Cardiac surgery in diabetics: challenges and advances
Dr Harinder Singh Bedi

Driven by rising obesity and inactivity and generally poor lifestyle habits, associated with recent affluence and increased motorised transport, a sharp increase in the number of diabetics in India is almost inevitable unless drastic steps are taken today. According to Prof Sir George Alberti, immediate past president of the International Diabetes Federation and Britain’s foremost expert on the disease, “It is a catastrophe waiting to happen.” The financial and social burden will be intolerable unless strong government action is taken now.

Diabetes affects 150 million people globally and causes 5 million deaths a year. The number of the affected has almost tripled in 50 years, from 55 million in 1955, and will rise to 300 million in 2025 - of this, 70 million will be in India . More than 80 per cent suffers will die of heart attack or stroke and more than a 1000 a year will need dialysis for kidney failure.

What is even more important to note is that diabetics are more prone to heart disease and related problems. Diabetes mellitus is an established risk factor for the development of coronary artery disease. Epidemiological data from the Framingham and other studies have clearly documented this fact. Coronary artery disease (CAD) is two-three times higher in diabetics than in non-diabetics - the risk being further higher in women. Accelerated coronary and peripheral arterial arteriosclerosis is one of the most common and serious chronic complications of long-term diabetes.

CAD is not only more prevalent in diabetics but is also more extensive, involves more vessels and is progressive. The arteries tend to be narrow in diabetics and the blockages are more diffuse. Also, when a diabetic develops heart disease, it is generally more severe and there is much higher risk of death than in a non-diabetic.

The risk multiplies if hypertension is associated with diabetes - a not uncommon combination. According to the American Diabetes Association, if you have a coronary problem and are diabetic, you are already “one heart-attack old”.

It is estimated that almost 3.2 million people die of diabetes across the world every year and there are 30 to 33 million diabetics in India now. Every fourth diabetic in the world today is an Indian. The World Health Organisation predicts that the number of diabetics in India would go up to 40 million by 2010 and 74 million by 2025. The country stands to become the “Diabetes Capital of the World.”

International health officials say diabetes needs much more attention, particularly in India. It is unfortunate that Indians are genetically more susceptible to diabetes. Compared to Americans, whose average age for the onset of diabetes is 59, in India it is much less at 43.

The management of diabetes has always been a matter of research and discussion. Over the years diabetes specialists have been adopting an aggressive approach towards the prevention and treatment of the disease and are adopting the following targets of prevention: BP to be 130/80 mm Hg, fasting blood sugar levels less than 120 mgl and cholesterol as low as possible.

Diabetic patients coming for coronary artery bypass grafting (CABG) are now generally younger, comprise more women, have a greater incidence of high blood pressure and previous heart attack, have a worse class of angina, have a higher incidence of heart failure, severe triple vessel disease or left main disease (known as ‘the widow maker’), a higher incidence of diffuse disease, a lower heart function, and a greater incidence of associated carotid and peripheral vascular disease and renal failure than non-diabetics.

It is well known that there is a much higher rate of recurrence (restenosis) after PTCA (angioplasty) and stent placement in diabetics. Insulin dependent diabetics fare worse than non-insulin dependent ones.

Cardiac scientists have risen to the challenge by using various methods for better control of diabetes, a better technique of harvesting the internal mammary artery, use of minimally invasive techniques to harvest the saphenous vein, use of off-pump techniques to avoid the heart-lung machine with all its attendant side-effects (immunological, haematological, neurological, pulmonary, renal, hepatic, psychological), development of robotic techniques for CABG and endoscopic vein harvesting techniques.

The single most important advance in CABG in the last decade has been the uniform acceptance of off-pump (beating heart) CABG first started in Punjab 10 years back - as a standard technique. Eliminating the heart-lung machine with its attendant neurological, pulmonary, renal, cardiac, hepatic, immunological and hematological adverse effects has a significant salutary effect on the high-risk diabetic, patients.

It has been clearly shown that with off-pump techniques in diabetics, there is a great benefit from less blood product usage, less incidence of prolonged ventilation, less incidence of postoperative renal failure requiring dialysis and less rhythm disorders. This translates into a much reduced incidence of infection and a shorter hospital stay.

In spite of our intention to use arterial grafts quite often, we are faced with the need for additional vein grafts. A significant morbidity in the diabetic patients is an infected leg/thigh wound, which prolongs the hospital stay and delays ambulation and physiotherapy. Special endoscopes have been developed which are hooked up to TV screens to give a magnified view of the endoscopic view. With special instruments, the surgeon is able to dissect out up to 40 cm of the greater saphenous vein via a 2mm incision at the knee. The patient has no incision, no pain, no possibility of leg wound infection and is able to ambulate early. This writer has been the first in Asia to have independently used this technique in 2001.

Continuous advances will ensure that the risk to the patients continues to decline and the long-term results further improve in the high-risk vasculopaths.

The writer, who was earlier associated with Escorts, New Delhi, is Director and Chairman, Cardiac Sciences, Ludhiana Mediciti Superspeciality Hospital, Ludhiana.

EYESIGHT
New generation intra-ocular lenses
Dr Mahipal S. Sachdev

Intra-ocular lenses or IOLs are the artificial lenses that replace/ substitute the natural lens, which is removed during cataract surgery. Thick glasses after cataract surgery were a common thing in the days before the use of IOLs. IOLs gave independence from these glasses to the operated patients.

Fifty-five years ago when the first IOL was implanted in the human eye, a revolution started in the field of ophthalmology. Since then we have come a long way in developing newer generation IOLs keeping pace with the advancements in the cataract surgery procedures like phaco-emulsification.

The current technology for cataract surgery involves the procedure of phaco-emulsification with the implantation of an IOL which is either non-foldable or foldable. A lot of development has taken place as far as material and design of the IOL is concerned. This has helped in getting better visual outcomes for cataract patients.

The lenses in common use evolved from non-foldable to foldable as cataract surgery became stitchless. The most common lens implant is a single power or "monofocal" lens. Monofocal lenses have a 20-year track record of safety and satisfaction. Patients usually obtain clear glass-free vision at one "working distance" and require glasses or contact lenses to function at other viewing distance. We can often control where the working distance of the unaided eye will fall after surgery. If you and your surgeon choose a monofocal lens you will be asked to choose a "target" working distance, at which your eye undergoing surgery should have good "uncorrected" vision. While your particular choices may be limited by condition of the other eye, in general the choices include the following:

Monofocal Near - It is good for reading fine print and doing crafts. Patients will need glasses to see distant objects, to drive, play golf and other social activities. Usually, it is less preferred as one needs to look at a long distance for longer hours as compared to near work.

Monofocal Intermediate — It gives good vision at arms length for cooking, desk work, computer screens and some social activities. Usually, one can read large print uncorrected but needs glasses for fine print and driving.

Monofocal Far — It is good for driving without glasses and many sports. One always needs reading/ computer glasses for near work. It is preferred
routinely.

Monovision — Patients with cataract in both eyes have the freedom to achieve good glass-free near and far vision with monofocal implants by selecting one eye for distance vision and one eye for near. This strategy is called "monovision". Patients with monovision are less dependent on glasses than those with both eyes focused at the same working distance. Monovision patients experience less glare and better contrast sensitivity than those with multifocal lenses. The disadvantage of monovision is a reduction in depth perception, and some individuals feel that one eye is blurred without glasses.

Bifocal Lens Implants — If you have cataract in both eyes and little astigmatism, you might be a candidate for a bifocal lens implant. This lens typically provides simultaneous near and far vision without glasses. Patients with this lens experience somewhat more glare after surgery than the monofocal lenses, but typically gain the ability to see both near and far without glasses, e.g. Technis Bifocal IOL

Multifocal IOLs — The development of multifocal IOLs is a major technology jump as it has made possible for a cataract patient to have both long-distance vision and near vision after cataract surgery. This would help eliminate the need for glasses or reduce the dependence on glasses in some cases.

These IOLs work in a manner that at any given time when one focus is being used, the other focus becomes so blurred that it becomes imperceptible. Therefore, at any given time, the brain visualises only one image either for distance or for near.

The multifocal IOLs available today include ReZoom IOLs, Array Multifocal and Acrysof ReSTOR

However, in a very small population of cataract patients (5 per cent), the pre-existing structure of the eye produces some refractive error like cylindrical number, which is not corrected by these lenses. Therefore, a person may feel more comfortable with the use of the appropriate cylindrical power occasionally in order to get sharper vision. So, this technology essentially speaks of reduced dependence on glasses. Another factor of concern is the night-time halos.

These IOLs would offer a very viable choice to those patients who have been facing such problems in their active professional and home life. There are many more advances coming up in the IOLs.

These new generation IOLs unfold a plethora of lifestyle changes. Imagine the plight a 50-year-old patient, operated for cataract, who takes his guest to a restaurant and when he starts reading the menu he realises that he has forgotten his reading glasses at home.

With these IOLs, one can make such complaints history!

The writer is Chairman and Medical Director, Centre for Sight, New Delhi. E-mail: msachdev@bol.net.in.

Ayurveda & you
Avoid anger and save your health
Dr R. Vatsyayan

“From anger arises delusion, from delusion confusion of memory, from confusion of memory loss of intellect and from loss of intellect the man perishes.” This is how anger, the most negative of all emotions, has been described in the sacred Gita. Anger has also been explained as an off-putting emotional response to any situation affecting the individual who loses his temper and on whom it is lost.

Apart from the religious and holy texts belonging to all faiths, ancient ayurvedic literature, too, while discussing the ideal physical or mental conduct of a man, amply elucidated the bad effects of anger. Dealing with etiology of most of the diseases, anger has been perceived as one of the potential reasons which spoil the normal physiology of the body. Persistent anger starts certain psycho-physical chain of reactions having far reaching consequences.

Modern health scientists also believe that anger is a painful state of mind. Whenever we develop it, our inner peace immediately disappears and the body becomes tense and uncomfortable. This state is accompanied by a number of other symptoms like increased heart rate, raised blood pressure, breathlessness, irritability, anxiety and depression. In certain cases, its fallout is so severe that it can lead to an attack of migraine, angina and spasm in the coronary arteries. Studies suggest that angry individuals ranging between 40 and 60 years of age have a three times higher risk of heart attack.

Apart from confronting certain adverse situations like hurt, frustration, annoyance, harassment, inconvenience and defiance, to be endowed with a never satisfied attitude is also thought to be a very common reason of anger. Psychologists believe that anger, though a natural human emotion, becomes a problem if it is mismanaged and allowed to spoil our health, causing conflicts in the smooth functioning of life. Domestic and workplace violence, road rage, addiction to drugs and marital disharmony are some of the ugliest fallouts of uncontrolled anger which, after forming a vicious cycle, affect our over-all normalcy.

According to ayurvedic perceptions, anger is a “pitta” condition which shows up either as a personality trait or takes a vitiated form as a disease and demonstrates its episodic manifestations along with an aggravated “vata”. Anger has its variations. In our day-to-day life, we come across a few persons who are “hotheaded”. They get angry at any pretext and make intense outbursts. Some people are born irritable and touchy and have a low tolerance level. There are also those who do not express their anger loudly but are chronically irritable and brooders, and withdraw socially, sulk or get physically ill.

In general, anger is the most poorly handled emotion which robs us of reason and good sense. Most of us most of the times do not know how to express it. There are psychological tests measuring the intensity of angry feelings indicating how prone to anger a person is and also how well he can handle it. If one feels acting in ways that seem to be out of control and frightening, he definitely needs medical advice and counselling.

Uncontrolled anger exposes many of our weaknesses, and our failure to understand it gives us a lot of problems, including bad health, spoiled relationships and social deprivations. Identifying the basic cause of anger, whether it is situational, momentary or due to bad temperament will be a step closer to getting rid of it.

The writer is a Ludhiana-based senior ayurvedic physician.