Splitting tablets?

Dr Deb – TMA member in Brisbane  

A recent study looking at the accuracy of tablet splitting, found large variations in dose in some of the splits. Some tablets are easier to split than others, and some drugs are more dangerous than others if you get the dose slightly wrong.

The major finding of the study was this “Based on our results, we recommend use of a splitting device when splitting cannot be avoided, for example when the prescribed dose is not commercially available or where there is no alternative formulation, such as a liquid.”

Tablet splitters can be purchased from most pharmacies. More info.

 

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Spain

  prepared by Dr Joan Chamberlain, TMA member in Rockhampton.

Generally we felt reasonably secure but all bags must be held close and be closed firmly. Pick pockets do well. Loose items disappear quickly. We let our guard down in the last 15 minutes before leaving the conference hotel (5 star) and were rewarded with one of our bag being stolen: Camera, chargers for phones, power converters, medical kit and coats. Take care with your goods.

Madrid is more metropolitan and Spain’s largest city. You can taste all of the flavours of Spain here. We found the smaller places of good value and with a very large variety of good wholesome, well priced food. We found free Flamenco bars where the passion was as strong as the alcohol in the beverages. Parks open at 10am and people are flooding in at 8-9pm while the daylight still shines.The bigger cities come alive from 9pm onwards. 

The art word reigns supreme in Madrid, followed closely by the History of Spain in both Museums and architecture. There are amazing shops that sell genuine armoury still made in the famous Toledo factory. Cross bow 25E, just don’t expect to get it through customs. Your local shopping mall has the men’s section complete with underwear, suits and leather coats, selection of fishing gear, knives for hunting as well as a full Gun collection. Everything a real man needs.

Central Spain. We had a brief one day visit to Avila and Segovia. The change in foods, wine and scenery was incredible. You first pass near the highest mountains in Spain, complete with ski resorts, then along amazing cliffs and ravines. Out from here lies the fertile central Spanish plains. Central Spainproduces some of the most amazing wines in Spain, re-noun especially for their Red wines, the whites are not to be dismissed. Their suckling pig, plethora of hams, cheeses and extensive variety of Horticultural produce is impressive.

Lessons learned on the Trip:

  1. Be prepared and know the area you are going to. You will appreciate better what you see and find.
  2. Many of the best experiences are not far away or too expensive. But be prepared to pay for inside knowledge when needed.
  3. Most people will help you and appreciate you making the effort to speak at least a few basic words in Spanish eg hello, thank you, please, good buy and their name.
  4. Never leave your possessions unattended and be vigilant.
  5. It’s a long way to fly from Australia to Spain.

 

 

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Tran Siberian Express

Prepared by TMA member Gold Coast

Travel Health Doctors Gold Coast clients, Kate and Matt experienced the longest and arguably one of the most fascinating train journeys of all time – the Trans Siberian Express. The couple boarded the train in Frankfurt then onward to Warsaw and St Petersburg. The official journey then commenced in Moscow. From there Kate said she was amazed by the diversity of the landscape.

“It was so brilliant to see the unexpected variety in the landscape – such eye catching scenery from European forests through to Siberian forests, snow and desert” she said

Also what surprised them was, although not travelling in the height of the winter, the Gobi desert was covered mostly in snow and when it wasn’t snowy, the land was mostly rocky instead of sandy -only a small percent of the Gobi desert is actually sand. Throughout these rocky regions of the desert, a huge number of dinosaur relics can be found.

 

As self adventurers, highlights for Matt and Kate along the way included a three day horseride along the Mongolian step which proved a real eye opener for them.

“It was fascinating to see nomadic families move to greener and warmer pastures – just packing up their lives and livestock and moving in groups of three or four families to an area more sustainable” Kate said.

Away for nine weeks but spending three weeks touring Mongolia, Matt also lent a hand helping a farmer herd cattle along the way. To show their gratitude, the farmer insisted Matt and Kate accompany him home where he offered his “best yoghurt” – from a bucket just sitting outside. They thought for sure the yoghurt would render them sick for days but surprisingly were okay!

Travelling throughout Mongolia the couple do recommend employing local guides.

“Due to snow and the movement of nomadic tribes to let areas grow over with grass, the roads are ever changing and you would get hopelessly lost without a guide” Kate said.

At one stage they were blocked by a huge snowdrift and had to physically dig their way out before help arrived in the form of a local landrover which pulled their car to safety.

After this, the locals again extended their hospitality insisting on bringing them home to taste their proud home brew of warm, salty camel’s milk.

“Outside of the cities especially, the locals are so appreciative, interested in us and super friendly..

“We enjoyed tasting the local food, although you never really knew what you were ordering – one cafe had dishes called “Horse and Cart” and “The Merchant’s Daughter” ..which in fact was chocolate pancakes” Kate said.
Health wise the couple left prepared and were grateful not to experience any health issues as sometimes they were nearly three days’ drive to anywhere which could remotely help them.

Travelling for nine weeks, it’s difficult to condense such a life changing trip, but both Matt and Kate were amazed and humbled by the beauty and culture they experienced.

Travelling in September/October at the end of the tourist season, proved ideal with temperatures reaching -15 at night… instead of -40 which can occur in the Winter.

Considered the longest train journey in the world, the most extended stretch Matt and Kate spent on the train non-stop was 60 hours. Their tip is that you book both an upper and lower bunk instead of just upper bunks so you have more space to relax during the day.

“The train journey was ever-changing and we so enjoyed meeting some amazing people and glimpsing cultures and experiencing adventures we could only dream about” they said.

 

 

This report has been prepared by Travel Health Doctors, Southport.

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Safety of DEET (N,N,-diethyl-m-toluamide)

Insect repellents containing DEET are the most effective and the most commonly used world wide. DEET has been available commercially for over 50 years and has been studied extensively.

It is thought that DEET works by interfering with the mosquito antennae function, effectively making humans invisible to the mosquito. Generally, the duration of protection is related to the concentration of DEET. However, at a concentration of 50%, this effect plateaus. 30% DEET is the lowest effective dose.

DEET repellents have a very good safety record, when used as directed. When DEET is applied to the skin, some is absorbed into the circulation. However, if the same amount of DEET were to be taken by mouth, either accidentally, or non-accidentally, blood concentrations will be hundreds of times higher and seizures and death can result. Toxic effects have most often occurred as a result of ingestion, rather than skin application. Repellents should not be applied to the lips, mouth, sunburned skin, damaged skin, or deep skin folds, and hands should be washed after applying DEET.

The risk of disease due to the bite of an insect is far greater than the risk involved in applying DEET insect repellents to the skin. 30% DEET repellents are safe to use and are recommended for adults, pregnant women, breast-feeding women and children over 2 months of age.

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Wife White Knuckles – Hurning to Brisbane – in 5 hour hops

Julie Wright, Admin Staff, TMA Member Brisbane

After 10 years of dreaming, and 8 months of planning, my husband and I embarked on the adventure of a lifetime in August of 2006. (Six weeks prior to departing Brisbane, we of course consulted with Dr Deb Mills to ensure our health was optimal! ) We shared the small cockpit of a single engine Beechcraft Bonanza F33A at 10,000 feet, across half the world. Our fuel tank only allowed a 5 hour flight range, so we had to make 29 stops in 31 days. Our flight path took us – Hurning (Denmark), Copenhagen, Baden Baden, Barcelona, Corsica, Amalfi, Athens, Santorini, Istanbul, Adana, Tabriz, Esfahan, Dubai, Muscat, Karachi, Ahmedabad, Nagpur, Colcutta, Chiang Mai, Bangkok, Phuket, Singapore, Jakarta, Bali, Kupang into Darwin and on to Archerfield airport, Brisbane. To experience the many different cultures in quick succession was a fascinating experience. However, despite our careful preparation, the different terrain, along with language barriers, and unforeseen weather conditions presented both mental and physical challenges. We became known as the “Crazy Aussies” by many air traffic controllers. Sometimes we were met with an incredulous “You’re flying to Australia in that?” from commercial pilots on the ground. We planned the route with a German company that organises flight paths and permissions for cargo aircraft around the world. They successfully applied for our permissions, even organizing us to transit through Iran where we made stops for fuel in Tabriz and Esfahan. To smooth our dealings with Army and security on the tarmac at various terminals, they suggested we wear a uniform, so from Istanbul to Darwin, my husband and I wore collared white shirts with epilates and navy pants. We were seen as flight crew. We were to need it sooner than we thought.

On one occasion we had some problems that resulted in our passport stamped with the words Illegal Aliens… Our aircraft was only rated to fly in good visibility. In Esfahan, Iran, our refueling and paperwork took so long, that it was well into the afternoon before it was finalised. Problem. We had no visa to stay in Iran, only permission to transit. We were marched inside the airport under army guard. We sat for six hours in a tiny room with a young fully armed guard right beside us. We overheard the head of the police and the government officials yelling into their phones, trying to sort out what to do with us. We phoned our contacts, they called the Australian consulate. This went on and on.

At midnight we were taken from the airport, thankfully to a hotel, still under police guard – at least the guard stayed outside the room! How could we sleep with visions of being trapped in Iran forever running through our heads. The next morning, we were returned to the airport. Yet another official met with me. This time, thankfully, he had a big grin. I think he was as happy as we were, that a solution had been found. Our passports had been blessed overnight with a 7 day visa. In fact the now smiling official even warmly welcomed us to stay a few days in Iran! We made all the proper polite comments and hurried to our aircraft. As we were waiting on the tarmac, running through our flight checks, we heard a huge roar from the runway. A mick fighter took off and flew vertically at great speed in front of us. What a sight! I looked over at the Iranian police, unsure why the tower had put the mick fighter up in the air before our take off. The officials were all smiling, pointing to the fighter in the air and hands on their hearts yelling, “Ours, ours!” with much pride. Now it was our turn, my husband and I sat waiting for the radio signal from the tower that would giving permission to take off. Silence…. We watched the fighter land and be towed off the runway. Only then, were we given permission to take off. As we looked over at the smiling Iranians, we realised that we had been honoured with a display and fighter ‘send off’.

I earned the nick name ‘wife white knuckles’ after episodes like that, along with sand storms in Tabriz, dust storms in Dubai and a raging torrential storm over Singapore. The realization of our dream would not have been possible without an extraordinary team of many helpers from across the world. In 2006, we, “the Crazy Aussies”, were the 187th in the world to fly this particular route in a small single engine aircraft.

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Traveling with Diabetes

While you’re having a great time on your holiday, if you have diabetes you need to continue your monitoring and care routine.

Having meals later or more irregularly than usual, time zone changes and the heat of tropical countries can all affect how well you manage your blood sugar levels. Before you hit the road, have a look at some of these suggestions click here for info.

The Heat of Summer or the Tropics

Heat can affect your blood glucose (sugar) levels and also increase the absorption of some fast-acting insulin, meaning you will need to test your blood glucose more often and perhaps adjust your intake of insulin, food and liquids.

  • Drink plenty of fluids, especially water (always bottled or boiled if in less developed countries!), to avoid dehydration. Avoid sugar-sweetened soft drinks and fruit juices.
  • Check the product information in your boxes of medications to learn when high temperatures can affect them.
  • If you’re traveling with insulin pens or vials, don’t store them in direct sunlight or in a hot vehicle. Keep it in a cooler if possible, but do not place it directly on ice or on a gel pack to avoid freezing it.
  • Check glucose meter and test strip packages for information on use during times of high heat and humidity. Do not leave them in a hot car, by a pool or on the beach.
  • Heat can damage insulin pumps and other equipment. Do not leave the disconnected pump or supplies in the direct sun.
  • Undertake physical activity in air-conditioned areas, or exercise outside early or late in the day, during cooler temperatures.
Don’t Forget Your Medication
  • Take more medication than you would expect to need, in case of travel delays or lost luggage.
  • Keep snacks, glucose gel, or tablets with you in case you have a ‘hypo’. If you use insulin, speak to your Doctor before you go about taking a glucagon kit; this is an injection that can e given in case of a more severe drop in blood sugar.
  • Carry medical identification that says you have diabetes.
  • Keep time zone changes in mind so you’ll know when to take medication.
  • Keep all insulin in the original pharmacy labeled packaging. Get a letter from your Doctor stating you need to take syringes or insulin pens with you.
  • Take copies of prescriptions with you.
In the Air
  • Place all diabetes supplies in carry-on luggage in case checked in luggage goes missing. Keep medications and snacks at your seat for easy access.
  • If a meal will be served during your flight, call ahead for a diabetic, low fat, or low cholesterol meal. Wait until your food is about to be served before you take your insulin.
  • Make sure to pack snacks in case of flight delays.
  • Reduce your risk for blood clots by moving around every hour or two.
  • More Info on using insulin pumps during flight here.
Staying Healthy
  • Changes in what you eat, activity levels and time zones can affect your blood glucose. Check levels often. Stick with your exercise routine. Make sure to get at least 150 minutes of physical activity each week.
  • Protect your feet. Be especially careful of hot pavement by pools. Wet or sweaty feet are more prone to tinea as well; consider taking an anti fungal cream such as Lamisil with you.
  • Make sure you have all the vaccinations you need for your destination.
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Riding Motorbikes in Vietnam; THINK TWICE!

… Prepared by TMA Member Narre Warren: Dr Michael Long

There is plenty of evidence statistics to suggest that Vietnam is quite simply in love with the motorbike. Motorbike travel in Vietnam was popularised further with Western TV viewers with the 2008-9 Top Gear Vietnam special where the heroic Jeremy Clarkson with his friends May and Hammond sputtered their way on feeble underpowered motorcycles from Saigon to Ha Long Bay.

“Motos” are a common sight on the roads of Vietnam and far outnumber cars. The current estimate of the motorbike population in Vietnam is approximately 20 million, one for every four and a half people of their population of 90 million; (indeed they are often the family sedan with Mum, Dad and 2 kids traveling on a small 50-100cc motorbike or motor scooter.)

Motos are not just for transporting people either. Not having a car doesn’t hold the Vietnamese back at all as you can just attach 3 metre lengths of timber cross ways across your moto, attach 30 coconuts to the back, pull a motorbike trailer behind you carrying anything, or even carry a moto on the back of your moto! (the writer observed all of these on a recent trip).

Driving on the right hand side of the road is the least of your worries riding motos in Vietnam. Road rules are often regarded as optional, motos ride on footpaths in Saigon peak hour, no one gives way at roundabouts and pedestrian crossings are completely ignored. The country’s rampant love affair with motorbikes has been associated with a substantial number of collisions; the road toll in Vietnam is approximately 13,000 per year which is 2-3 times the rate per capita in Australia.

Despite their kamikaze attitude to road rules and safety, there remains a great interest in motorbikes in Vietnam. You don’t need a license to ride a moto in Vietnam, but remember the commonest cause of death in travelers overseas is not some exotic illness like malaria, but is due to the depressingly familiar occurrence of motor vehicle accidents.

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Exploring the World’s Remotest Rivers

… Prepared by Kevin Casey (visitor to Brisbane TMA members clinic)

 

 

One of the very best things about exploring the least known and most pristine rivers on the planet is that I experience the earth in its most natural state. What I do as the Remote River Man is certainly unique – I venture into extremely remote places, normally alone for a month or more, usually with only what can be carried on my back, or in a kayak or pack raft. I have filmed bears in Canada, been leech-bait in Borneo, trekked and paddled the most isolated parts of the Kimberley, got lost (on purpose) in an Argentinean swamp and shared meals with African pygmies. I plan these journeys, conduct them, film the adventures with lightweight video gear, and edit it all when I get home. I have no script, no film crew and no support team. The trips are expensive, so I can’t afford to get sick or have a careless accident while I’m enjoying myself out in the middle of nowhere. It’s not unusual for me to go a whole month in the wild without seeing another human, or be 400 kilometres away from the nearest one.

So how do I go medically with these far-flung journeys? So far pretty well, in over a quarter century of remote river exploration. I did get malaria once in New Guinea, and have had a few stomach complaints in various countries, and suffered the odd blister, cut or bruise, but the dangers of wild places are grossly exaggerated. I like to say (only half joking) that the most dangerous part of my remote river explorations is the car trip to and from the airport.

The real dangers in wilderness are the mundane ones – a sharp branch at eye level, loose rock on downhill slopes, a bad infection, drinking bad water or eating contaminated food, pushing too hard in the heat, etc. The insects make life interesting, too.

When it comes to food, I’ve eaten all sorts – donkey stew, lizard, wood grubs, roasted grasshoppers, raw queen fish (30 seconds after it came out of the ocean), stewed antelope, termite soup and a range of plant foods, from waterlily seed damper and hibiscus buds to palm heart and boab nut pulp. A lot of natural foods are actually more nutritious than the more adulterated stuff you buy in the shop. Generally the rivers I explore have no human habitation upstream which is always a help, but there are still plenty of microbes just waiting patiently for the ill prepared.

Insects are never to be taken lightly. I soak all my clothes in a permethrin solution before I go away, and carry a good repellent. 25-30% DEET is more than enough, unless you want to chemically burn holes in your nylon tarp, or melt the plastic case of your camera or sunnies. I like the Repel roll-on myself. I always sleep in either a mozzie-proof tent or in my trusty netted Clark Jungle Hammock. If I’m headed for a tropical country where I suspect bedbugs, fleas or other surprises might be joining me in my hotel bed, I’ll carry a very lightweight one-man Bug Bivy (Outdoor Research makes a nice one) and actually set that up right on top of the hotel bed, so nothing can get at me during the night. You can’t always assume a third-world hotel is going to provide a mozzie net, or if it does, that it won’t be full of well-hidden holes.

A comprehensive first aid kit is a must, and it’s always a struggle to balance keeping it lightweight and ‘covering all the bases’.

Getting into Dr. Deb’s Travel Medicine Clinic is something I always do at least 3-4 months before I head off overseas on a remote river exploration. Sooner is better than later for sorting out what’s needed, and since some of my destinations are exotic and seldom visited by tourists, it’s especially important for me to have up-to-date expertise, so I can then get down to the challenging business of exploring my chosen river, getting some amazing footage, and returning home safely so I can start editing all those Remote River Man DVDs!. Checkout Kevin’s website www.remoteriverman.com.

 

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Traveller’s Thrombosis

 … Prepared by Dr Cormac Carey – TMA member Toowoomba

Travellers Thrombosis or Deep Vein thrombosis (DVT) is a rare but dangerous medical problem which occurs when blood in the legs of travellers clots. The serious problems occur when the clot dislodges from the leg and moves to the heart or lungs where it interferes with their performance.

While it is several years since “Economy Class Syndrome” entered our travel jargon the recent release of newer and safer anti- clotting agents make it pertinent to reappraise our approach to this issue. In practical terms, risk factors need to be identified and their importance weighed against appropriate medical advice for each individual traveller.

Risk factors for travellers thrombosis

The following factors may increase an individual travellers’ risk of suffering a thrombosis during travel:

  • Flights longer than 5 hours
  • Family history of abnormal clotting
  • Genetic clotting disorders
  • Recent lower limb surgery
  • Recent soft tissue injury of lower limbs
  • Pregnancy or shortly after delivery
  • Recent abdominal or pelvic surgery
  • Cancer
  • Female smokers who take the contraceptive pill

Persons with more than one risk factor are at even higher risk; E.G. Use of hormone replacement therapy in a woman, coupled with a genetic predisposition can lead to a thirteen times increased risk compared to the average traveller.

Perhaps the most important risk of all is having had a past episode of a Deep Vein Thrombosis with no recognised obvious trigger.

Some travellers have no particular risk factors. In that case, exercises as described on the aircraft instruction cards, plus plenty of water e.g. 200mls per hour are sensible precautions.

Low Risk Travellers

This would include persons over 40 years of age, overweight, or who have had recent minor surgery.
This group would be recommended to do as per low risk plus flight socks or grade 1 wear compression stockings
Note that persons with diabetes should seek medical advice before wearing any compression stockings.

Medium Risk Travellers

People aged over 50 years, previous DVT or pulmonary embolism (clot on lung), recent lower limb injury, treatment for heart failure, or women who have had a baby less than 6 weeks earlier.
Consideration should be given to booking an aisle seat, and wearing grade 2 compression stockings. Such stockings provide 20-30mmHg compression and only need to be knee high. They should be tried well in advance of the flight, as they can be difficult to put on when new.

High Risk Travellers

This category includes persons who have had DVT within the past twelve months, persons with a lower limb in a plaster cast or immobilizing splint, who have had a recent stroke or heart attack or major surgery within previous three months.
In addition to exercises, fluids, and aisle seat, consideration would usually be given to taking injections of low molecular weight heparin to lessen clotting during flight. Patients already on warfarin do not need heparin as well.

Persons who are hesitant to give themselves an injection prior to a flight, or who will have trouble carrying and storing injectible medication, will be happy to know there is now a medical breakthrough. There are new oral anti-clotting agents e.g. rivaroxaban. This is a prescription medicine that has been shown to prevent deep vein thrombosis in patients following hip and knee replacement surgery. Common dose for travel is one tablet daily, on the day before the flight, the day of the flight and the day after the flight.

Like all medications including the injectible heparin there is a potential for bleeding in the event of an injury, or a risk of interactions with other medications. The treating travel medicine doctor would consider these factors.

Aspirin

There is still no evidence that aspirin is helpful in preventing DVT as it affects the platelets and stops arterial clotting, but has very little effect on clotting in the veins. Users may experience side effects and be lulled into a false sense of security. If a person has significant risk, they should be on effective anticlotting medication as noted above.

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Exercise in Type 1 Diabetics

… Prepared by Dr Norman Hohl – TMA member Gold Coast

A fascinating presentation in Perth late yesterday at the Australian Diabetes Conference by a Paul Fournier showed the progressive fall in glucose for 2hrs after moderate exercise in Type 1 Diabetes, can be prevented by a 10 sec maximum intensity sprint immediately after the moderate exercise. This could be of critical benefit for travellers who find themselves unexpectedly without their carbohydrate emergency supply at hand.

(For regular sports, or adventure travellers, he showed convincingly that a 4 sec burst of max intensity sprinting every 2 minutes during moderate exercise, also decreased significantly the hypoglycaemia occurring in the 2hrs after.)

Clearly this is only for the emergency as carrying the glucose is better, but the unintended can happen, particularly when travelling, and this could prevent loss of consciousness.

A unique resource is now available for specific effective practical advice on exercise for type 1 diabetes. This is really an amazing web-based tool, that I am sure any Type 1 diabetes (T1D) traveller would find invaluable, as well as those who are fearful or confused about exercise and are not travelling.
Have a look at www.exT1D.com.au site here.

Allan Bolton has put enormous personal effort into writing this and has had to charge a subscription fee to make it viable. He is lobbying to get it available free without biased sponsorship deals, but currently it costs $85, but any T1D who likes sport and travel, or parent who wants their child to be active and liberated would find it well worthwhile.

 

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