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What every patient should know about coronary artery bypass surgery

by L. Dalpadado, FRCS

Coronary Artery Bypass Surgery (CABS) is the commonest surgical operation performed in the world today. In Sri Lanka over 2000 operations are performed annually and with an aging population, the number of patients who would benefit from surgery is expected to rise dramatically. In developed countries, it is estimated that up to 400 patients per one million population may have to undergo surgery every year.

Coronary Artery Bypass surgery can now be performed with a very low mortality and a high success rate. After surgery, the patients' whole life style changes. Most patients feel that they have been given a new lease of life and often comment that they feel ten years younger. This is because over a period of time angina has cramped their lifestyle and some of the drugs that are given to control angina actually slows the patient down.

Also coupled with the fact that swallowing 10-15 tablets a day, reminds the patient that he is not in the best of health.

Despite recent advances in various angioplasty techniques including stenting, the best long term results so far is following CABS, especially for patients with blocks in more than one coronary artery.

Coronary Artery Bypass surgery achieves the following:

1. Relief of angina

2. Reduction in severity and incidence of heart attacks

3. Improvement in exercise capacity

4. Improved heart muscle function

5. In certain cases, improved heart valve function.

The operation is usually performed under General anaesthesia but a few have been performed under Epidural anaesthesia. The current trend is to use both Internal Mammary Arteries (IMAs) to increase the blood supply to the heart muscle. The arteries are joined together in an inverted "Y" fashion and used to "jump graft" several blocked arteries like in a sprinkler system (See Fig 1). This technique is known as Total Arterial Revascularisation with LIMA-RIMA composite Y graft.

This is akin to constructing a side - road or bypass when a bridge is under repair, allowing cars to cross to the other side. One of the greatest advantages of RIMA-LIMA "Y" technique is that the surgeon does not have to handle or clamp the aorta (the main artery to the body), as in on-pump surgery. When the aorta is manipulated, cholesterol deposits can get dislodged and travel to the brain causing strokes. This is one of the biggest fears that a heart surgeon has. By adopting the above No-Touch technique the risk of stroke is totally eliminated.

In bad diabetics, an artery from the forearm (Radial Artery) is used instead of the Right Internal Mammary artery. This is to prevent sternal wound infection which may be a problem if both mammary arteries are used in diabetics.

Use of leg veins is no longer recommended as leg veins get clogged up much earlier than arteries.

Incision and vein removal from the leg leads to pain, swelling and difficulty in walking. Leg wounds are also prone to wound infection especially in diabetics causing delayed ambulation and is charge from hospital. The current recommendations also favour Beating Heart Surgery (Off Pump) as opposed to on-pump surgery. In Off-pump surgery (OPCAB) the bypass grafting is carried out whilst the heart is beating and without the assistance of the Heart - Lung machine, OPCAB surgery allows early recovery with fewer side effects and early discharge from hospital.

So, with so many doctors and hospitals, exalting the virtues of one technique or other, how does one select a surgeon and the hospital?

Ask around to find out about hospital Mortality for a particular surgeon and the hospital. If the death rate is more than 0.5% for elective surgery, one should look for a hospital with better results. If the surgeon uses leg veins, better to find a surgeon who is doing total arterial revascularisation. Ask the surgeon whether the operation is carried out off-pump or on-pump.

The recovery is faster and better with off-pump surgery. Also find out whether he is practising the No-Touch technique. You are less likely to suffer a stroke with a surgeon who is practising the No-Touch technique.

In summary try and get the surgeon to answer the following questions:

Is the mortality for elective surgery less than 0.5%?

Are the grafts all arterial?

Is he performing grafting Off-Pump?

Is he practising the No-Touch technique?

If your surgeon is coy in giving straight forward answers - get a second opinion. And if you are interested in learning more about total Arterial Revascularisation and Beating Heart Surgery try the Cardiothoracic surgeons website www.ctsnet.org, or the Minimally Invasive Cardiothoracic Surgery website www.ismics.org.

Although aimed at qualified professionals both sites are well laid out, simple to follow and an excellent source of information.

The writer is Chief, Div. Of Cardiovascular & Thoracic Surgery, Suwasevana Hospital, Kandy

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Medical practitioners' Oath

All doctors entering the profession now have to take what they call - medical practitioners oath, not the hypocratic oath, as it was called earlier.

The SLMC President Dr. H.H.R. Samarasinghe told the Health Watch, that the oath can be taken before a council member.

Often doctors take it in groups, but when he administers the oath he does it individually getting the doctor to say it aloud, to impress upon him the responsibility that goes with a doctor in practice.

Dr. Samarasinghe said the general public too would be interested to know what is in this oath, and requested the Health Watch to carry it.

The oath

* I solemnly pledge myself to dedicate my life to the service of humanity.

* The health of my patient will be my primary consideration and I will not use my profession for exploitation and abuse of my patient.

* I will practice my profession with conscience, dignity, integrity and honesty.

* I will respect the secrets which are confided in me even after the patient has died.

* I will give to my teachers the respect and gratitude, which is their due.

* I will maintain by all the means in my power, the honour and noble traditions of the medical profession.

* I will not permit considerations of religion nationality, race, party politics, case or social standing to intervene between my duty and my patient.

* I will maintain the utmost respect for human life from its beginning even under threat, and I will not use my medical knowledge contrary to the laws of humanity.

I make the promise solemnly, freely and upon my honour.

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On Charcoal Trial, Colombo Medical Faculty assures the Kurunegala public

Prof. Risvi Sheriff Professor of Medicine Colombo Medical Faculty, with three other doctors - Dr. Alahakoon, Dr. Gunasekera, Dr. Senanayake and Dr. Eddleston in a statement to the Health Watch on the media report (not in the Lake House group) of a recent death of 2 patients in the Kurunegala Teaching Hospital where a Colombo Medical Faculty conducted trial is under way of treating poison ingested patients with activated charcoal, state.

"The patient concerned in the media report had ingested a pesticide called Dimethoate - a very dangerous pesticide which kills three out of every ten people who drink it, a far higher number than occurs with some other pesticides. Clinically the patient died of this pesticide poisoning and not from the charcoal administration".

The statement adds.

Activated charcoal

* Activated charcoal treatment for positioning is not "experimental". It has been used across the world since the 1820s and in Sri Lanka for some patients since at least the 1950s. Unfortunately, we do not yet know whether it actually benefits patients when given in hospital.

* The brand being used, Carbomix, is used in many countries worldwide. It differs from the charcoal being used in Sri Lankan hospitals only in being twice as effective.

* Charcoal has an excellent safety record - it is an inert substance and there have been no deaths reported from its safe administration into the stomach. Hundreds of thousands of patients have received activated charcoal safely.

* The patient in question had ingested a pesticide called dimethoate- a very dangerous pesticide which kills three out of every ten people who drink it, a far higher number than occurs with some other pesticides. Clinically, he died from his pesticide poisoning, not from the charcoal.

* He was admitted in an unconscious state and was treated by an English medical registrar (with MRCP and SLMC registration) and two pre-intern doctors. His condition was stabilized and he made a good recovery in the first 12-24 hours. Unfortunately, he subsequently developed delayed respiratory failure, a well recognized and highly dangerous complication of pesticide poisoning, and died on his second day in hospital.

* Throughout his time in hospital, he was under the care of one of the hospital's consultant physicians. Although initially treated by the study team, he was subsequently seen regularly by the Kurunegala medical doctors. He received all treatments normally given to pesticide poisoned patients.

* The study has ethical clearance from the Universities of Colombo and Oxford. It is being carried out with the full support and cooperation of the Ministry of Health and WHO.

Ethical permission was taken from the patient's relatives. The purpose of the trial and the risks and benefits to the patient were carefully explained by the two pre-intern doctors and the relatives were given time to think about their decision. They chose after five minutes deliberation to allow their relative to enter the trial.

Pesticide poisoning is a massive problem in Sri Lanka - in Kurunegala District, in particular. Only 3 months ago, media itself carried an article, quoting the same Coroner that over 4000 pesticide poisoned patients had been admitted to hospital in the district during 2001. Over 1000 died - a 25% death rate which emphasizes the severity of the problem. We simply do not know the best way to treat pesticide poisoned patients.

Something needs to be done to reduce this loss of life. We have set up a study with the Ministry of Health to find out how best to treat these patients. Our long-term ambition is to halve the number of deaths from pesticide poisoning in Sri Lanka - saving thousands of lives in the process.

We have so far recruited over 1600 patients to the trial of charcoal in three hospitals. The death rate for patients who present unconscious and are entered into the trial by their relatives is half that of patients who do not enter the trial. The trial is already saving many lives - the information it supplies will be used by the Ministry of Health to save many more in the years to come.

We were disappointed that some newspapers not Lake House group published these accusations without checking with either the Consultant responsible for the patient or the Director of the hospital. We believe that the Coroner was misled by inaccurate statements made to him by doctors not involved in either the study or the care of this patients.

The people of Kurunegala District can be reassured that they will not be 'experimented on' in their Teaching Hospital. Poisoned patients will receive care that is of an international standard if they chose to enter the trial. The information gained from the trial will not only benefit people of Kurunegala but also people throughout Sri Lanka and the rest of the world where pesticide poisoning is a problem.

The statement has been issued by Prof. R. Sheriff, Professor of Medicine, Colombo University.

Dr. Alahakoon, Consultant Physician, Kurunegala Teaching Hospital.

Dr. A. Gunasekera, Director, Kurunegala Teaching Hospital.

Dr. Senanayake, Judicial Medical Officer, Kurunegala Teaching Hospital. Dr. M. Eddleston, Honorary Research Fellow, Colombo University

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Sri Lanka Medical Council on the Piliyandala Pre-clinical Teaching institute

Health Watch last week met the President, Vice-president and the Registrar of the Sri Lnaka Medical Council, Dr. H.H.R. Samarasinghe, Dr. Ananda Samamarsekera and Prof. P.S.S. Panditharatne respectively to find out the delay with regard to recognition being given to the Tanzania University's Pre-medical Teaching Institute set up in Piliyandala, Sri Lanka as a BOI project for Sri Lankan students, joining that university for the MBBS degree, which has already been recognised by the SLMC.

The position taken by the SLMC in this regard was that the SLMC has recognised the Tanzania University degree done in that university as a whole, meaning the entire course, and not a twinning programme, like what has been put before the Council now. The pre-medical part to be done here in Piliyandala.

The SLMC has no objection to this provided that the Piliyandala Institute has at least the minimum standards expected of a pre-medical teaching institute.

Dr. Samarasinghe said the SLMC has a great responsibility by the public to ensure that the Sri Lankan doctors coming out of the universities area of a acceptable standard. One of the main tasks of the SLMC is to fulfil that.

In recognising an Institute of this nature the SLMC has to ensure among other facilities, that the teaching staff is properly qualified and not retired people. The SLMC has to check the qualifications of the staff to make sure that they are genuine, because if a problem crops up later the parents and the general public will blame the council for irresponsibility in discharging its duties by the public.

Therefore the council wants to make doubly sure that everything is in order and upto the minimum standard before giving recognition to this Institute.

This process takes time, one has to understand that. Dr. Samarasinghe said the council wishes to inform the students who are awaiting to join this Institute, and their parents that the council is taking time over this matter in their interest.

Dr. Samarasinghe said that in a similar twinning programme of a UK University in Australia, the SLMC went to Australia and inspected that institute before giving recognition.

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Sugar can ruin your health

by Dr. D.P. Atukorale

continued from last week

Australian guidelines currently state "Eat only a moderate amount of sugar" Sugar is a major contributor to obesity. Sugar consumption has increased by approximately 50% in the past decade during which time obesity and diabetes have also risen. Growing obesity reflects a fall in energy outpout and increased intake of energy (aetiology, complications and management of obesity will be discussed in a future article).

Obesity in children

Obesity in children correlates strongly with intake of sugar and sweetened drinks. Each additional serving of sugar sweetened drink per day increases the risk of obesity by 60%. Thus advising a reduction in sugar intake may be a useful public health measure where diabetes and obesity are concerned. "Consume only moderate amounts of sugar and foods and beverages containing added sugar (O'Dea K et al, Med. J.Aust. 175, 165-6, 6th August 2001).

Sucrose consumption has increased by approximately 50% in the past decade and obesity prevalence has doubled during the same time.

Obesity is the result of genetic predisposition acting in conjunction with environmental factors. Energy expenditure has fallen as a result of our increasingly sedantary lifestyle.

Many low fat products are energy dense because they have high sugar component. Moreover sugar enriched beverages are major contributor to total energy intake.

A study published in Lancet showed the importance of the form in which sugar is consumed. Pure food is poor food. Reducing dietary fat intake is not the most effective method of weight loss. Reducing carbohydrates is a better option although high fat diets have been implicated in obesity.

The ideal diet to prevent heart disease (I.H.D.) is based on complex carbohydrates and not on simple carbohydrates. Complex carbohydrates include fruits grains, vegetables and legumes (beans) in their natural forms and sugar found in complex carbohydrates are absorbed slowly thereby helping to keep the blood sugar levels constant and so they do not stimulate your body to produce excessive amounts of insulin. In contrast simple carbohydrates sugar and other concentrated sweetners like honey and alcohol which your body converts to sugar are absorbed rapidly causing your blood sugar to rapidly increase. In response your body secretes insulin to lower blood sugar levels to normal.

Some other effects of insulin

Besides regulating your blood sugar level, insulin stimulates the secretation of lipoprotein lipase which is an enzyme that increases the uptake of fat from your blood stream into fat in your body's cells. As a result when your body produces more insulin you are more likely to convert the dietary calories into body fat. In other words, consuming a lot of sugar gives you a double whammy: you can consume virtually unlimited amounts of sugar calories without getting full and sugar stimulates your pancreas to produce insulin which increases the conversion of these calories into body fat.

Insulin also stimulates liver enzyme, HMG-COA reductase that causes your liver to make more cholesterol. This is the same enzyme that drugs like lovastatin, simvastatin and atorvastatin are designed to inhibit. Because of this, eating too much of sugar may increase your blood cholesterol.

Excess insulin may enhance the growth of smooth muscle cells which is turm clog up your arteries. People with high levels of insulin have higher rates of heart attacks - Insulin may also increase stress levels.

After many years of overproducing insulin, some people become insulin resistant causing them to secrete even more insulin to compensate in a vicious cycle. These people tend to have high triglycerides and low HDL levels. This condiction is linked to higher rates of heart attacks.

It has been found that people become more insulin sensitive when they follow a vegetarian diet based on complex carbohydrates.

Adult onset (Type II) diabetics usually are able to reduce and in some cases to discontinue insulin injections when they follow a vegetarian diet (of course under the supervision of their family physicians) and reduce the ravages of diabetes on the eye, kidney, heart and the nerves which can be reduced if people can normalize their blood sugar.

Courtesy Reversing heart disease By Dr. Dean Ornish.

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Health watch Question Box

Breast cancer and diet

Mrs. K. S. de Silva from Mattakkuliya in a letter to the Health Watch states: What is the relationship between breast cancer and diet? I have a daughter who is living in the states, and two of her daughters have developed breast cancer which the doctors there have attributed to the diet they have been taking. I would like to know the true position in relation to this.

Reply.

Dr. Roacsh Wiresinghe Colombo South Hospital to whom we referred your letter replies. A fact sheet for Health Professionals provided by the cancer control Branch of the California Department of Health services on this subject states.

Study findings

In a study we have done on children of immigrants Hawaii, where breast cancer is higher than in the native lands of the immigrants in this case Japan, we have found that the children suffer from cancer rates similar to the prevailing rates in the new country.

What has been found in this study is that when Japanese women immigrate to Hawaii their daughters born in the US have a 1 in 9 risk of developing breast cancer compared to a five fold lower risk if they were born in Japan.

This indicates that lifestyle or the environment influence the development of breast cancer, and diet is one of the major lifestyle changes that people make when they immigrate and thus it is suspected that diet is a factor for international variation in the incidence of breast cancer.

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Nutrition of adults and the elderly

From a paper read before the Nutrition Society of Sri Lanka.

by T.W. Wikramanayake, M.B,B.S. (Ceylon), Ph.D. (Glassgow), Hon. D.Sc (Peradeniya, Ruhuna and Glasgow), Hon. Fellow, Sri Lanka College of Pediatricians, Fellow of the National Academy of Sciences, professor emeritus, University of Peradeniya.

When I think of my friends and relatives who are anywhere near my age, I try to find reasons as to why, I at 84 yr, am fitter and happier than many who are nearing 70 or 75 yr. I have to be thankful that I did not contract any of the diseases that plague the aged until I was over 65 yr. That is the policy we should follow, viz, postpone as long as possible conditions such as osteoporosis, chronic rheumatoid arthritis, diabetes, hypertension, arterial disease and cancer that have any relation to environment, nutrition and lifestyle. Increased longevity without quality of life is an empty prize. Health expectancy is more important than life expectancy.

Osteoporosis

This condition is characterised by a low bone mass and deterioration of the architecture of bone tissue, resulting in increased fragility and fracture risk.

Of the 3.5 million women in Sri Lanka over 50 years of age about 20% suffer from osteoporosis. One out of three women over 90 years will sustain a hip fracture.

After menopause, calcium absorption is lowered and bone density falls due to withdrawal of oestrogen. Loss of calcium is assisted by a low calcium intake and low vitamin D intake (or synthesis, due to inadequate exposure of skin to direct sunlight). Increasing physical activity will retard the process.

In men, the prevalence is 30% in the 70 to 80 yr groups <40% in the > 80 yr groups >60% in the > 90 yr groups Bone mineral is laid down in a matrix of protein. Bone formation depends on the intake of protein, calcium, vitamin D, vitamin C, Vitamin K and on physical activity. Peak bone mass (PBM) is reached in early childhood and remains steady for years.

Bone is regularly broken down and also laid down, this remodelling occurring with physical activity and the pull of muscle on bone. Therefore a high calcium intake must be maintained throughout childhood and adolescence. Higher the intake of meat, the higher the loss of calcium in the urine. A recent study in Canada has shown a high incidence of osteoporosis among adolescents drinking large volumes of carbonated drinks, especially of cola drinks.

In the adult, bone resorption equals bone laid down so that there is a steady state.

During pregnancy, calcium is given to the foetus so that the intake has to be increased. During lactation calcium is passed on to the milk and the intake has to be greatly increased, throughout lactation, and a high intake maintained in between pregnancies.

The lesson to remember is that prevention of osteoporosis begins very early in life, during adolescence, when as high a peak bone mass as possible should be laid down. A high level of physical activity should be continued throughout life.

The calcium intake could be increased with a regular intake of milk and other dairy products. Bones greatly increase calcium intake. Small fish (sprats, salaya, hurullas) when fried could be eaten with the bones. For small children dried sprats, powdered and sieve, could be added to curries and the kiri hoddha.

Metabolic syndrome The other conditions I listed (other than arthritis) are included in what the WHO refers to as the Metabolic Syndrome, due to the Nutrition Transition that has already begun and is expected to accelerate during the coming decade, with the result that, if steps are not taken to prevent this epidemic, countries like Sri Lanka will have an enormous economic burden to bear in caring for and managing the growing population of the elderly, who will be suffering from diabetes, heart disease, stroke and cancer.

There is a general demographic, nutritional and epidemiological transition accompanying development and urbanisation. One facet of this transition is Nutrition Transition, characterised by -

1. A shift away from relatively monotonous diets (based on indigenous staple grains and/or starchy roots, locally grown legumes, vegetables and fruits and a limited amount of foods of animal origin) towards a more varied diet that includes more processed foods, more foods of animal origin, more sugar and fat and often more alcohol.

2. Reduced physical activity in work and leisure, both of which lead to an increase in body weight, and obesity, which leads to other chronic, diet-related diseases such as insulin resistance, which results in diabetes type 2, dyslipidaemia, cardiovascular disease (including ischaemic heart disease, hypertension and brain attack or stroke).

There is thus an epidemiological transition from dietary deficiency and infectious disease towards diet-related chronic diseases, generally late in life.

Two hypotheses have been proposed to account for the rapid increase in prevalence of the Metabolic Syndrome already seen in developed countries and now progressing in developing countries.

The Thrifty Genotype Hypothesis: When the food supply is unstable a person would maximize storage of energy to maximize the probability of survival. Genetic selection would favour energy-conserving genotypes in such environments.

The genome of our ancestors of the Palaeolithic period (about 40000 yr ago) suited the conditions under which they lived. Their food supply was intermittent, sometimes fast - or famine, and their genes would minimise renal loss of glucose and maximize energy storage, i.e. their genome will be "thrifty". A low intake of carbohydrate needs the secretion of minimum amounts of insulin, sufficient for synthesis of glycogen and fat and for preventing glycolysis and lipolysis till times of need, e.g. for fight or flight.

The mutation rate of nuclear DNA is about 0.5% for a million years. During 10000 yr since the dawn of agriculture there could have been less than 0.005% of change. The modern human is therefore nearly identical in his metabolism with pre-agricultural humans.

Residents in industrialised countries may be viewed as hunter-gatherers displaced over a period of 40000 years, to a foreign and a hostile environment, and exposed to psychological, nutritional and physical stresses of "space age" existence. The discord between their basic biology and their present life-style has resulted in the emergence of the major degenerative diseases which are responsible for 75% of all mortality in industrialised countries.

Similar adverse changes in disease patterns are taking place in Sri Lanka, in persons switching from rural to urban life-styles, and in rural Sri Lankans spending some years in employment abroad.

There is an increase in obesity and in lowered glucose tolerance, conditions that were not problems in the past. The Thrifty Phenotype Hypothesis. A second explanation, proposed by Hales and Barker (1995) is that most of the metabolic syndrome is programmed in utero. Intra-uterine undernutrition leads to low birth weight and thinness at birth and low weight at end of the first year. Children in this category run an increased risk of the metabolic syndrome in later life. The strongest relationships are found between birth weight and loss of glucose tolerance, hypertension, and raised plasma triacylglycerol (TAG) concentration. This relationship is enhanced by obesity.

The effect of low birth weight (LBW) is independent of social class, being detrimental even in those of a higher social order and are seen in a wide variety of different populations throughout the world. Therefore, there is something linked to low birth weight that predisposes to loss of glucose tolerance, and this factor is probably environmental, not genetic. Foetal and perinatal insults caused by undernutrition of the mother and her foetus probably results in metabolic changes that are adaptive to nutritionally stressful circumstances in utero.

As the child grows, the metabolic efficiencies that were necessary to cope with undernutrition become maladaptive to subsequent overnutrition, leading to development of abnormal lipid profiles, altered glucose and insulin metabolism and obesity. Such foetal programming does not by itself lead to increased morbidity.

Rather, it shifts metabolism such that LBW infants become more susceptible to obesity, type 2 DM, and CVD when faced with a richer, more energy-dense diet, reduced physical activity and increased adiposity, as children and adults.

Sri Lanka has the double burden, of undernutrition amongst pregnant women, infants and young children, and overnutrition and low physical activity amongst the urban and other affluent. A high prevalence of LBW babies makes it imperative that action be taken to reduce energy-dense diets and promote greater physical activity. The incidence of over weight and obesity in any country will be a function of the energy density of the diet and levels of physical inactivity.

Obesity is becoming a major public health problem in Asia.

In many households, underweight and over weight persons coexist. The speed of nutrition transition is increasing the likelihood that both underweight and overweight will coexist in the same household. Because shift towards energy-dense diets are occurring more rapidly among lower income households, an increasing proportion of such household will have both overweight and underweight members in the future. Therefore overweight and underweight are not opposing public health programmes and it is necessary for public health programmes to address simultaneously both underweight and overweight.

Action to be taken

Central to the Metabolic Syndrome is obesity, and efforts to control obesity will also lead to reducing the prevalence of the other components of the syndrome, such as diabetes, heart diseases and hypertension.

Genetic engineering?

The components of the syndrome represent disturbances of complex metabolic systems in which various genetic components are normal genes with unknown ramifications. Until these are well understood, action in terms of gene therapy will not be possible. Gene therapy is feasible for monogenic disorders, when genetic engineering (a conscious effort to improve the genome) might be considered.

What is needed here is "culture engineering".

To be continued

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Ensuring hand health Dr. Jayasuriya speaks

Even though our hands play a major part in our life, most of us pay little attention to ensure hand safety and hand health when getting about with our work in day-to-day living.

Dr.N.D.Jayasuriya on left

Dr. N. D. Jayasuriya, Consultant Orthopaedic Surgeon in Apollo Hospital, Colombo, has sent us a short account on this topic, which is of much educative value to our readers and the general public. Here's the account he wrote to us, and we thank him very much for the contribution.

Affections of the hand

The hand is one of the most important organs in the human body as it is with the hand that we physically interact with the environment around us. The hand is used for nearly all-physical tasks. Therefore any condition that affects the hand will have a profound effect on our life.

Affections can be divided into congenital disorders i.e. deformities that the person is born with and conditions that the person acquires due to injuries, infection or disease.

Common congenital conditions include extra digits (polydactily), webbed fingers (syndactily) and absence of digits. It is important to show these conditions to a properly qualified hand surgeon as early as possible as most of these conditions can be corrected before the child begins school.

Duplication of digits (polydactily) is the commonest hand anomaly and is seen in about 1:10000 live births and has even been recorded in biblical literature. Duplication of the little finger is the commonest followed by the thumb. These are usually genetically inherited. The extra digit may only have soft tissue or it may also contain bone and may resemble a normal finger. Therefore it is important to x ray the hand when a baby is born with an extra finger and if it is composed of only of soft tissue a ligature can be applied in the nursery to the finger and it will fall off.

The next common congenital hand condition is webbed fingers. Surgical correction should be done before the child is of a school age. Unfortunately this does not always happen in Sri Lanka and the child may be subjected to unnecessary mental stress. Recently I had a young woman who came to me to get her webbed fingers (ring and little finger) separated as she was getting married and she could not wear her wedding ring! Most surgeons will separate the fingers when the child is about 18 months.

Injuries to the hand account for approximately 40% of all injuries to the body and are common in developing countries like Sri Lanka where industrial safety standards are low.

Ideally all hand injuries should be treated in a hospital as incorrect treatment will lead to loss of function of the hand. Facilities are now available in major hospitals in Colombo and Kandy for reimplantation of severed (amputated) digits. If a finger is severed this should be quickly put in a plastic bag with saline and this bag should be kept in ice. It is important that the ice does not come in direct contact with the severed digit.

If this is done as quickly as possible the digit can be kept viable for up to 12 hours. Other common conditions of the hand include Carpal Tunnel Syndrome and Trigger finger. Carpal tunnel (CTS) is commonly seen in females and they usually complain of pain and numbness of the fingers, especially at night. This condition may be also seen during pregnancy and immediately after childbirth. In these instances only symptomatic treatment is necessary as the majority of women recover within 6 weeks after delivery.

This condition is also common in diabetics. CTS can be completely cured by a small operation under local anaesthesia. In trigger finger there is painful locking of the finger when the person tries to straighten the finger. Further attempts to straighten the finger will cause the finger to snap open. This condition is also common in diabetics. A steroid injection to the tendon sheath usually cures this condition. If steroid injections fail a small operation to release the trigger finger can be done.

Rheumatoid arthritis and Osteoarthritis can also affect the hand. In these cases the small joints of the finger and the joints of the wrist may be involved. Rheumatoid arthritis of the hand is usually treated initially with medication. However as the disease progresses there may be severe joint destruction leading to joint deformity and loss of function of the hand. The patient may not be able to do even simple things like feeding him or her self. In these instances the hand surgeon has a major role to play, as now it is possible to replace these damaged joints with artificial joints. Joint replacement will give the patient a pain free functioning joint.

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Organisation and service development initiatives for old age psychiatric services in Sri Lanka

by Dr. B. Somasunderam

Sri Lanka has a population of about 20 million and I understand that there are only about 25 psychiatrists practising in the health services which in my opinion is not sufficient for an adequate psychiatric service.

Five per cent of people over 65 years of age and twenty per cent of people over the age of 80 suffer from dementia, mainly Alzheimer's disease which presents as a gradual increase in forgetfulness, confusion, disorientation together with perceptual disturbances such as hallucinations and delusions and also behaviourial problems, for example aggression, agitation and wandering at a later stage of this illness.

In the health service in Sri Lanka the old age psychiatric service has not yet been developed. The people who suffer from senile dementia - Alzheimer's disease are cared for by their own families at home and are rarely seen by any psychiatrist. The carers go through enormous stress but continue to cope and they themselves can develop mental illness such as depression. The reasons for which are. a) The misconception in the families that the forgetfulness is due to old age and not due to a mental illness.

b) The obligation to look after their elderly relatives who suffer from mental illness is their own homes and not facilitate them to be seen by a psychiatrist for issues of both stigma of mental illness and indifference towards a situation which may result in their elderly parents being admitted to a psychiatric hospital for further assessment and treatment.

The above two issues are culture bound in most Asian countries

B. What I intend to do

I have already been in contact with Dr. Tametigama, Chairman of the Alzheimer's Disease Society in Sri Lanka explaining my intentions to develop the old age psychiatric services in Sri Lanka. I will be giving two lectures on Monday the 17th February 2003 in Ward 59 of the National Hospital in Colombo at 2 pm and again on Thursday 20th February 2003 at 2 pm in the Medical Faculty in Peradeniya.

These lectures that I will be giving and my future involvement with the development of old age psychiatric services in Sri Lanka will result in.

1. Raising awareness in both the public and the medical profession. I have arranged these lectures in collaboration with Dr. L.E. Rodrigo, the President of the Sri Lankan Psychiatrists Association in Sri Lanka who is also a Consultant psychiatrist. Raising awareness is an important issue in Sri lanka to understand about the mental illness in old age and also to come to terms with the stigma of mental illness. By raising awareness in the lay people this will result in them getting more involved in the development of the services, which is very effective.

2. Training psychiatrists. Dr. Tony Elliott who is a Consultant on old age psychiatry in Shropshire UK is the associate director of an organisation - Dementia plus. This organisation is affiliated to the Wolverhampton University and is involved not only in training doctors in old age psychiatry all over the UK but also it has links internationally with Universities. Dr. Elliott is a personal friend of mine and has been with me to Sri Lanka on a psychiatric conference organised by professor Nalaka Mendis of the Department of Psychiatry in Colombo in collaboration with myself in April 2002. This conference was held in the Taj Samudra Hotel in Colombo. Dr. Elliot loves Sri Lanka very much and wishes to extend his services towards the development of old age psychiatry.

3. Develop service initiatives in old age psychiatry. Dr. Elliot and myself in collaboration with Dr. Rodrigo, Psychiatrists, Voluntary Organisation, interested lay people and religious leaders will from a special interest group who will take forward the service initiatives towards developing the services in old age psychiatry initially for a small target population in Sri Lanka. Dr. Eliott and members of the Dementia Plus organisation, and myself hope to visit Sri Lanka once or twice a year to work towards achieving the above goals which would be a great asset to the Health Services in Sri Lanka. I very well know there are other Sri Lankan psychiatries practising in the UK who are already involved with the training of psychiatrists in Sri Lanka.

The writer is Consultant in Old Age Psychiatry/ President of the Sri Lanka Psychiatrists Association (UK)

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Alzheimer's Disease International (ADI) vice president to visit Sri Lanka

The Lanka Alzheimer's Foundation announces the anticipated visit of Dr. Nori Graham in late February 2003. She is an Honorary Vice President of Alzheimer's Disease International (ADI) and its immediate past Chairperson Prior to serving as the Chairperson of ADI, Dr. Graham served as the National Chairperson of the Alzheimer's Society of England.

During her six year tenure as the Chairperson of ADI the membership grew from 40 to 64 countries, with most new members coming from developing nations, including Sri Lanka.

Dr. Graham's primary interest is the inclusion of all countries in one global family working towards a commitment to address a common goal on the growing concern over dementia.

Dr. Graham's visit will highlight the work the Lanka Alzheimer's Foundation wishes to undertake. The Mission of the Foundation calls for building awareness of dementia, as a risk to elders. About 100 varying disorders of the brain have been identified. The most prevalent is Alzheimer's disease and collectively those disorders are called the dementias.

The stress and confusion of care givers who have undertaken the task of caring for persons afflicted with dementias are addressed by the Foundation. Almost 100% of those afflicted with the dementias are cared for in the home. The Foundation wishes to provide support, understanding and recommended care of those persons. Requisite training and education specific to the holistic needs of those being cared for and the caregivers are part of the Mission of the Foundation.

Dr. Nori Graham is a graduate of the University of Oxford and University College Hospital Medical School, London. She is Emeritus Consultant in the Psychiatry of Old Age at the Royal Free Hospital. Over the last twenty years she has run a comprehensive service for elderly people with all forms of mental disorders, based at the Royal Free Hospital, London. She is currently Mental Health Consultant to Nightingale House, a large nursing home in Clapham, London. In 1996 she was awarded an honourary doctorate for public service by the Open University.

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correcting an error

We had this letter from Dr. Harold Gunathilake of the Oasis Hospital Colombo, thanking the Health Watch for correcting an error he had made in an article written by him and published in this page on 24.1.03 on Omega oil. He writes to us.

Correction of Omega-3 Oil dose

I would like to write a note regarding the mistake pointed out by Prof. Emeritus, University of Peradeniya, appearing in the article on "Food based dietary guidelines", on Health Watch on Friday 24th January 2003, in Daily News, where I had quoted 1,000 gms of Omega 3 Oil capsules to be taken daily, in a feature article appearing in Sunday Island, when it should read as 1,000 mg. The error is regretted, and I am thankful to the Professor for pointing it out. The daily recommended dose is 1,000mg three times a day, Entric coated capsules are available in other countries. These oils may cause gastric reflux, diarrhea and other gastro - intestinal upsets.

Hence, the entric coated, and not gelatin coated capsules, are more friendly.

- Dr. Harold Gunathilake, Oasis Hospital (Pvt) Limited, Colombo 5.

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