Helmut Schroeder was 49 when he began noticing a loss of balance and an inability to slow his movements.

He crashed while attempting to turn right while skiing. He even started to experience difficulty doing everyday tasks such as opening a door.

A hospital visit revealed the traumatic news that the qualified psychiatrist was suffering the early onset of Parkinson’s disease, an incurable degenerative disorder that attacks the body’s motor system.

Now 67, Schroeder has since written a book in German about living with the disease, which he describes as a “roller-coaster ride for the hardcore”, and is now embarking on a new phase in his battle with Parkinson’s, thanks to a brain-implant procedure that is now coming into wider use.

Schroeder received the deep brain pacemaker at the Goettingen University Clinic 18 months ago. The US-made device sends tiny jolts of electricity through neurons, which helps control his tremors, rigidity and other kinetic symptoms. Schroeder’s speech has also improved and he now requires less than half the medication he used to take prior to the operation.

“I can now carry out all the movements I want. I can even ride a bike and again enjoy the old hobbies I used to love,” he says.

“My wife used to have to care for me all the time, but is now virtually unemployed.”

The operation has given Schroeder a new lease of life, but the decision to go under a surgeon’s scalpel was still a daunting one.

Two battery-operated electrodes were implanted in his brain to target the thalamus, subthalamic nucleus, and a portion of the globus pallidus. These areas of the brain control movement and the neurostimulator, which is similar to a heart pacemaker, blocks the abnormal nerve signals that cause tremor and other Parkinson’s symptoms.

The five-hour operation is normally carried out under local anaesthetic, since the patient has to assist in the procedure so that the electrodes are positioned correctly.

“The surgery is very unpleasant,” says Schroeder.

The electrodes are inserted through a small opening in the skull and implanted in the brain. An insulated wire is then passed under the skin of the head, neck, and shoulder, and connects the electrodes to the neurostimulator, which is implanted in the stomach or chest area.

The operation costs in the region of 30,000 euros (Bt1,200,000) and it can take up to two weeks until the neurostimulator is correctly calibrated.

The procedure is used only for patients whose symptoms can no longer be adequately controlled with medications.

Previously, neurostimulators were on average only implanted 12 to 14 years after diagnosis, but this delay has since been reduced to seven years, says Alfons Schnitzler, head of Institute of Clinical Neuroscience and Medical Psychology at Dusseldorf University Clinic.

Fellow neurology professor Lars Timmermann from Cologne University Clinic believes that in certain cases, implants are ideal for patients under the age of 61.

However, the procedure is not suited to all Parkinson’s sufferers and numerous tests have to be carried out first.

“It’s not a miracle cure, but it is a great option for some patients,” says Timmermann.

Patients suffering from strong tremors can enjoy coordination again within seconds, once the pacemaker is switched on.

“We have seen dramatic therapeutic effects, but still do not know to this day how it works in detail,” admits Schnitzler.

Technology is improving by the day and adaptive deep brain stimulation is the next step to more specifically identify the precise brain target that will be stimulated, thus reducing the effect on healthy brain area.

Schnitzler believes the technology will be in place within three years, meaning the brain is no longer under 24-hour stimulation but instead the brain’s electrical signals are only blocked when necessary.

The surgery can result in cranial haemorrhaging and even induce acute or manic depressive episodes, but Schroeder has noticed no side effects since undergoing his operation.

“I can play chess again and have even entered competitions again,” he says.

“People should realise, however, that this operation is not a cure for Parkinson’s, but simply slows its progress by years.”

Breast cancer is the most common cancer among women worldwide. Each year about 1.4 million new cases of breast cancer are diagnosed worldwide, and over 450,000 women will die of the disease annually. Breast cancer is also the leading cause of cancer death among Thai women with more than 5,000 women dying from the disease each year.

Although it only affects 15 to 20 per cent of breast cancer patients, the HER2-positive type is one of the most aggressive as it causes cancer cells to reproduce uncontrollably.

On the brighter side, it is one of the cancers for which scientists have developed a targeted therapy known as trastuzumab that can prolong life and allow victims of the disease to enjoy more time with their families.

Developed by a team of scientists with Roche’s Genentech Company in the US, trastuzumab was approved by the US Food and Drug Administration for HER2-positive metastatic breast cancer in 1998 and is available as a treatment of choice in Thailand.

One of the Genentech team who worked on the drug Dr Mark Sliwkowski was recently on a visit to Bangkok and explained to oncologists and selected members of the press how it works.

The HER2 (Human Epidermal Growth Factor Receptor 2) proteins are receptors on breast cells. Normally, HER2 receptors help control how a healthy breast cell grows, divides, and repairs itself. Once it doesn’t work correctly, HER2 will copy of itself and make the breast cells grow and divide in an uncontrolled way. Sliwkowski and his team believed that the only way to stop this HER2 amplification was by using monoclonal antibodies – man-made copies of proteins that the body’s immune system creates to fight off bacteria and viruses in the hope that these antibodies would not only stop tumours from growing but also shrink them.

Using laboratory mice as their subjects, the team developed a mouse antibody that was later refined into to a humanised antibody that wouldn’t be rejected when injected into the human body.

There were several challenges along the way, not least because no previous work had been done on humanised antibodies. “As scientists and drug developers, we fail frequently, which I think is something people don’t appreciate. If your ego or personality can’t accept failure, you don’t learn from the failures. You can’t move on from the failure and so you are not going to be successful,” says Sliwkowski who has been working on the HER2 therapy for decades.

Trastuzumab was initially approved by the US FDA for use in the advanced stage of cancer but is now also used in early stage HER2-positive breast cancer.

Genetech has continued its research into treatments for the disease and has developed the second and third generation of trastuzumab for advance stage treatments. These are Pertuzumab and the latest TDM-1.

In Thailand, trastuzumab is used for early stage HER2-positive breast cancer after the patient has already received chemotherapy or surgery A trastuzumab injection is given every three weeks for 12 months and can prevent the cancer from returning.

However here, as in some other countries, price is a major factor. Each injection costs Bt40,000, which translates to more than Bt1 million for the entire treatment. Patients under the universal Bt30 healthcare scheme and social security are covered for the treatment.

However that cover is no longer applicable for treatment with Trastuzumab, Pertuzumab or |TDM-1 should the cancer return |at a later date.

Today, nearly half of all tennis players suffer from this disorder at some point. However, tennis players account for just five cent of patients who visit physicians with this disorder. The others have never swung a racket in their lives.

The cause of the inflammation of the tendon on the outside of the elbow is due to injury in the tendon and muscle which is attached to the bones on the outside the elbow. This may be caused by an acute injury, such as an accident, or by repetitive use over a long period of time, causing degeneration of the tendon. This includes using sports equipment that has incorrectly been designed for the individual player, incorrectly playing sports, or being involved in jobs that require frequent lifting and dragging of heavy objects, such as that of a cleaner whose daily activities include sweeping, wringing clothes, and kitchen work.

When the tendons and muscles are injured, the patient’s muscles are not at its optimal strength. Often, the torn tendons have not been given time to heal completely before they are subject to being used again. This results in repetitive tear in tendons, causing inflammation and swelling, and the repair mechanism in the body slows down by six to 12 weeks.

The inflammation of the elbow can just be a result of tendonitis but the inflammation often includes the area in the body where the muscles and tendons are attached to the bone or joint at the elbow (epicondylitis).

Signs and symptoms of tennis elbow include:

• Recurring pain on the outside of the elbow
• Pain at the back of the hand that extends to the wrist
• Pain that intensifies when lifting objects, especially when the hand is facing down while, for example, washing dishes or stir-frying food.
• Some people may experience severe pain and are unable to |completely extend their hands or brush their teeth

A diagnosis can easily be made by history and physical examination as well as from the symptoms mentioned above. However, there are some symptoms that are often mistaken for tennis elbow, such as pain in the inside of the elbow joint, also known as Golfer’s Elbow. Another condition is pain at the back of the elbow, called Bursitis, which is caused by a cyst. Since the pain is caused by an injury to the tendon in the specified area, the best treatment is to relax and stop the use of the hand that is in pain. When the pain alleviates, begin exercising your hand to strengthen the muscle. If you are required to return to work, the pain in your hand may aggravate or recur. Spend at least 5-10 minutes exercising your hand muscles before using it again.

Physicians generally prescribe anti-inflammatory medicines to patients in the first stage, when they are not experiencing great pain. If these medications are not effective in the treatment, the physicians will recommend steroid injections into the site of the inflamed tendon. This can alleviate the pain and inflammation but should not be used continuously over a long period of time, as it may cause side effects such as whitening of the skin around the injection site, fat atrophy, or rupture of the tendons.

If the above treatment is not effective, then surgery should be considered to remove the damaged tissue and to repair and tighten the tendons. As with everything, prevention is better than cure. Here are some suggestions for preventing the injury.

• Lift objects with palm facing up
• Exercise by regularly stretching your hand muscles
• Always do warm up exercises by stretching your hands before the start of any activity
• Stop engaging in any activity that causes pain in your elbow. If you must work, then do some warm up exercises to stretch your elbow muscles, at least 5-10 minutes before using your elbow and then immediately apply a cold compress after you have finished your work. Take short breaks between work.
• Use a stretchable cloth or a ready-made fabric as an elbow wrap or support. This will help reduce and protect against any force or impact with the elbow. Use this support while playing sports or lifting heavy objects.
• If your condition and pain persists for several days, consult a physician. If you allow the pain to continue and become chronic, you may lose the ability to move the elbow permanently, or the pain may be caused by other factors, such as gout, infection, inflammation or a nerve compression in the neck.

ASSOCIATE PROFESSOR CHATHCHAI POOKARNJANAMORAKOT, MD |is an orthopaedic surgeon specialising in sports medicine and arthroscopy at Samitivej Sukhumvit Hospital. Call (02) 711 8494-6

You might not be overly concerned about your appearance. But here’s a sobering thought. Your wrinkles and sun spots may be reflect more than just your age, they may reflect your exposure to the sun. And this is a matter for concern, as it could be a manifestation of photoageing.

The word photoageing refers to premature ageing of the skin caused by radiation from ultraviolet (UV) rays (or light, that is, phos in Greek, which is the root of photo, and hence the name photoageing). Most of our UV exposure comes from the sun. In fact, the Canadian Dermatology Association attributes 90 per cent of skin ageing to the harmful effects of sun exposure. Artificial UV sources include tanning booths, mercury vapour lamps, and halogen lights.

Signs of photoageing include wrinkles around the eyes, mouth, and forehead; spider veins on the face and neck; paler and thinner lips; frown lines that are visible even when you are not frowning; leathery and loose skin; age or liver spots (solar lentigines in medical terminology); easy bruising of skin; and red and scaly spots (referred to as actinic keratoses).

Our skin has three layers: the epidermis which is the outermost, the dermis which is the next, and the subcutis which is the deepest. UV rays, specifically UVA rays make their way through the epidermis and into the dermis. Here, they damage collagen, one of the fibres responsible for skin structure. Our body is not entirely helpless, so it deploys enzymes that help rebuild this collagen.

However, repeated exposure and damage could cause the enzymes to malfunction. This would lead to incorrectly rebuilt skin, which eventually appears as wrinkles and leathery skin. Similarly, age or liver spots are the result of a congregation of melanocytes on a particular patch of skin. Melanocytes are the cells that create melanin, which gives our skin its colour. Reacting to excessive sun exposure, melanocytes proliferate in a particular location. For instance, among men, liver spots are usually found on the hands, arms, face, and back, which are more exposed to the sun than other parts of the body.

What makes photoageing dangerous is the fact that any one of its symptoms could be an indicator of skin cancer. Actinic keratoses are particularly dangerous. These usually red, scaly or crusty, rough growths that appear on sun-exposed skin could, if left untreated, morph into squamous cell carcinoma (SCC), one of the three most common types of skin cancer.

Photoageing is very easy to guard against. Avoid tanning booths, for one and limit sun exposure. The harmful UVA rays are at their strongest from 11am to 3pm. So, it is best to avoid stepping out into the sun during this time.

If you cannot do this, remember not to leave home without adequate protection for your skin. Doctors recommend liberal use of sunscreen that has a sun-protection factor (SPF) of 30 or higher and offers broad spectrum protection from UVA and UVB rays. Ensure that all exposed skin is treated with sunscreen. If possible, wear sunglasses that offer UV protection, long-sleeved clothes, and a wide-brimmed hat (or carry an umbrella).

Much has been written about our need for Vitamin D and how the sun is the best source for it According to doctors, lighter-skinned people need only a few minutes of sun exposure per day to meet their quota of Vitamin D, while darker-skinned or Asian people would need 20 minutes.

Remember that lighter-skinned people with lesser melanin in their skin are more at risk of photoageing than darker-skinned individuals.

However, all is not lost if you think you have developed symptoms of photoageing. The first step is a comprehensive self-examination to detect such signs. Then, consult a doctor, ideally a dermatologist, to ascertain if any of these are causes for concern. If you are light-skinned, have a history of sunburn, have relatives who suffer from melanoma (another common type of skin cancer), then doctors advise regular self-examinations to detect skin abnormalities and annual medical examinations to determine if you are at risk of skin cancer.

If your doctor finds evidence of photoageing, he or she will recommend an appropriate course of treatment. Photoageing treatments are also anti-ageing treatments, including those that we have all heard about at some time — botox and fillers. Laser, chemical peels, and the administration of retinoids (synthetic derivatives of Vitamin A) are some other popular treatments prescribed for photoageing. In fact, recent studies have found that some treatments for photoageing, such as chemical peel, laser and retinoid, could prevent skin cancer as well. However, this is not true for all treatments. Botox, for instance, is merely a cosmetic treatment.

Given the link between photoageing and cancer, it is important to take treatment advice seriously. It is foolish to dismiss the signs of photoageing as part of the natural process of growing old. You could opt to avoid anti-ageing treatments if your situation is not considered medically threatening but to ensure that it isn’t, consult your dermatologist at the earliest.

DR SAROJ SUVANASUTHIP is a Dermatologist at Samitivej Sukhumvit Hospital. Call (02) 711 8700-2.