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St. Maarten-St. Martin – One Island, Two Countries

A plane coming in for landing on Maho Bay Beach, Saint Martin, Caribbean. (Photodisc/Thinkstock)
A plane coming in for landing on Maho Bay Beach, Saint Martin, Caribbean. (Photodisc/Thinkstock)

Map of the island.
Map of the island.

A bird's eyeview of the harbour and shopping area.
A bird’s eyeview of the harbour and shopping area.

Westin Resort
Westin Resort

Hussein, Alia, Sabiya and Noorali
Hussein, Alia, Sabiya and Noorali

First, we should get the name right. Is it St. Maarten or St. Martin?

Both names are correct. The northern part of this Caribbean island is French with 21 square miles (54 km2) of land. The southern part of the island is Dutch with 16 square miles (41 km2) of land. The French call their part of the island St. Martin and Dutch call their part of the island St. Maarten. Collectively, the two territories are known as “St. Maarten/St. Martin”.

This tropical island is the smallest inhabited island in that area with a population of the entire island of approximately 72,000 people. Both parts of the island live in harmony. You can go from one end of the island to the other without restrictions. No questions are asked. But culturally the two areas are different.

We arrived at the Princess Juliana International Airport on St. Maarten’s side of the island. We were impressed by the ultra-modern airport for such a small island. It offers nonstop flights from the United States, Canada and Europe. We had to fly to Toronto and then take a flight to St. Maarten.

We stayed at the Westin Dawn Beach Resort & Spa, St. Maarten. It is a beautiful resort featuring 310 luxurious guest rooms and 15 suites, each with french doors leading to a balcony with an ocean or island view. Our rooms faced the beautiful beach. The resort offered many beach activities including the usual water sports.

Touring the island, we immediately realized how different the two parts of the island were.

On the French side, they speak French or English with a distinct French accent. They use Euro as their main currency and the main town, Marigot, has a distinct European flavour. The clothing stores have mostly European style apparels. About 35,000 people live on this part of the island. The French side is known more for its nude beaches, clothes, shopping (including outdoor markets), and rich French and Indian Caribbean cuisine.

On the Dutch side, English is more widely used although Dutch is the primary language. Netherlands Antillean guilder is their main currency although American dollar is accepted on both sides of the island. The main town, Philipsburg, looks and feels like a typical Caribbean island town. About 37,000 people live on the Dutch side. This part of the island is known for its festive nightlife, beaches, jewelry, exotic drinks made with native rum-based liquors and plentiful casinos.

The island is also known as a shopper’s paradise as it offers high quality duty-free goods in numerous boutiques. Popular goods include local crafts and arts, exotic foods, jewelry, liquor, tobacco, leather goods as well as most designer goods.

Salt and sugar cane industries are dead. The main economy is tourism and many Caribbean cruises include a stopover in Philipsburg. Phillipsburg has twelve gambling casinos and four duty-free streets full of shops and restaurants along the harbour. Also there is a beach and a board-walk just where the ship docks. One million tourists visit the island each year.

If you are an ardent environmentalist and a naturalist and are looking for a nudist colony then keep French side in mind. They don’t believe in wearing designer clothing on nude beaches. I wonder where I lost my Speedo!

We had a wonderful and relaxing time. I would not hesitate to go again (http://www.st-maarten.com/).

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Inflammatory Breast Cancer is a Rare and Very Aggressive Disease

A woman making a heart frame for the pink badge. (iStockphoto/Thinkstock)
A woman making a heart frame for the pink badge. (iStockphoto/Thinkstock)

Inflammatory breast cancer accounts for less than five percent of all breast cancers diagnosed in North America. Most inflammatory breast cancers are invasive ductal carcinomas. They develop from cells that line the milk ducts of the breast and then spread beyond the ducts.

It is a very aggressive disease with symptoms that include redness, swelling, tenderness, and warmth in the breast. As if you have an abscess of the breast. But it may be cancer.

The breast swells up because cancer cells block lymph vessels in the skin of the breast. The disease progresses rapidly, often in a matter of weeks or months. By the time the diagnosis is made it is either stage III or IV, depending on whether cancer cells have spread only to nearby lymph nodes (stage III) or to other tissues as well (stage IV).

It is more common and diagnosed at younger ages (median age of 57 years, compared with a median age of 62 years for other types of breast cancer). It is more common in African American women than in white women. It is more common in obese women than in women of normal weight. It can occur in men.

Rapid diagnosis and treatment is key to successful treatment. An international panel of experts published guidelines on how doctors can diagnose and stage inflammatory breast cancer correctly. These are:

1. A rapid onset of redness, swelling, and a peau d’orange (skin of an orange) appearance and/or abnormal breast warmth, with or without a lump that can be felt.

2. The above-mentioned symptoms have been present for less than 6 months.

3. The redness covers at least a third of the breast.

4. Initial biopsy samples from the affected breast show invasive carcinoma.

A diagnostic mammogram and an ultrasound of the breast and regional (nearby) lymph nodes is part of the diagnostic workup. A PET scan or a CT scan and a bone scan is done to see if the cancer has spread to other parts of the body.

Inflammatory breast cancer is treated first with systemic chemotherapy to help shrink the tumor, then with surgery to remove the tumor, followed by radiation therapy. This approach to treatment is called a multimodal approach. Studies have found that women with inflammatory breast cancer who are treated with a multi-modal approach have better responses to therapy and longer survival. If a woman’s biopsy samples show that her cancer cells contain hormone receptors, hormone therapy is another treatment option.

What is the prognosis of patients with inflammatory breast cancer?

Since this is an aggressive tumour, in general, women with inflammatory breast cancer do not survive as long as women diagnosed with other types of breast cancer. According to statistics from National Cancer Institute’s Surveillance, Epidemiology, and End Results (SEER) program, the 5-year relative survival for women diagnosed with inflammatory breast cancer during the period from 1988 through 2001 was 34 percent, compared with a 5-year relative survival of up to 87 percent among women diagnosed with other stages of invasive breast cancers.

National Cancer Institute’s website encourages women with inflammatory breast cancer to voluntary for ongoing research. The research, especially at the molecular level, will increase our understanding of how inflammatory breast cancer begins and progresses. This knowledge should enable the development of new treatments and more accurate prognoses for women diagnosed with this disease. It is important, therefore, that women who are diagnosed with inflammatory breast cancer talk with their doctor about the option of participating in a clinical trial.

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Shingles Vaccine may be Viewed as a Quality of Life Vaccine

An example of shingles. (iStockphoto/Thinkstock)
An example of shingles. (iStockphoto/Thinkstock)


A man with shingles of the face.

Shingles is caused by chickenpox virus called varicella zoster virus. The first indications that chickenpox and shingles were caused by the same virus were noticed at the beginning of the 20th century.

The incidence of shingles is mainly in adults. There are approximately four cases per 1000 population per year and a lifetime risk of 20 to 30 per cent.

Chickenpox generally occurs in children. Once the child gets over the illness the virus does not disappear from the body. Virus can settle down in one of the nerve cell bodies and lay dormant for many years.

When your resistance is low and this can be due to any reason, the virus may break out of the nerve cell and travel down the nerve causing viral infection of the skin in the area supplied by that nerve. This can happen decades after the chickenpox infection. Exactly how the virus remains latent in the body, and subsequently re-activates is not understood.

Shingles starts with burning pain, itching and tingling followed by painful rash and blisters in the area supplied by the affected nerve. The pain and rash most commonly occurs on the torso, but can appear on the face, eyes or other parts of the body. If the nerve to the eye is involved then a person may suffer loss of vision. It usually affects one nerve on one side of the body.

The rash and blisters heal within two to four weeks but some sufferers experience residual nerve pain for months or years. This condition is known as postherpetic neuralgia. About 20 per cent of patients with shingles suffer from this.

If the diagnosis of shingles is made early then it helps to start antiviral medications within 72 hours of the appearance of the rash. This reduces the severity and duration of the illness. The antiviral medications should be used for seven to ten days. The blisters crust over within seven to ten days, and usually the crusts fall off and the skin heals. But sometimes after severe blistering, scarring and discolored skin remains.

Until the rash has developed crusts, a person is extremely contagious. During the blister phase, direct contact with the rash can spread the virus to a person who has no immunity to the virus. This newly infected individual may then develop chickenpox, but will not immediately develop shingles.

Since 2008-2009, a vaccine for shingles is available for adults age 60 and over. The vaccine is used to boost the waning immunity to the virus that occurs with aging. The effectiveness of the vaccine is about 60 per cent. It is kind of a “quality of life” vaccine. It does not prevent death from shingles (an extremely rare event) but does help with postherpetic neuralgia (pain).

Booster doses of the vaccine are not recommended for healthy individuals. The efficacy of protection has not been assessed beyond four years and it is not known whether booster doses of vaccine are beneficial. This recommendation may need to be revisited as further information becomes available.

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Use of MRI in Evaluating Breast Lumps

A woman receiving a scan. (iStockphoto/Thinkstock)
A woman receiving a scan. (iStockphoto/Thinkstock)


A woman with locally advanced breast cancer.

The traditional way to assess a breast lump is to take a history, do a physical examination, do a fine needle aspiration cytology (examination of a breast lump aspirate under a microscope), mammogram and/or ultrasound, core biopsy under ultrasound control and finally, if there is no satisfactory answer then do a surgical biopsy.

A surgical biopsy gives us a definitive answer. But there are drawbacks to sending every patient with a breast lump for surgery. To start with it causes severe anxiety. You have to take a day off work. It requires local or general anaesthetic. There may or may not be postoperative complications like bleeding, bruising, discomfort, infection and pain.

On a long term basis, surgical biopsy will leave you with a scar and may be another lump which may be just a scar tissue but could be suspicious for cancer. Then you have to go through the whole process all over again.

Is there anything else we can do before going for surgery to make sure that there is no cancer in the breast?

You can ask for a second opinion. If all investigations are negative then there is a less than five per cent chance that cancer has been missed. In that case, we can leave the lump alone and provide follow up care with clinical examination and mammography or ultrasound, on a case by case basis. Sometimes a patient will ask for MRI.

MRI (magnetic resonance imaging) is a procedure that uses a magnet, radio waves, and a computer to make a series of detailed pictures of areas inside the body. MRI does not use any x-rays.
MRI is not available for routine screening. It is expensive and requires specialized equipment and personnel with good solid training to read the images. Hence, it is available in bigger cities only and is not covered by government insurance plans. MRI is more often used for breast imaging in the US than Canada because of the prevalence of private health care.

MRI is sensitive to small abnormalities in breast tissue. MRI also has limitations. For example, MRI cannot detect the presence of calcium deposits, which can be identified by mammography and may be a sign of cancer.

The value of breast MRI for breast cancer detection remains uncertain. And even at its best, MRI produces many uncertain findings. Some radiologists call these “unidentified bright objects,” or UBOs.

In women with a high inherited risk of breast cancer, screening trials of MRI breast scans have shown that MRI is more sensitive than mammography for finding breast tumors. Screening studies are ongoing.

Breast MRI is not recommended as a routine screening tool for breast cancer. However, for women at high risk, women with previous breast cancer, MRI can be useful in certain circumstances.

Start reading the preview of my book A Doctor's Journey for free on Amazon. Available on Kindle for $2.99!