Vascular disease: a preventable killer
Dr Harinder Singh Bedi

Vascular disease is a major health problem in India. One in 20 people over 50 years of age have vascular disease. It is not just "poor circulation." It has various forms: peripheral arterial disease affects the arteries taking blood to the arms and the legs; carotid artery disease affects the arteries taking blood to the brain, and renal artery disease limits the blood flow to the kidneys causing high blood pressure or renal failure.

Arterial disease is most often caused by atherosclerosis (hardening of the arteries). When atherosclerosis develops, the normally smooth linings of the arteries become narrow and rough from the buildup of plaque, which is made up of cholesterol and calcium deposits.

Symptoms for different vascular diseases which are, otherwise, preventable:

(Patients with any of these disorders may have no symptoms):

Peripheral artery disease

Leg pain with exercise

Leg swelling

Weakness or tiredness in the legs

Sores on the feet or legs that won't heal

Carotid artery disease

Temporary loss of vision in one eye, or blurred or double vision

Confusion

Loss of balance or coordination

Numbness or weakness on one side of the body

Slurred speech or difficulty in speaking

Change in the ability to use arms and legs

Stroke

Abdominal aortic aneurysm

Often no symptoms

Dizziness

Sudden onset of abdominal or back pain

Renal artery disease

High blood pressure (hypertension)

Acute renal (kidney) failure

Mesenteric artery disease

Abdominal pain, especially after eating

Unwanted weight loss

Venous disease

Leg swelling

Sores on lower legs that do not heal

Leg pain

Dilated varicose leg veins

Risk factors for vascular disease

Cigarette smoking is the first risk factor for developing vascular disease

Obesity

Diabetes mellitus

High cholesterol and lipids

Heart disease

High-stress lifestyle

Older than age 50

Sedentary lifestyle

High blood pressure

How can you lower your own risk factors?

The more you know about vascular disease and what causes it, the better you can address the problem and work to lower your chances of getting it. The best way to lower your risk of developing vascular disease is to:

l Stop smoking
l Maintain your management of diabetes --- if you have the disease --- with diet and medications
l Exercise regularly
l Maintain a healthy diet (heart healthy, low sodium)
l Tell your doctor if you have any of the symptoms of vascular disease.
l Control your blood pressure, with diet or medications
l Lower blood cholesterol levels, if elevated, with diet or medication

Treatment Options: Individual treatment options depend on a number of factors that will be explained by the physician. One size does not fit all in managing the disease. Often a combination of risk reduction, medicines, less-invasive treatment options and surgery provides the patient with the best chance for a good outcome.

The writer is Chairman, Cardio-Vascular Sciences, Sigma New Life Heart Institute, Ludhiana. He was formerly Senior Consultant, Escorts Heart Institute, New Delhi.

Pollution can make you fat
Geoffrey Lean

Pollution can make children fat, startling new research shows. A groundbreaking Spanish study indicates that exposure to a range of common chemicals before birth sets up a baby to grow up stout, thus helping to drive the worldwide obesity epidemic.

The results of the study, just published - the first to link chemical contamination in the womb with one of the developing world's greatest and fastest-growing health crises - carry huge potential implications for public policy around the globe. They undermine recent strictures from the Conservative leader, David Cameron, that blame solely the obese for their own condition.

A quarter of all British adults and a fifth of children are obese - four times as many as 30 years ago. And so are at least 300 million people worldwide. The main explanation is that they are consuming more calories than they burn. But there is growing evidence that diet and lack of exercise, though critical, cannot alone explain the rapid growth of the epidemic.

It has long been known that genetics give people different metabolisms, making some gain weight more easily than others. But the new study by scientists at Barcelona's Municipal Institute of Medical Research suggests that pollution may similarly predispose people to get fat.

The research, published in the current issue of the journal Acta Paediatrica, measured levels of hexachlorobenzene (HCB), a pesticide, in the umbilical cords of 403 children born on the Spanish island of Menorca, from before birth. It found that those with the highest levels were twice as likely to be obese when they reached the age of six and a half.

HCB, which was mainly used to treat seeds, has been banned internationally since the children were born, but its persistence ensures that it remains in the environment and gets into food.

The importance of the study is not so much in identifying one chemical, as in showing what is likely to be happening as a result of contact with many of them. Its authors call for exposures to similar pesticides to be "minimised".

Experiments have shown that many chemicals fed to pregnant animals cause their offspring to grow up obese. These include organotins, long employed in antifouling paints on ships and now widely found in fish; bisphenol A (BPA), used in baby bottles and to line cans of food, among countless other applications; and phthalates, found in cosmetics, shampoos, etc.

— The Independent

EYESIGHT
Managing the uncontrolled glaucoma
Dr Mahipal S. Sachdev

Childhood glaucomas are associated with a very poor visual outcomes. Despite multiple procedures, the pressure remains uncontrolled and the child may go blind. The commonly performed procedures are trabeculotomy and trabeculectomy with or without anti-metabolites such as Mitomycin C. The advent of glaucoma drainage devices has opened new vistas for the management of such difficult cases and offers a ray of hope to such children as would otherwise lead a life plunged in darkness.

Uncontrolled glaucoma cases are those where routine medications are not able to maintain the desired eye pressure to avoid progressive visual loss, or even routine surgical options fail over time. Since the visual damage because of glaucoma is irreversible, managing these cases is a difficult task.

Traditionally, glaucoma drainage devices have been reserved for difficult or complicated glaucoma cases in which conventional glaucoma surgery has failed or is likely to fail. Other indications for shunt placement are active uveitis, neovascular glaucoma, or glaucoma after cataract surgery.

The rationale of a valve device is to provide a minimal amount of flow resistance, preventing excess drainage by creating a “cut-off switch” to stop the flow when a certain eye pressure is reached.

The non-valved glaucoma drainage implants consist of a single plate and a double plate.

These valves are a boon to such uncontrolled glaucoma cases as that is the only way by which eye pressure is kept under control. This helps in salvaging whatever vision is there in such eyes and preventing/delaying blindness.

When conventional glaucoma surgery or glaucoma drainage tube/valve has failed to control glaucoma, then the option of cycloablation (ablation or destruction of the ciliary body which produces the aqueous fluid) is considered. Because cycloablation involves permanent destruction of the ciliary body, it is usually the last line of treatment for uncontrolled glaucoma. Before the advent of laser, this was done using a cryoprobe (freezing probe) to freeze the ciliary body (cyclocryotherapy). This was often an uncomfortable procedure as it was associated with significant pain. Starting in the 1990’s, cyclocryotherapy was largely replaced by a laser procedure called CycloPhotoCoagulation or CPC.

Diode Laser Cyclophotocoagulation (DLCP) is a useful procedure for a refractive glaucoma which cannot be controlled by medication and surgery. The advantage of DLCP is that it can be repeated, if needed. The recovery period is usually 4-6 weeks. The follow-up visits are not as intensive as the filtering surgery, and this may offer advantage to some patients. Because DLCP can be associated with a decrease in vision post-operatively, DLCP is commonly reserved for patients who already have reduced vision from either glaucoma or other causes pre-operatively.

Managing uncontrolled cases of glaucoma is a difficult task. Valves bring a ray of hope to such patients. An uncontrolled glaucomatous eye is usually a painful blind eye. DLCP helps in making it a painless eye, which is important for the patient.

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

Diabetes can affect pregnancy
Dr Meenal Kumar

Before pregnancy, women with diabetes mellitus should be educated about the need for good control of diabetes at the time of conception. Drugs like statins, angiotensin-converting enzyme (ACE) inhibitors, angiotensin II receptor blockers (ARBs), and most oral antidiabetics should be stopped or taken strictly under medical supervision.

Effective contraception is recommended until stable, acceptable blood sugar control is achieved. Optimal goals throughout pregnancy are fasting and after-meal blood glucose levels of 60 - 99 mg, and 100 - 129 mg respectively. To prevent spontaneous abortions and congenital malformations, target hemoglobin A1c before pregnancy should be less than 6 per cent. The same goal is recommended throughout pregnancy.

If diabetic ketoacidosis (DKA) is detected during pregnancy it requires hospitalisation. Urine ketone testing during illness or when glucose is above 300 mg should be a must.

Some other aspects of diabetes with pregnancy :

l Large birth weight occurs in two-thirds of infants of mothers with diabetes, and the mid-trimester glucose level is the best predictor. Too tight glucose control (< 80 - 90 mg) is linked with foetal growth restriction. Such babies are at greater risk throughout life.
l Foetal hyperglycemia causes hypoxia and acidosis, which contributes to stillbirth.
l Target gestational weight gain for mother should be on the lower side to prevent excess weight gain, and carbohydrate intake and size of meals should be monitored.
l Folate intake should be 600 µg daily.
l Oral drugs should be stopped and insulin started and titrated.

Prevention of diabetic complications

l Women should have a high index of suspicion for DKA in pregnancy, especially if there is vomiting, nausea and abdominal pain.
l Screening should be conducted for thyroid dysfunction in all women with diabetes before or during early pregnancy, as autoimmune thyroid disease is common (35- 40 per cent).
l Evaluation for cardiovascular risk is best performed before pregnancy, with screening for smoking, hypertension, high cholesterol levels, albumin-urea, and family history of DM.
l Blood pressure (BP) should be kept to less than 130 mm Hg systolic and less than 80 mm Hg diastolic in the preconception period.
l In addition to lifestyle changes, women with BP more than 140/90 mm Hg should be considered for safe drugs during pregnancy: methyldopa, long-acting calcium channel blockers, and selected beta-adrenergic blockers.
l The low-density lipoprotein (LDL) cholesterol level should be less than 100 mg in women without heart disease and less than 70 mg in women with it.
l Albumin-urea and glomerular filtration rate should be assessed and dietary guidance to restrict protein intake provided by dieticians.
l Eye examination should be conducted in the first trimester and laser photocoagulation indicated to prevent vision loss in those at high risk for diabetic retinopathy.

Health Notes
Your dentist can now give you best dental
fillings without gaps

Washington: Scientists at the Fraunhofer Institute for Mechanics of Materials IWM in Freiburg have devised a new method of simulation that can enable a dentist to choose the best plastic fillings to close cavities, to prevent gaps from appearing between the tooth and the filling.

The plastic that dentists use to fill the cavity tends to shrink slightly as it hardens, occasionally producing tension that can cause tiny gaps to form between the filling and the tooth. Bits of food can get caught in these gaps and lead to more caries.

Though manufacturers of filling materials offer a variety of plastics to choose from, dentists often find it hard to determine which filling is best suited to a particular shape of cavity. — ANI

How immune cells help tumours grow blood vessels

Washington: Scientists at City of Hope National Medical Center in Duarte have uncovered how immune cells help tumours grow blood vessels, promoting cancer progression.

Study leader Hua Yu says that new results have implicated a role for the protein Stat3 in the induction of tumour angiogenesis by tumour-associated myeloid cells in mice.

Past research had revealed that constitutively activated Stat3 in tumour cells plays a role in promoting tumour angiogenesis.

It was found in the study that Stat3 is also constitutively activated in myeloid cells isolated from mouse tumours, and that these cells could induce angiogenesis in vitro, because the constitutively activated Stat3 induced the cells to produce angiogenic factors.

Cells stimulated by HIV

Washington: An Indian-origin researcher at New York University says that she has gained fresh insights into the role of human immune cells known as plasmacytoid dendritic cells (pDCs) in the anti-HIV immune response.

Nina Bhardwaj says that pDCs become activated when they interact with HIV, secreting large amounts of the soluble factor IFN-alpha, which is a key component of the anti-HIV immune response.

However, in vitro studies have shown that HIV-1-stimulated human pDCs induced uncommitted CD4+ T cells to become Tregs, which are T cells that suppress immune responses. — ANI

Obese ‘at increased cancer risk’

London: Overweight people are at a significantly higher risk of developing a range of common cancers, according to a new study.

In the study, carried out at the Washington University School of Medicine in the US, researchers analysed data from around the world on obesity, weight gain and weight loss in relation to cancers of the breast, pancreas, kidney, colon, prostate, oesophagus and endometrium, which is the lining of the womb.

“Most people associate high body weight with conditions like diabetes and heart disease, and a lot of people are not aware of the links between body weight and cancer,” the Telegraph quoted Ed Yong, health information manager at Cancer Research UK, as saying. — ANI