Sunday, February 17, 2013

Varicose veins – is there a cure?

What are varicose Veins?

Normally, varicose veins are an outcome of wear and tear of the body. Just as different organs/parts of the body experience some loss of efficiency with passing years/decades, a similar outcome in the veins of the lower limb leads to this condition of varicose veins.

How does one identify the problem of varicose veins?
The affected veins get enlarged, are seen as soft swellings just beneath the skin – these are called as varicosities.In efficiency of these veins leads to slowing down of the venous circulation, resulting in pooling up of blood in the lower limbs. This is what causes the complaints of ache, heaviness, and feeling of exhaustion – that is aggravated with physical activity.

Which part of the body is usually affected by varicose veins?
The lower limbs are the part of the body where anti – gravity movement for the circulating blood to reach the hearth is the maximum. This is why effects of weakness of the veins are seen first in the body in this region.

Though this is problem due to wear and tear of the body, what else can aggravate the problem?
There may be other reasons besides age that can aggravate this problem. Any problem causing pressure on the lower limb veins in the groin or abdomen can cause this problem much earlier, besides a few birth defect problems. This is the reason why varicose veins may be seen in the groin or lower limbs in the last few months of pregnancy.

The pattern of the varicose veins can usually alert the doctor to the possibility of any additional underlying problem, besides inherent weakness of the veins

How can this problem be prevented? 
There are no blood tests or any other tests that can detect these problems before they develop. Once they develop, the soft bluish swellings are the earliest indicators – other than the symptoms that may suggest the problems. A Doppler Scan can identify the altered pattern of problems in the venous blood flow.

How can this problem of varicose veins be tackled?
If there is some obvious problem causing external pressure on the veins, that needs to be tackled. If not, the problem is due to internal weakness of the veins – called Primary Varicose Veins, which is the most common situation.Such problems can only be controlled, as the weakness that has set in cannot be reversed. However, the changes (problems) due to the weak veins can be controlled by some simple means, such as:
  • 1.       Use of well fitting external support stockings.
  • 2        Avoid prolonged periods of standing, which will increase the venous poling in the lower limb.
3.       If the weakness in the veins is causing major leakage of blood at any point, the particular area needs treatment by intervention – to offset the local effects of stagnated blood and poor circulation.

How to cure this problem?
Strictly speaking, cure for this problem does not exist in modern science. All existing treatment options are directed towards controlling the problem or the damage that results due to it.
This makes the preventive measures (to prevent further damage) even more relevant – most important of this is use of correctly fitting stockings. Interventional therapy is sometimes useful to correct some specific local weakness of severe variety. This involves blocking of inefficient venous pathways, and leavingonly the unaffected OR more efficient ones to carry the venous blood to the heart without causing symptoms.
This intervention can be open surgery, sclerotherapy OR laser surgery.
Neither of these can in any way change the chances of the remaining veins from developing the same problem later on.

This is exactly why early detection, prompt evaluation and strict use of compression therapy (before any further problems develop) are the cornerstones of therapy of Varicose veins.

Obesity treatment – why does it fail?

Obesity has been described as an epidemic of modern times – an outcome of junk food, poor exercise and unhealthy lifestyle. Though Obesity, as a disease, was initially considered a rich man’s disease, affecting the population of the developed Western world, it was soon realized that countries like India, that have a rising population of prosperous individuals, was competing with the West for the total number of people suffering from Obesity. Unfortunately, the authorities are yet to realize this fact and hence attention to this health problem is highly inadequate.

Enough has been written about the severity of the possible problems that develop due to Obesity, the need to correct the problem, and the potentially life threatening issues that may develop. Thus once the given person/their doctor conclude that there is a problem that needs treatment, the person is usually asked to reduce food intake, do exercise and lose weight! That’s it. As if everyone knows how to rule out underlying problems that may have caused the fat accumulation, revamp their diet OR identify problems or limitations related to physical exercise! It is now easy to see why ‘asking someone to loose weight and control intake is doomed to fail’

So, how does one go about to ensure that these efforts to tackle the problem will move in the right direction?
Identify if any underlying diseases have caused the weight gain: For people with Morbid Obesity – BMI > 36-37 In Indians – a clinical and hormonal screening is needed for this purpose. Trying to reduce intake or doing exercise in this scenario is utterly useless.

Have a discussion with a dietician: Once background problems are ruled out, people with mild to moderate Obesity – BMI between 27 – 37 – need a discussion with a dietician decide details about a diet that cuts down on the caloric intake, without loss in the nutrition or satiety value. Calories can be reduced without decreasing the quantity of food, which is needed to ensure the person does not get fed up with the diet and give up his efforts. Simply trying to cut down the food intake cannot be continued for long.

Identify problems in exercising: before exercise is recommended, it is essential to see if the deformity due to the obesity permits the person to exercise at all! There have been people with huge ‘pot bellies’ who cannot be expected to begin exercising at all – unless they are able to bend and move about with reasonable comfort. Another person, a lady with normal body weight, but excess fat in just the arms, had a very awkward feeling of heaviness just below the shoulders – she was unable to lift even the lightest variety of dumbbells at the gym. Obviously, both these groups of people need something else.

Generalized measures for local obesity: options such as diet control, exercise or even the medicines to loose weight work by shedding excess fat from the entire body. Neither of these can work on one specific area – as in someone with local fat excess – say tummy, hips, arms or thighs (called local Obesity) – OR with General Obesity by disproportionate fat excess in some areas. Such cases need reliable measures to tackle local fat. This is what the Body Reshaping procedures can offer, once approved by a competent Plastic Surgeon. Depending on whether the local fat excess is super added to Generalized obesity, these Cosmetic surgery procedures may be done alone or in coordination tin Bariatric Surgery.

Thus simple measures can be effective when used in the right situation – if not, treatment failure is very likely,  and and bad name resulting to the physicians involved, the person using it and even the treatment itself!

Sunday, February 3, 2013

A Surgeon's Sojourn - into Zanskar Valley, Ladakh

Do professionals need a break?

A recent legal document reminded me of the definition of a professional person – in the eyes of the law - Someone who works in an area where ordinary men do not venture.

Thus, whatever the sphere of life may be, the services of a professional person are always highly sought. In this background, there are a couple colleagues I am aware of, for whom taking a break from his/her highly successful professional life is something they cannot imagine. Will society not be deprived of the services of the professional – for the period of his unavailability?

Well, I belong to the breed of professionals who think it is essential to take a break – indulging in something that borders the wild, allows you to let your hair down (or up as seen in my example further ahead), that disconnects you completely from your existing world. My forays in this context have been in the field of Mountaineering and Hiking.

My exposure to this field began right from my days as a professional ‘in training’ – read medical school… the experiences gained have changed my life to such an extent that I would not hesitate to dedicate a large part of my professional achievements to the lessons learnt during the breaks I took.

Having reasonably settled down in the last (and the longest) phase of my Medical Career since a few years – my Medical Practice – I finally felt it was time to come out of my self-imposed exile from the Mountains.
With this in mind, three of us college friends set off on a venture to experience the harsh environment and physical challenges in the heart of the Zanskar Valley – a trek up a river of ice, on the frozen Zanskar river -  in Ladakh Province at the northern limits of our country. Thanks to our young but supportive families, we set to explore not just the mountains, but new limits to physical endurance and boundaries of our inner self.

As we set off on the venture, the thought did play in our minds -Why would someone ‘taking a break’ give up a life of comforts and take on new challenges and face difficult times?

The obvious answer is “You must be off your rocker...”  However, with our past experience to support us, we went on…

We faced temperatures of upto -30OC on a regular basis, but beyond a point it did not really matter. The presence of a colleague who will support – no matter what – was enough to take on the challenge. 

Ice formed on eyelashes and face of the author - from condensation of body vapour in the breath and discharge from the eyes...

Cut off from all forms of modern communication with the outside world, the entire duration of the venture was a unique experience. Finishing dinner 7PM daily, we had ample time to reflect till 7AM next morning, while we fought off the cold, within our tents and sleeping bags. Though we left behind worried families, without any idea of our progress, it gave each of us an opportunity to introspect and reorganize our priorities, on our roles in the fast paced life and materialistic world.

The group of friends in front of a …frozen waterfall...

Standing water has the least kinetic energy, flowing water some more, while falling water has the most. The ability of the environment to freeze flowing water speaks of it's intensity...

The knowledge that our soldiers, guarding the country a few kilometres away, on the icy tops of the Siachen... at 24,000ft and – 700C...  was enough to make our effort seem insignificant. While our experience made us realize the enormity of their sacrifice, it also gave us the confidence that we low-landers coming from sea level did have it in us to cope with challenges thrown at us from 11,000.


With Sepoy Ravi Pandey at Rohtang La - 18,350ft altitude. He was returning from Siachen after his 5 month stint at 24,000 ft.


                                             Negotiating a rocky mountain stretch
                                                  to bypass a stretch of tricky ice

As in the life of a Surgeon, a Plastic & Cosmetic Surgeon in my case,  there is no end to how much an outcome can be improved, by meticulous planning and attention to the details. These attributes were immensely useful on the mountains as well. While in the former scenario, it had an impact on someone else’s life; here it was our own!
We three pals had been fortunate to have been exposed to the mountains way back in our teens, while we began our stint at Medical School at Pune. Looking at few of our colleagues on the venture, one with a post-polio leg shortening, one with a traumatic ankle deformity and others who were well into their sixth decade – one even hitting the seventh decade of life -  made us value the opportunities that our short life had given us so far!

The rarefied atmosphere and unconventional terrain converted even the daily tasks of life into a huge effort – whether it was performing the morning ablutions, or maintaining body hygiene. Coming out of and re-entering the multi layered sleeping bag to attend nature’s call at night was such a drudgery, we had one colleague even remark – “never again shall i ever complain about making my bed every morning at home”.

...and coming back to the question posed at the professionals need a break – that too indulging in something which involves such hardships? Well, we realized that taking on new challenges and difficulties is a requisite for progress in life... the experience gained and endurance achieved, in solving problems in a field of one’s choice, can be fruitfully used to address issues in daily life, in less pleasant circumstances... as some wise man has said, “The only constant thing in life is Change”. I believe such experiences leave us better placed to bring about this change!

The author at 18,000 ft above sea level...
in the wilderness of the Ladakh province

We returned to the plains, having strengthened old bonds and made newer plans, to return back to the mountains another time!

 for more images on the same, please click on