Parksinson's Disease

Pathophysiology

Parkinson's disease belongs to a group of conditions called motor system disorders.

The disease is both chronic and progressive. It is not contagious nor is it usually inherited.
Parkinson's disease is the most common form of Parkinsonism, the name for a group of disorders with similar features. These disorders share the four primary symptoms described above, and all are the result of the loss of dopamine-producing brain cells. Parkinson's disease is also called primary parkinsonism or idiopathic Parkinson's disease.. In the other forms of Parkinsonism either the cause is known or suspected or the disorder occurs as a secondary effect of another, primary neurological disorder.

Parkinson's disease occurs when neurons, in the substantia nigra die or become impaired. Normally, these neurons produce dopamine which is a neurotransmitter between the substantia nigra and the corpus striatum, to produce smooth, purposeful muscle activity. Loss of dopamine causes the nerve cells of the striatum to fire out of control, leaving patients unable to direct or control their movements in a normal manner.

The cause of the destruction of these nerve cells is currently unknown but many researchers believe that a combination of four mechanisms - oxidative damage, environmental toxins, genetic predisposition, and accelerated aging - may be responsible.

Symptoms

The four primary symptoms are tremor or trembling in hands, arms, legs, jaw, and face; rigidity or stiffness of the limbs and trunk; bradykinesia or slowness of movement; and postural instability or impaired balance and coordination. Patients may have difficulty walking, talking, or completing other simple tasks.

Other symptoms of Parkinson's disease

Depression: This is a common problem and may appear early in the course of the disease, even before other symptoms are noticed. Depression may not be severe, but it may be intensified by the drugs used to treat other symptoms of Parkinson's disease.

Emotional changes: Some people with Parkinson's disease become fearful and insecure. Perhaps they fear they cannot cope with new situations. They may not want to travel, go to parties, or socialize with friends. Some lose their motivation and become dependent on family members. Others may become irritable or uncharacteristically pessimistic. Memory loss and slow thinking may occur, although the ability to reason remains intact. Whether people actually suffer dementia from Parkinson's disease is a controversial area still being studied.


Diagnosis

There are, as yet, no sophisticated blood or laboratory tests available to diagnose the disease. The physician observe the patient for some time until it is apparent that a tremor is consistently present and is joined by one or more of the other classic symptoms.

Treatment

Not all patients require drug treatment and medications are considered when the symptoms are sufficiently bothersome for the patient.

LevodopaThe gold standard of present therapy is the drug levodopa (also called L-dopa). L-Dopa (from the full name L-3,4-dihydroxyphenylalanine) is a simple chemical found naturally in plants and animals. Levodopa is the generic name used for this chemical when it is formulated for drug use in patients. Nerve cells can use levodopa to make dopamine and replenish the brain's dwindling supply. Dopamine itself cannot be given because it doesn't cross the blood-brain barrier. Usually, patients are given levodopa combined with carbidopa which delays the conversion of levodopa into dopamine until it reaches the brain, preventing or diminishing some of the side effects that often accompany levodopa therapy. Levodopa delays the onset of debilitating symptoms and allows the majority of Parkinsonian patients to extend the period of time in which they can lead relatively normal, productive lives

Side Effects of LevodopaThe most common side effects are nausea, vomiting, low blood pressure, involuntary movements, and restlessness..

Support Groups

One of the most demoralizing aspects of the disease is how completely the patient's world changes. The most basic daily routines may be affected - from socializing with friends and enjoying normal and congenial relationships with family members to earning a living and taking care of a home. Faced with a very different life, people need encouragement to remain as active and involved as possible.

Contributed by John Lee

Source: http://www.medicinenet.com/parkinsons_disease/article.htm

Tasks for PCL 13: Nageswari's Wish

Legal issues related to withdrawing treatment for a patient > Chris

(ethical issues to be debated in class)

Nursing Home Facilities - include staffing/ M'sia vs Aus > Shantz

Comparison between Old Folks Home & Nursing Home > Vivian

Legal issues related to Euthanasia > Madhura

(ethical issues to be debated in class)

Summary of Parkinson's disease >John

Atrial Fibrillation > Lawrence

Orthostatic Hypotension > Sri

Depression in old folks > Christine

MMSE > JK

Psychosocial Issues related to obesity

Social Stigmatization

In American and other Westernized societies there are powerful messages that people, especially women, should be thin, and that to be fat is a sign of poor self-control. Negative attitudes about the obese have been reported in children and adults, in health care professionals, and in the overweight themselves.
People's negative attitudes toward the obese often translate into discrimination in employment opportunities, college acceptance, less financial aid from their parents in paying for college, job earnings, rental availabilities, and opportunities for marriage.
Much of the research on the social stigma of obesity has suffered from methodological limitations. There has been a lack of research that has looked at the impact of obesity in the context of other variables, such as physical attractiveness, the situational context, and the degree of obesity. In addition, social stigma toward the obese has primarily been assessed among white individuals.
In addition, the degree of acceptance of obesity among people of lower education and income has not been well studied. Thus, these data are very incomplete with respect to racial and ethnic groups other than whites.

Psychopathology and Obesity
Research relating obesity to psychological disorders and emotional distress is based on community studies and clinical studies of patients seeking treatment. In general, community-based studies in the United States have not found significant differences in psychological status between the obese and non-obese. However, several recent European studies in general populations do suggest a relationship between obesity and emotional problems. Thus, it may be premature to state that there is no association between obesity and psychopathology or emotional distress in the general population. More focused, hypothesis-driven, and long-term studies are needed.
Overweight people seeking weight loss treatment may, in clinic settings, show emotional disturbances. In a review of dieting and depression, there was a high incidence of emotional illness symptoms in outpatients treated for obesity. However, several factors influenced these emotional responses; including childhood onset versus adult onset of obesity (those with childhood onset obesity appear more vulnerable). Another study that compared different eating disorder groups found that obese patients seeking treatment showed considerable psychopathology, most prominently mild to severe depression.

Body Image
Body image is defined as the perception of one's own body size and appearance and the emotional response to this perception. Inaccurate perception of body size or proportion and negative emotional reactions to size perceptions contribute to poor body image. Obese individuals, especially women, tend to overestimate their body size.
People at greater risk for a poor body image are binge eaters, women, those who were obese during adolescence or with early onset of obesity, and those with emotional disturbances. It is no surprise, then, that in some groups of obese persons, these individuals are more dissatisfied and preoccupied with their physical appearance, and avoid more social situations due to their appearance.
Body image dissatisfaction and the desire to improve physical appearance often drive individuals to seek weight loss. However, obese persons seeking weight reduction must come to terms with real limits in their biological and behavioral capacities to lose weight. Otherwise, weight loss attempts may only intensify the sense of failure and struggle that is already present among many obese individuals. For this reason, psychosocial interventions which incorporate strategies to improve body image may be helpful for those who want to lose weight and are very concerned about their physical appearance.

Side effects of slimming pills

Many slimming pills have now been taken off the market because of potential side effects and complications.

Amphetamine-type slimming pills were popular 30 to 40 years ago, but it took some time for doctors to realise they can be addictive and harmful. Few people managed to diet successfully with them and keep weight off, and many became physically hooked.
Even the more recent appetite-suppressant drugs, such as dexfenfluramine, have now been taken off the market in most countries, as research has linked their use to long-term problems such as heart disease.

New slimming drugs

Some new medicines to help people lose weight have been licensed in recent years. One, called sibutramine, alters the chemical messages in the brain that control how the person feels about food. By influencing brain chemicals called noradrenaline and serotonin, sibutramine helps to make a person feel full. Another, called orlistat, changes the way the stomach or intestines function, so that less fat enters the bloodstream. Several other drugs are in the development stage.

But, like any treatment, they have side effects. Sibutramine sometimes increases blood pressure, for example, while orlistat can cause diarrhoea and flatulence.

Anti-obesity drugs are only really suitable for very overweight people. Doctors are advised to only prescribe them in special circumstances. For example, as part of an overall treatment plan for the management of obesity for people aged 18 to 65 years with a body mass index (BMI) of 30 or more. Or where someone has a BMI of 27 or more and has another significant disease, such as type 2 diabetes or high cholesterol. The person must have already made serious attempts to lose weight by dieting, exercise and/or other changes in their behaviour.

See also Article: Asia's Killer Diet Pills @
http://www.time.com/time/magazine/article/0,9171,333902,00.html

Contributed by John Lee

http://www.nhlbi.nih.gov/guidelines/obesity/e_txtbk/ratnl/22112.htm

http://www.bbc.co.uk/health/ask_the_doctor/slimmingpills.shtml

South Beach Diet

This diet teaches participants to rely on the right carbohydrates and the right fats - the good ones. As a result, participants lose weight, lower their cholesterol, reduce their risk of heart disease and diabetes, and eliminate cravings without feeling hungry. Some call it the “updated version of the Atkins diet”
The origins of the South Beach Diet lay with Arthur Agatston, MD, a cardiologist whose motivation was to improve the cholesterol and insulin levels of his patients, who had heart disease, by developing a healthy eating plan. Agatston has also published a book about his plan, The South Beach Diet: The Delicious, Doctor-Designed, Foolproof Plan for Fast and Healthy Weight Loss which is growing in popularity by the day.
Although a glamorous name the South Beach Diet involves a high degree of determination and self motivation. It appears to be scientifically based and is rich in vegetables, fruits, whole grains, and lean protein, and it doesn't omit any major food groups.
According to Agatston, at the end of two weeks, most participants on the South Beach Diet are 8 to 14 pounds lighter. He notes the weight loss does not happen because participants eat less, but rather because eliminating simple carbohydrates has broken a bad eating cycle. As a result, participants continue to lose weight after the initial two-week period.

South Beach Diet Phases

Phase 1, The Strictest Phase of the Diet - Lasts 14 days
In the first phase, you eat normal-sized helpings of lean meats, such as chicken, turkey, fish, and shellfish. Vegetables are also allowed, so are nuts, cheese, and eggs. The goal is to eat three balanced meals a day, and to eat enough so that you don’t feel hungry all the time.
Diet Foods to enjoy includes tenderloin, sirloin, skinless chicken or turkey breasts, all types of fish, boiled ham, turkey bacon, whole eggs, fat-free cheeses, peanuts and pistachios, green vegetables, legumes, canola and olive oils.
Diet Foods to avoid include, beef rib steaks, honey-baked ham, breast of veal, all yoghurt, ice cream, milk including whole, low-fat, soy, and full fat cheeses, beets, carrots, corn, yams, fruits and fruit juices, all alcohol, all starchy foods such as bread, cereal, oatmeal, matzo, rice, pasta, pastries, baked goods, crackers, etc.
Expected Weight Loss: 8-13 pounds.
________________________________________
Phase 2, More Liberal Phase Lasts Until You Reach Your Weight Loss Goal
The second phase is similar to the first phase, but you reintroduce some of the banned foods and eat from all the dietary food groups. You can start eating high-fibre carbohydrates, such as whole-grain breads, which raise your insulin levels in a much milder way that do simple, starchy carbohydrates.
Additional Diet Foods to enjoy include most fruits, fat-free or 1 percent milk, other low-fat dairy foods, whole grain starches, barley and pinto beans and red wine.
Diet foods to eat sparingly, include: refined wheat baked goods, potatoes, beets, carrots, bananas, pineapple, watermelon and honey.
Expected Weight Loss: 1-2 pounds per week.
________________________________________
Phase 3 - Weight Maintenance
This diet phase, which is an even more liberal version of the initial diet plan, lasts the rest of your life. It should be used to maintain your healthy weight. Agatston describes this phase as a “way of life.” Should your weight begin to climb, you repeat the diet plan.

Drawbacks of the South Beach

Although weight loss is achieved on the South Beach Diet some questions have been raised about the ability of the South Beach Diet to induce ketosis. This is a state when your body does not have carbohydrates to digest and results in rapid weight loss being achieved. Some health professionals are not convinced that by dropping carbohydrates and placing a greater emphasis on protein this is enough to induce ketosis.

Much of the initial 8-13 pounds weight-loss is likely to be water-weight-loss caused by carbohydrate restriction. This weight loss is usually regained, as soon as carbohydrate intake resumes. A further drawback of the South Beach Diet is that it doesn’t fully cater for people who don't or can't eat dairy. Many snacks are dairy-based, yet the diet bans soy in the first two weeks.
Although Dr. Agatston has concerns regarding the liberal intake of saturated fats permitted on the Atkins diet plan, and offers sound advice on the subject, the issue on complex carbohydrates remains unaddressed. Most of the world outside America thrives on complex carbohydrates and these foods do not keep us overweight, nor do they warrant a 14-day ban.
As with any diet, despite the many positive aspects of Agatston's South Beach Diet, participants should consult a doctor before commencing. A balance diet and healthy lifestyle combining exercise is vital to maintaining weight loss.
The South Beach and Jenny Craig diet plans are lacking in any sort of clinical evidence. As mentioned earlier, the biggest problem with all of these diets is simply the adherence. In many of the randomized studies, drop-out rates were as high as 45%. And those that did manage to stay with the diet were not very strict in following the diet exactly as it requests.

Contributed by John Lee

http://www.healthyweightforum.org/eng/diets/south_beach_diet/

Sear's Diet

Sear’s Diet aka Zone Diet

Celebrities like Madonna, Demi Moore and Jennifer Aniston swear by the results of the Zone Diet created by Barry Sears, PhD. The Zone Diet contains 40% carbohydrate, 30% protein and 30% fat and is also known as the 40-30-30 plan. The Zone Diet works on the premise that 100,000 years ago, we were meat eaters and our bodies was designed to handle the demands of a meat-based diet.
As we have evolved, more carbohydrates have been introduced into our daily diet, causing an imbalance. The reason for our extra weight could be attributed to the many grains and starches in our diet (pasta, rice, breads, and potatoes). The Zone Diet’s strategy calls for a return to the diets of our ancestors where meat, fruits and vegetables are the main dietary items.
How Does The Zone Diet Work?
The Zone Diet works by working the right ratio of carbohydrates to proteins and fats in order to control the insulin in the bloodstream. Too much of the hormone (insulin) can increase fat storage and inflammation in the body (conditions that are associated with obesity, type 2 diabetes and heart disease). Sears asserts that by using the Zone Diet, you are actually optimizing the body’s metabolic function. Through the regulation of blood sugar, you allow your body to burn excess body fat.
The Zone Diet does not actually prohibit you from any particular food group; however food with high fat and carbohydrates such as grains, starches, and pastas should be avoided. Fruits and vegetables are the preferred source of carbs and monounsaturated fats (such as olive oil, almonds, avocados) are the ideal choice of fats. The Zone Diet claims to use food as a drug for overall good health, weight loss and prevention or management of heart disease and diabetes.

Risks/ Disadvantages

The AHA (American Heart Association) classifies the Zone Diet as high protein and does not recommend the Zone Diet for weight loss. They assert that the Zone Diet has not been proven effective in the long term for weight loss. They issued an official recommendation warning against diets like the Zone Diet.
They believe that the Zone Diet is hazardous as it restricts the intake of essential vitamins and minerals present in certain foods.
They are concerned that the protein ratio in the Zone diet is too high even if the minimal fat ratio is good. Robert H. Ecker M.D of the A.H.A., finds the Zone Diet’s theory on insulin flawed and argues that there is no scientific proof that the hormone insulin plays a big role in weight regulation.
According to Bonnie Liebman, at the Center For Science in the Public Interest, it's nothing new. "Miracle diets come and go like hemlines, hair-dos, and celebrity romances." Furthermore, they don't work; and all of them have the potential of raising low density lipoprotein (LDL) levels. And finally, what do these diets do for the authors themselves? Both Dr. Atkins and Barry Sears have exceeded the upper limits of weight recommended by federal guidelines.
Clinical studies conducted during the last half century, clearly show that a high-protein, high-fat, low-carbohydrate diet leads to higher rates of heart disease, stroke, hypertension, adult onset diabetes, and many types of cancer.
The relationship of animal fat to cancer is stronger than ever before. According to new studies released by the Environmental Protection Agency, potent carcinogens from industrial wastes, such as dioxin and other chlorinated compounds, are known to be concentrated in the animal fat of meat, fish, and dairy products. On the other hand, vegetables, fruits, and grains contain only small amounts of these compounds.
Its followers defend it vehemently, largely because they find the rapid weight loss irresistible. Like most low carbohydrate diets, however, a great deal of the weight loss is dehydration. Ordinarily, three grams of water are stored with every gram of carbohydrates in the form of glycogen in the liver and skeletal muscles. When this is sharply limited, the desperate "zonies" think they are losing up to a pound of fat a day. It's also low in calories (about 1,700), causing the unhealthy depletion of lean body mass along with the minimal fat loss.
Also, without careful monitoring, this type of diet may lead to "ketosis" (an unnatural form of acidosis), which often causes some degree of anorexia and even euphoria. Sears denies that this happens with the amount of carbohydrates he allows.

Contributed by John Lee

http://www.vegsource.com/attwood/zone.htm
http://www.southbeach-diet-plan.com/other_diet_plan/zone_diet.html

Complications of Overweight/Obesity

Hypertension
- related to substances produced by adipose tissue and the increase in the hormone insulin
Diabetes
- obesity is the leading cause of diabetes; risk of diabetes increased over 53 fold with severe obesity
- Type II Diabetes not Type I
Hyperinsulinemia, insulin resistance, glucose intolerance
Elevated cholesterol
- every 10 lbs of excess fat produces 10mg of cholesterol per day
Fatty liver
- Non-Alcoholic Steato-Hepatitis caused by excessive fat deposition in the liver
- Due to excess fat intake
- Results in silent inflammation, usually detected by liver function tests
- If untreated, can develop cirrhosis or liver failure
Cancer
- in females, 3 fold increase in the incidence of breast, uterine, cervical and ovarian cancer
- in men, there is an increased incidence of colon and prostate cancer
Degenerative arthritis (osteoarthritis)
- increased weight causes more wear and tear of the joints
- adipose tissue produces cytokines that “destroy” the normal cartilage in joints
Gallstones
- due to increase in cholesterol
- cholecystitis
CVD (Heart attacks, angina pectoris, CHF) and strokes
- increased incidence of strokes and heart attacks
- due to elevated blood pressure, diabetes, and elevated cholesterol
Sleep disorders
- feel tired all the time and have problems obtaining a restful sleep
- could be sleep apnea: becomes more difficult to breathe as their weight increases
- heart rhythms can become irregular leading to heart attack
- could lead to depression and anxiety due to lack of sleep
Polycystic ovarian syndrome
Pregnancy complications

(Posted by: Vivian)

Causes of Overweight

Causes of Overweight / Obesity
LOOI, Ji Keon

Overview
•Inherited
•Environment
•Psychological
•Endocrine
•Medications

It runs in the family!!!
•Determination of body composition is polygenic (>600 genes)
•Heritability of BMI is relatively high (50-90%)
•Genetic predisposition to obesity is proven
•Monogenic forms of obesity are relatively rare
•Metabolic syndrome
–high cholesterol & high blood pressure
•gene mutations in the mitochondria
•Shared familial characteristics in the environment
–Food preferences
–Lifestyle factors

It’s everywhere!!!
•Fast food / junk food
•Busy work
•Sedentary lifestyle – couch potatoes!
•Inadequate physical exertion

Psychological factors
•Food <-------> emotion
•Depression and stress lead to eating disorder, hence obesity.
Endocrine
•Cushing’s Syndrome – excess cortisol stimlating appetite
•Hypothyroidism – low basal metabolic rate
•Impeded leptin production – inability cells to signal satiety
•Insulinoma
•Polycystic Ovarian Syndrome


“Fattening” Medications
•Note: May have different properties in different individuals.

•Lithium for manic bipolar disorders
•Cortisone for rheumatism and allergies
•Anti-seizure medicines (Valproate)
•Antidepressants
•Migraine medicines (Sandomigrin, Ergenyl, Trypizol)
•Oestrogen (Follimin, Follinett, Neovletta)
•Insulin for type 2 diabetes (Insulatard, Humulin, Actrapid)
•Breast cancer medicines (Nolvadex, Tamoxifen)
•Beta blockers (Inderal, Cardura)
*Incomplete List

Have a nice Raya!And not to overeat!

•Thank you

Tasks for Week 12 PCL

what can BMi tell you?(shantz)
how to determine your body fat? instrument to measure(shantz)
def of obesity,overweight, etc.(shantz)
distribution of fat in the body as an indicator of pathology and determinant for Mx ( Sri)
psychosocial issues of being overweight- stress, self esteem, desperate measures(slimming pills, side effect) -(john)
mx- relation to daily activities(exercise), diet planning(dietician)- (Madhura)
relationship between smoking and losing weight -(lawrence)
cause of overweight -(Ji Keon)
complication of overweight -(Vivian)

http://www.acadmed.org.my/cpg/CPG-Obesity.pdf
http://www.nhmrc.gov.au/publications/pdf/n33.pdf
http://www.ifnotdieting.com (ji keon, madhura, chris)

find out what each of the following diet involve,proposed mechanism by which it is claimed to produce weight loss, scientific support, possible risks, disadvantages (lawrence, john, Shantz)
-ornish (lawrence)
-pritikin (lawrence)
-atkin (shantz)
-sears' the zone and the south beach diet(restricted carbo diet) - (John)
-weight watchers-> point system - (John)

use internet, search 'unilever' + 'Atkins Diet' -> what impact does it have on mainstream public health nutrition campaigns and how should this issue be addressed (christine, vivian)
-find examples of what potential impact a popular diet might have on
- low fat diet food industry (Christine, Vivian)
- the food industry in general (Christine,Vivian)

Psychosocial Issues

Psychosocial Issues

- financial: expensive to undergo surgeries; colostomy bags can be expensive; also to go for check ups (rectal examination, colonscopy, barium); genetic screening (?)

- emotional: have faced it before; saw how it affected his father; could cause him to not have faith in the modern interventions; either scares him to taking the treatments earlier or go for some other forms of treatments (CAM); could affect his children seeing their father, uncle and grandfather getting the disease; worried that they might get the disease as well; the need to go for check-ups can be traumatising; can affect his wife, not sure if her husband might be affected severely; how would she support the children

- socialising: if need to use colostomy bag, might not feel comfortable when being out with friends; feel inferior; passing gas and possibility of a bag blowout; could offend others if do not know how to handle the situation

- exercise/work: might feel reluctant to exercise if need to use the colostomy bag because it is inconvenient; could be jeered at by his students

- adapting to life: difficulty swimming and showering; may need to adjust his diet if using the colostomy bag; learning to deal with the smell from the stool

- social support: could join cancer patient support groups; colon cancer support groups (eg. colostomy association in UK)

(Posted by: Vivian)

Causes And Risk Factors for Colon Cancer

Cause of Colorectal cancer:

The exact cause of colorectal cancer is unknown.

Risk Factors

NB: Definitions: (Merriam Webster Medical Dictionary)

Predispose: To make susceptible.
Risk factor: Something which increases risk or susceptibility.

SO, what is the difference between a predisposing factor and a risk factors? Looks the same to me.

Anyway, these are some factors that increase a person's risk of developing the colorectal cancer:

Age. The risk of developing colorectal cancer increases as we age. The disease is more common in people over 50, and the chance of getting colorectal cancer increases with each decade.

Gender. The risk overall are equal, but women have a higher risk for colon cancer, while men are more likely to develop rectal cancer.

Polyps. Polyps are non-cancerous growths on the inner wall of the colon or rectum. Adenomatous polyps increase the risk of developing colorectal cancer.

Past Medical history. Research shows that women who have a history of ovarian, uterine or breast cancer have a somewhat increased risk of developing colorectal cancer. Also, a person who already has had colorectal cancer may develop the disease a second time. In addition, people who have chronic inflammatory conditions of the colon, such as ulcerative colitis or Crohn's disease, also are at higher risk of developing colorectal cancer. The risk for cancer begins to rise after eight to 10 years of colitis.

Family history. Parents, siblings, and children of a person who has had colorectal cancer are somewhat more likely to develop colorectal cancer themselves. If many family members have had colorectal cancer, the risk increases even more. A family history of familial polyposis, adenomatous polyps, or hereditary polyp syndrome also increases the risk.

Diet. A diet high in fat and calories and low in fiber may be linked to a greater risk of developing colorectal cancer. It is believed that the breakdown products of fat metabolism lead to the formation of carcinogens.

Lifestyle factors. You may be at increased risk for developing colorectal cancer if you drink alcohol, smoke, don't get enough exercise, and if you are overweight.

Diabetes. People with diabetes have a 30-40% increased risk of developing colon cancer.
(Read news article on CBS @ http://www.cbsnews.com/stories/2004/10/01/health/webmd/main646860.shtml)


Genetics and colon cancer

A person's genetic background is an important factor in colon cancer risk. Among first-degree relatives of colon cancer patients, the lifetime risk of developing colon cancer is increases threefold.

Even though family history of colon cancer is an important risk factor, majority (80%) of colon cancers occur sporadically in patients with no family history of colon cancer. About 5 % of colon cancers are due to hereditary colon cancer syndromes. Hereditary colon caner syndromes are disorders where affected family members have inherited cancer-causing genetic defects from one or both of the parents.

Chromosome damages cause genetic defects that lead to the formation of colon polyps and later colon cancer. In sporadic polyps and cancers (polyps and cancers that develop in the absence of family history), the chromosome damages are acquired. The damaged chromosomes can only be found in the polyps and the cancers that develop from that cell. But in hereditary colon cancer syndromes, the chromosome defects are inherited at birth and are present in every cell in the body. Patients who have inherited the hereditary colon cancer syndrome genes are at risk of developing large number of colon polyps, usually at young ages, and are at very high risk of developing colon cancer early in life, and also are at risk of developing cancers in other organs.

Contributed by John Lee

Sources:
http://www.medicinenet.com/colon_cancer/page2.htm
http://www.webmd.com/colorectal-cancer/guide/risk-factors-colorectal-cancer
http://www3.mdanderson.org/depts/hcc/
http://www2.merriam-webster.com/cgi-bin/mwmednlm

ix for colorectal carcinoma

Investigations for colorectal carcinoma

Blood count and routine biochemistry
Serum carcinoembryonic antigen level (related to outcome)
Colonoscopy is gold standard for investigation and allows for biopsies and polypectomies to obtain specimens for histological examination
Sigmoidoscopy
Endoanal ultrasound and pelvic MRI are used for staging rectal cancer
CT and PET scanning help to evaluate tumour size, local and secondary spread and hepatic metastases

ENDOSCOPY

Video endoscope have three chips mounted on the tip of the instrument to relay colour images via an image processor to a television monitor.

The tip of the endoscope can be angulated in all directions, channels are present in the endoscope for air insufflation, water injection, suction and for the passage of biopsy forceps or brushes for obtaining tissue.

Sigmoidoscopy: views the rectum. There are rigid and flexible sigmoidoscopy. Rigid ones can reach lower 20-25 cm of lower bowel. Flexible sigmoidoscopy gain better access than rigid ones but about 25% of colon cancers are still out of reach.

Pre-procedure: give 2 phosphate enemas; get written consent.

Colonoscopy: allows good visualisation of the whole colon and terminal ileum. Biopsies can be obtained and polyps removed. 90% success rate of reaching the terminal ileum.

Prep: prescribe sodium picosulfate 1 satchet morning and afternoon, the day before the procedure. Obtain written consent.

Procedure: sedation and analgesia are given before a flexible colonoscope is passed per rectum around the colon

Complications: abdominal discomfort; incomplete examination, perforation(0.2%) haemorrhage after biopsy.

Pathophysiology of Colorectal cancer

Ji Keon LOOI

Polyps
•small protrusion on the end of a slim stalk
•can grow out of the membranes lining various areas of the body.
•grow either singly or in clusters.
•Mostly benign
•Most cases of colon cancer begin as small, non-cancerous (benign) clumps of cells called adenomatous polyps. Over time some of these polyps become colon cancers.
•Others: hyperplastic, inflammatory polyps

Colon Cancer and Polyp

Background of Colorectal Cancer
•Vast majority of colorectal cancers are adenocarcinomas – 95%
•Arises from preexisting adenomatous polyps that develop in the normal colonic mucosa
•Associated with discrete molecular genetic alterations
RevisionPathogenesis of cancer
•Tumour suppressor gene
•Oncogene

Properties of Cancer Cells:
•evading apoptosis
•self-sufficiency of growth factors
•increased cell division rate
•altered ability to differentiate
•ability to invade neighbouring tissues (metastasis)
•ability to promote blood vessel growth (angiogenesis)

Genetic Basis for Colon cancer
•Mutations of APC (adenomatous polyposis coli) gene
–familial adenomatous polyposis (FAP), and
–Sporadic colorectal cancer

•The protein encoded by the APC gene targets the degradation of beta-catenin, a protein component of a transcriptional complex that activates growth-promoting oncogenes, such as cyclin D1 or c-myc.

More about genetics of colon cancer
•Leads to imbalance in genomic DNA methylation
•global hypomethylation è oncogene activation
•regional hypermethylation è silencing of tumor suppressor genes
•Bcl2 over-expression è inhibition of cell death signaling (antiapoptotic)è colorectal cancer development

Familial adenomatous polyposis (FAP)
•autosomal dominant
•less than 1% of all colorectal cancers and has an incidence of 1 in 10,000
•presence of 100 or more tubovillous adenomas in the colon
•almost all of gene carriers have polyps by 40 yo. Untreated polyps è malignant transformation

Autosomal Dominant Inheritance

Attennuated Familial Adenomatous Polyposis
•a milder version of FAP
•less than 100 colon polyps
•autosomal dominant
•very high risk of developing colon cancers at young ages.
•Also at risk of gastric polyps and duodenal polyps

Hereditary non­polyposis colon cancer
•gene carriers will develop a small number of tubovillous adenomas, but not more than 100
•Mismatch repair genes
•Knudson’s two hit hypothesis
–Failure to repair mutations in tumour suppressor genes è adenoma carcinoma

•Also at risk of developing uterine cancer, stomach cancer, ovarian cancer, and cancers of the ureters, and the biliary tract
Colorectal Cancer

Thank you
•Any Questions?

Symptoms of Colorectal Cancer

Constipation

Constipation, having a bowel movement less than three times a week, can be your body's way of suggesting that you make some minor adjustments in diet or exercise. However, constipation can also be a symptom of a colon cancer. In the beginning of the colon, waste material is slushy and can easily maneuver around anything that gets in its way. But as it nears the end of the colon, stool solidifies and is less forgiving of obstacles. A tumor in the rectum or far end of the colon can make it very difficult for waste to get by, thereby causing constipation.

Thin Stool

Once stool is no longer in its slushy phase and begins to take shape, how it looks when it leaves your body can provide clues to what's going on inside. For example, thin stool can sometimes indicate that your waste squeezed by some sort of obstacle on its way out. In the case of colon or rectal cancer, that obstacle would be a tumor in the latter part of the colon or the rectum.

Stomach Cramps

Sometimes a tumor causes a bowel obstruction, which is basically a road block in your colon. Depending on the severity of the blockage, solids, liquids, and even gas may be prevented from passing by. This leads to abdominal cramps that can be severe, especially if the blockage restricts blood flow to the colon. Painful cramps may also indicate that a tumor has perforated (poked through) the bowel wall; bowel perforation is a medical emergency.

Bright Red Blood in Your Stool

Tumors tend to bleed -- not a whole lot and not constantly, but they do bleed. As a result, some of that blood may show up in your stool. If the tumor is in the beginning of the colon, the blood will most likely be dry and virtually invisible by the time the waste leaves your body. However, if the tumor is in the rectum or toward the end of the colon, it may still be fresh and therefore, bright red.

Unexplained Weight Loss

Many of us wouldn't want to question unexplained weight loss. We'd just be happy to be losing weight! But unfortunately, effortless weight loss is generally a sign that something is wrong. In the case of colon cancer, unexplained weight loss can be a sign that a tumor is stealing the nutrients intended for your body.

Sense of Fullness

A tumor that grows toward the end of the colon or in the rectum may cause a sense of fullness. This is because your body senses that there's something else hanging around by its exit. What it doesn't know is that it's a tumor and it's attached, so it isn't going anywhere. It basically sees the tumor as a stubborn piece of waste, so you get that "I still have to go" sensation that can't be relieved.

Nausea and Vomiting

The occurrence of nausea and vomiting alone, without other symptoms, is unlikely an indication of colon cancer. There are lots of reasons for feeling sick and throwing up. Potentially cancer-related ones include pain, poor blood flow, and constipation. For example, a tumor that's large enough to cause a bowel obstruction may lead to constipation, restrict blood flow, and cause painful abdominal cramping. Any one or all three of these underlying colon cancer symptoms can result in nausea or vomiting.

Gas and Bloating

A pattern of gas and bloating may be an indication that a tumor is growing in the colon and occasionally causing a blockage. Even if the tumor isn't large enough to cause a bowel obstruction on its own, stool may periodically get hung up on the tumor while it's passing by, causing a temporary obstruction. While your bowel is blocked and air is trapped, you'll be bloated. When the blockage resolves itself, all that air will need somewhere to go and you'll be gassy.

Lethargy

Sometimes the presence of a tumor causes iron deficiency anemia, a condition that can cause you to feel extremely tired (lethargic). Tumors tend to bleed, which results in a loss of iron -- an element that transports oxygen to your cells. This symptom is characteristic of tumors in the beginning of the colon. Since it's pretty roomy there, tumors can get fairly big and bleed a lot before causing any other colon cancer symptoms. The blood usually dries before leaving the body, too, which also allows the bleeding to go unnoticed.

Even though you have an idea of what to look out for, it's important to remember that a tumor can grow for years before causing any colon cancer symptoms. In addition, all of these symptoms are very poor predictors in and of themselves.

By Chris

Uitilization of TCM - Comparison between Rural & Urban Communities

TCM in Malaysia is generally well accepted by both rural and urban communities.

However, rural communities have a greater tendency to use TCM for certain conditions like musculoskeletal injuries and illnesses that are thought to be supernatural in nature.

Reasons for greater usage of TCM in rural communities:

· Perceived longer period of recovery from orthodox medicine (Musculoskeletal injuries)
· Fear of undergoing surgery & implantation with foreign objects like plaster & cast
· Trust experienced TCM practitioners more than young rural doctors
· Modern hospital or clinical setting provides limited opportunities for patients or family members to be involved
· Objections from elders and community residents in seeking modern treatment
· Cost - modern medicine generally more expensive than TCM
· Orthodox medicine tend to treat symptoms rather than causes/ Orthodox physicians do not address the concerns of the patients
· Inclusion of spiritual elements in TCM - key factor for rural Malay communities who respect the unseen supernatural forces of nature and their concept of universe

Contributed by John Lee

Source:
Preferential Utilization of Healthcare Systems by a Malaysian Rural Community for the Treatment of Musculoskeletal Injuries by K M Ariff

An Estate Injury

Patient’s perspective regarding work:

- patients in rural settings are more likely to be worried about their work when they get injuries

- in rural, many work in plantations, farm etc. (work for themselves, not under an employer)

- thus, any injuries would cause them to be unable to work

- no Medical Certificate, or sick leave, no compensation (?)

- when injured, lose source of income

- worse in men, usually the bread winner of the family. Seen as weak by the community

- in rural, community responses better. Smaller community, they know each other. When someone is sick, comes to visit. Tries to help out if possible

- different in urban setting. Don’t know your own neighbours. Too busy working no time to visit those who are sick.

- usually women would look after the sick. Take over roles if possible. Take care of the family. Different in urban areas because many women work.

(Posted by: Vivian)