virus infections, however. Mosquitoes are much more common at this time of year and so are the diseases that they transmit, most notably dengue fever. To reduce illness spread by mosquitoes we have to make it harder for them to breed and harder for them to bite us.
Small, stagnant pools of rainwater in urban areas are a major source of mosquitoes and they should be eliminated as much as possible. Wearing clothing with long sleeves, long trousers and using insect repellant will help to protect against mosquito bites.
The mosquito that transmits dengue and similar viruses has white spots and stripes, and she bites during the daytime as well as at the more typical feeding times of dusk and dawn. For this reason, it’s advisable to take precautions throughout the day and not just in the evening. Note that when using sunscreen, it’s better to use insect repellant on top of rather than underneath the sunscreen.
Actually, there is a vaccine against dengue fever too but it has some serious drawbacks. It isn’t licensed for use in people over the age of 45 years and currently isn’t recommended for tourists or expats under 45 years either.
Please continue to look after your own health: wash your hands frequently and keep a safe distance from other people. When leaving your home, wear a face-mask and consider taking measures against mosquito bites at this time of year also.
The Be Well Team
Hua Hin, 19 April 2020
In the current Covid-19 pandemic we recognise that many people are feeling a little uncomfortable about leaving their homes. To address this, we now offer a Video Consultation service for our members.
Medical consultations by video have been increasingly used around the world in recent times, and even more so since Covid-19 became such a problem. Many medical conditions are suited to this type of consultation although of course there are times when a physical examination or other tests are required. Some cases can be managed with the help of additional services such as home delivery of medicines or home visits of a nurse for blood sampling, blood pressure measurement, injections, etc. but for other cases visiting the clinic or a home visit from a doctor may be necessary.
To arrange a Video Consult appointment, simply call or email your request. The consultations are planned to last up to 15 minutes. All you need is a smart phone or a computer with camera and microphone, and an internet connection.
The fee for Video Consult is THB 500, the same as clinic visits for members. Payment can be made directly by bank transfer (details in the fees section of our website).
Note: this service is offered in response to the extraordinary circumstances of the coronavirus pandemic and governmental advice on staying home. The service requires the use of a third party software application; use is subject to the security undertakings of the software developer(s).