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8th March 1998

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By-passing by-pass surgery

Those who believe that heart attacks can be averted only by fantastic sounding surgical and technical methods such as "by-pass surgery'' and ''balloon - angioplasty'' have better news, even in this part of the world.

Mr. RaddlgodaThe following is the story of one patient, who says that his doctor's cardiac management techniques have miraculously converted him from a hobbling man who couldn't "walk hundred yards on a flat cement floor'' into a "man who could walk to world's end and back". ( ..the feat was accomplished by him and his family around a month back.) The fact is that , seven years ago, the patient, Mr. Asoka Raddalgoda, thought that his world had come to an end.

His prognosis was bad, because he had 100 per cent blockages in one coronary artery ( a coronary artery supplies blood to the heart muscle.) Other coronary arteries also had similar lesions, caused by blood clots, blocking a significant percentage of the free passage of blood in these arteries.

But , the consultant cardiologist who treated Mr. Raddalgoda, ( a former Senior Registrar of the Cardiology Unit of Colombo, now a consultant cardiologist of a leading government hospital), determined that he doesn't qualify for surgery because of his age. The alternative was a regimen of "cardiac management and assessment''. This involves a delicate process, which is carried out with the care and concern of the physician. One of the major components of the regimen, is to accompany medication with adequate limb movement, ( such as walking ) with the distance increased in stages until limb movement can be accomplished with no chest pains felt.

At the beginning, the process is such that no swinging of arms is advised, even to scrub one's body while showering.

Essentially there are two types of persons who are at high risk of developing ischaemic heart disease those with certain risk factors such as smoking, high blood pressure, diabetes, high cholesterol and a family history of heart disease.

The other category are those who have already developed heart disease such as a heart attack, or what is called angina.

The patient referred to in this account belongs to the second category, having developed unstable angina 7 years ago, and having staged a miraculous recovery with proper medication based upon cardiac assessment and management.

At the beginning, essentially both categories of patients referred to above, need to have their cardiac status assessed by laboratory tests blood tests, stress tests echo cardiography etc.,. By these methods, those who have developed heart disease without their knowledge, are able to identify potentially treatable risk factors, whereby they can avoid the progression of heart disease.

The other category of patients with established heart disease or acute angina can determine the severity of the disease, and decide whether the most suitable mode of treatment is surgery, or medical treatment.

Each person treated in this way will require detailed observation and assessment over a considerable period of time by the attending physician. Their cardiac management should be tailored to their own individual requirements.

The "patient'' referred to in this article is no longer a patient in the classical sense, though he continues with his assessment and management regimen. He feels the results achieved by him over a period of seven years, closely monitored by a consultant physician, is living proof of the benefits of cardiac management, for patients not fit for surgery, but would respond to other medical treatment.

He believes that there is a great deal of merit to be gained by introducing the concept of cardiac management and assessment to others.

The regimen to repeat is to help people who are unfit for surgery to get over heart disease, and live longer. Though there is no guaranteed success in any method, Mr. Raddalgoda is testimony to how the method works. He invites interested parties who (genuinely) have heart disease to contact him at telephone 841472 before 8 am and after 8 p.m.

Advice on how to get to a doctor who practices assessment and management will be given to callers free of charge.

Alcohol vs sex and fertility

The anaesthetic ef fect of brandy, so useful to the 19th-century surgeon, can equally well dull a lover's senses before he, or she, climbs into bed. Transitory impotence after heavy drinking is always thought to be a male problem, but a woman who has drunk to excess-perhaps only three or four glasses of wine - may lose not only her ability to have an orgasm, but also her ability to respond.

The effect of even small quantities of wine on female sexual response was explored by a colleague who worked as an assistant at my practice in Norfolk. He and his partner stayed with us for some months and we dined together each night. At first I could not understand why his usually healthy appetite for wine had become so controlled. After a couple of glasses all round, he would announce that we had had enough. It was a week or two before he admitted the truth: it took two glasses of wine to relax his girlfriend to the point where she wanted sex - any more and she was incapable of enjoying it.

The long-term effects of drinking on the reproductive system are even more significant. Alcohol taken in excess for a number of years produces physical changes in both sexes. Men can suffer from testicular atrophy shrinkage of the penis - a loss of body hair and gynaecomastia (enlargement of the breasts). The body shape changes, too: there is an acceleration of the normal redistribution of fat and loss of muscle that occurs in both sexes as they grow older. The arms and legs become skinny and the chest and abdomen increase in girth. Men develop a pot belly. Research has shown there is a direct relationship between the possession of a "beer belly" and the likelihood of being impotent.

The popular explanation for the long-term changes that occur in the male reproductive system is that the oestrogen/ testosterone balance is upset because of hormonal changes secondary to liver disease. Oestrogens are the hormones that determine femininity; testosterone gives a male his distinctive physique and personality. It is supposed that the damaged liver fails to metabolise adequately the oestrogens that circulate in all men. In addition, the testosterone is metabolised differently to oestradiol.

The combination of these two processes decreases the amount of testosterone and increases the oestrogen. And not all testosterone is free testosterone; that is, readily available in a form the tissues can use. In men with liver disease, much of the testosterone is not free, and so is comparatively useless at imparting male characteristics.

A quick glance around any dinner table will usually reveal that many men have "liver palms", a sign of liver disease. The fleshy portions of the palm are bright red while the back of the hands are pale, so that there is a "Plimsoll line" between the two sides. This condition is seen not only in heavy drinkers but also in women who are pregnant or taking the Pill, two states in which high levels of oestrogen are circulating.

The effects of heavy drinking on men are not all related to liver damage: high blood levels of alcohol also have a directly damaging influence on testicular function. The Leydig cells in the testes, which secrete testosterone, are vulnerable to alcohol. So in heavy drinkers not only has the metabolism of testosterone and oestrogen been altered, but the actual secretion of testosterone reduced.

The changes in a man are not confined to anatomy and physiology; his psyche is also altered. The heavy drinker loses his libido as his testosterone levels fall. High bloodalcohol levels also damage the semeniferous tubes, where the sperm are formed, thus impairing spermatogenesis.

Research published in the journal Gastroenterology in 1974 showed that 80 per cent of alcoholics were infertile. Consistently heavy drinking affects the sperm count, and more of the sperm are of abnormal form. Sperm motility is also reduced: they are less likely to swim strongly and in the right direction. To achieve maximum fertility, sperm have to swim with the determination of a greyhound springing from the traps.

Although less obvious, the effects of excessive alcohol are equally trying in women. There is some shrivelling of external genitalia and a loss of pubic and other bodily hair. The drinker tends to develop a pot belly, large breasts - the result of higher oestrogen levels - and skinny arms and legs. But women who drink in moderation need not fear that their female physical characteristics will disappear prematurely.

As always, the problem is that warnings about drinking to excess are directed at women who drink in moderation. This is demonstrated by the general approach to osteoporosis. No family health guide or women's magazine fails to mention the fact that alcohol contributes to osteoporosis, but few add that, whereas alcoholism and alcohol abuse are accepted risk factors, there seems to be little association between bone density and light to moderate alcohol intake. Studies have shown that bone density in post-menopausal women is not affected by modest drinking. As these studies have examined women who drink 5 to 14 units a week and found no significant increase in the incidence of hip fracture, it seems safe to tell women that a daily drink or perhaps even two - will not make their bones brittle.

As for women who drink during their reproductive years, the main concern has been for the babies they might conceive. The level of anxiety in the US and Canada about drinking during pregnancy seems to the British to be out of all proportion. No one denies the existence or seriousness of Foetal Alcohol Syndrome (FAS) which cause a child born to a heavy-drinking - usually socially deprived - mother the appearance of a mentally retarded, small-headed pixie. But it is said to occur only in women who regularly drink more than 2 to 2.5 ounces (at least four units) of alcohol daily throughout early pregnancy. And population studies have shown that there is a greater risk of FAS among inner-city mothers. In 1987 a study carried out in America of 32,870 women, nearly half of whom had taken alcohol during pregnancy, failed to find one case of FAS. Another survey showed the syndrome had a direct relationship to prosperity; it was almost absent in the presumably better-nourished sections of society.

Binge drinking in pregnancy has also been studied, and there is evidence that, in some rare cases, as few as five units in a single sitting may have contributed to a low birth weight. But in 40 years of medicine, I have looked after many mothers who knew their babies were conceived after an evening's heavy drinking, or who had drunk heavily before they were even aware that they were pregnant, and none of the children was adversely affected. Surprisingly, a 1995 report showed that women who were light drinkers in pregnancy had slightly heavier babies than those who did not drink at all.

I therefore feel confident in telling pregnant women that they need not be teetotal, but that they should drink only at formal or special occasions, with a meal and should not exceed two units in an evening or seven in a week.

(Courtesy The Times)

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