Monday, March 23, 2009
Friday, December 12, 2008
IMAGE - nov- dec.2008
FROM THE EDITOR’S DESK
AUDACITY OF HOPE ALONE CAN LEAD TO QUANTUM OF SOLACE !
Audacity of Hope coupled with Action – the ‘karma’, alone can lead to Quantum of solace. That is what was achieved thro’ IMA morcha, protesting violence against doctors.
After the successful march, an opinion was voiced about meeting ‘might with might’ ; another senior colleague thought, brain better over brawn – ‘acknowledge, accept mistake – to err is human – and approach Police & Legal system to solve the vexed issues’. I personally acknowledge both the views, combining it form a “MEDICAL LOBBY” working at peacetimes with Police, Press & Politicians & coming handy in Panic times as well. For this an organized strategy has to be in place, something very much akin to Jewish lobby in America. The Jews have managed to look after their interests inspite of being persecuted & victimized for so long ; physically surrounded as a small nation, Israel , by Muslim nations ; arch rivals & foes from historical times. We Indians have taken a cue & only recently started lobbying effectively, looking after our interests. And this networking has to be done from a position of strength – economic, intellectual, military whatever it takes. It definately cannot be done from a position of weakness, as victims which tantamount to almost begging. And this sense of collective empowerment does throw up ‘Charismatic’ leaders who can transcend petty interests to lead the whole society / nation with the audacity of hope of a Gandhi, Mandela & now an Obama. I sincerely wish Raj Thackeray, Uddhav Thackeray, Rahul Gandhi & Mayawati show similar “O” ‘karishma’ to not only ‘Navnirman’ a state but the whole country, transcending language, caste , creed etc. We have remained divided, in the name of “Unity amidst Diversity” for 60 plus years – let us acknowledge we are a divided house – ACCEPTANCE is the first step towards transformation.
That brings me home to our own medical fraternity. Aren’t we a divided lot, looking after our petty interests, even at times at the cost of patient’s interests – undercutting opinions, advise & price ; exaggerating colleague’s mistakes just to boost self image – Ego with that one patient / family alone ; at the cost of our own fraternity & society. All our lobbying will come to a naught if we have daggers hidden in our cloaks (or scalpels in aprons ! ) all the time – hunting as hyenas while appearing to run with hares ! I think we all have to use our individual good will with our patients - families, going beyond petty politics, for common good not only of the society but ourselves as well – they say Charity begins at home !! “Let us be the change we want to see in the world”, to quote Mahatma Gandhi.
While drawing inspiration from Jews (they have established themselves not only in business enterprises but academically also with maximum Noble Prizes to their credit), little did I know that 26 / 11 was waiting to happen…. The terrorists bullets have indeed shook the collective psyche of the nation. The need of the hour is awakening of the country, the SYSTEM before it falls into stupor once again – a 2nd freedom struggle so to speak! The first freedom fight was led by intellectuals, the lawyers, the likes of Gandhi, Nehru, Rajendra Prasad etc. Can WE, Doctors & other professionals & intellectuals rise to the occasion to lead the 2nd freedom struggle; freedom from apathy, complacency, a “chalta hai” mindset which is letting the country sink.
How to reach out to the society to help bring about a transformation ? Remember, we doctors are uniquely placed vis-a- vis other professionals & intellectuals. We by the virtue of our profession are able to interact with a cross section of the society , right from lower socioeconomic class to upper strata. Thus we are in a enviable position to ‘influence’ all sections of the society, to bring about a social change, whether that be, to vote on election day or population control. In true sense we will act as the guardians of the health of the society.
Nothing is so strong as an idea, a thought whose time has come in the human consciousness. Let us use our good will with our patients, our contacts & involve them in this awakening to create a social movement for better governance & a safe society, “where the mind is without fear & the head is held high……into that heaven of freedom, my Father let my country awake”.
Come, let us take the first step in “ MAHAN RASHTRA NAVNIRMAN”.
After the successful march, an opinion was voiced about meeting ‘might with might’ ; another senior colleague thought, brain better over brawn – ‘acknowledge, accept mistake – to err is human – and approach Police & Legal system to solve the vexed issues’. I personally acknowledge both the views, combining it form a “MEDICAL LOBBY” working at peacetimes with Police, Press & Politicians & coming handy in Panic times as well. For this an organized strategy has to be in place, something very much akin to Jewish lobby in America. The Jews have managed to look after their interests inspite of being persecuted & victimized for so long ; physically surrounded as a small nation, Israel , by Muslim nations ; arch rivals & foes from historical times. We Indians have taken a cue & only recently started lobbying effectively, looking after our interests. And this networking has to be done from a position of strength – economic, intellectual, military whatever it takes. It definately cannot be done from a position of weakness, as victims which tantamount to almost begging. And this sense of collective empowerment does throw up ‘Charismatic’ leaders who can transcend petty interests to lead the whole society / nation with the audacity of hope of a Gandhi, Mandela & now an Obama. I sincerely wish Raj Thackeray, Uddhav Thackeray, Rahul Gandhi & Mayawati show similar “O” ‘karishma’ to not only ‘Navnirman’ a state but the whole country, transcending language, caste , creed etc. We have remained divided, in the name of “Unity amidst Diversity” for 60 plus years – let us acknowledge we are a divided house – ACCEPTANCE is the first step towards transformation.
That brings me home to our own medical fraternity. Aren’t we a divided lot, looking after our petty interests, even at times at the cost of patient’s interests – undercutting opinions, advise & price ; exaggerating colleague’s mistakes just to boost self image – Ego with that one patient / family alone ; at the cost of our own fraternity & society. All our lobbying will come to a naught if we have daggers hidden in our cloaks (or scalpels in aprons ! ) all the time – hunting as hyenas while appearing to run with hares ! I think we all have to use our individual good will with our patients - families, going beyond petty politics, for common good not only of the society but ourselves as well – they say Charity begins at home !! “Let us be the change we want to see in the world”, to quote Mahatma Gandhi.
While drawing inspiration from Jews (they have established themselves not only in business enterprises but academically also with maximum Noble Prizes to their credit), little did I know that 26 / 11 was waiting to happen…. The terrorists bullets have indeed shook the collective psyche of the nation. The need of the hour is awakening of the country, the SYSTEM before it falls into stupor once again – a 2nd freedom struggle so to speak! The first freedom fight was led by intellectuals, the lawyers, the likes of Gandhi, Nehru, Rajendra Prasad etc. Can WE, Doctors & other professionals & intellectuals rise to the occasion to lead the 2nd freedom struggle; freedom from apathy, complacency, a “chalta hai” mindset which is letting the country sink.
How to reach out to the society to help bring about a transformation ? Remember, we doctors are uniquely placed vis-a- vis other professionals & intellectuals. We by the virtue of our profession are able to interact with a cross section of the society , right from lower socioeconomic class to upper strata. Thus we are in a enviable position to ‘influence’ all sections of the society, to bring about a social change, whether that be, to vote on election day or population control. In true sense we will act as the guardians of the health of the society.
Nothing is so strong as an idea, a thought whose time has come in the human consciousness. Let us use our good will with our patients, our contacts & involve them in this awakening to create a social movement for better governance & a safe society, “where the mind is without fear & the head is held high……into that heaven of freedom, my Father let my country awake”.
Come, let us take the first step in “ MAHAN RASHTRA NAVNIRMAN”.
JAI HIND.
Dr. Hemant Agrawal
Dr. Hemant Agrawal
PRESIDENT’S MESSAGE
My dear Friends & Colleagues,
At the outset, I sincerely apologize for the delay in bringing out this issue of ‘IMAGE’. The delay occurred due to Technical reasons arising out of change in Editorial Team. We welcome our newly appointed Editor Dr. Hemant Agrawal, a very dynamic personality. With this and the forthcoming issues, you will notice drastic changes in the quality and contents of ‘IMAGE’. We sincerely hope the new Editor rises up to your expectation.
Friends, the year 2008 saw two major calamities:
The economic slowdown due to global recession, and
The ugly face of terrorism.
Even though economic recession originated in the U.S.A., its effects are felt by us, directly or indirectly. The market is tight and there is liquidity crunch. In a way, we are also affected – patients are holding on and adopting a wait-and-watch policy in elective procedures. Emergency work, of course, will remain unaffected. Salaries and payments are expected to slowdown. Still confined to the West, we are not as much affected as they, and we hope to recover soon.
The biggest challenge facing us today is terrorism. Terrorists have tried to hold our city to ransom. Many innocent lives have been lost and extensive damage has been done to properties, including the heritage ones. The aim of the terrorists is to create panic, cripple the economy and divide the people. Even though there is temporary loss of great magnitude, our Government has shown the terrorists that there is no room for negotiation and terrorists will be dealt with firmly. We applaud the role of our brave police force, army, navy and NSG Commandos in the fight against terrorists, a number of whom have sacrificed their lives in the process. We deeply mourn for them.
Friends, we are concerned with the social issue as well apart from medical activities. At this hour of grief and loss, we request you all to contribute generously to the Fund created for the families of the deceased policemen in our Suburbs. Your contribution will be duly acknowledged in our Circulars and the next issue of ‘IMAGE’. Let it be known that by their dastardly act, the terrorists have only united us together instead of dividing us.
Together we stand united in this period of grief and pledge that no act of terrorism can shake our loyalty and faith in our democratic country. We are determined to root out the evils of terrorism.
JAI HIND, JAI MAHARASHTRA
LONG LIVE IMA MULUND
At the outset, I sincerely apologize for the delay in bringing out this issue of ‘IMAGE’. The delay occurred due to Technical reasons arising out of change in Editorial Team. We welcome our newly appointed Editor Dr. Hemant Agrawal, a very dynamic personality. With this and the forthcoming issues, you will notice drastic changes in the quality and contents of ‘IMAGE’. We sincerely hope the new Editor rises up to your expectation.
Friends, the year 2008 saw two major calamities:
The economic slowdown due to global recession, and
The ugly face of terrorism.
Even though economic recession originated in the U.S.A., its effects are felt by us, directly or indirectly. The market is tight and there is liquidity crunch. In a way, we are also affected – patients are holding on and adopting a wait-and-watch policy in elective procedures. Emergency work, of course, will remain unaffected. Salaries and payments are expected to slowdown. Still confined to the West, we are not as much affected as they, and we hope to recover soon.
The biggest challenge facing us today is terrorism. Terrorists have tried to hold our city to ransom. Many innocent lives have been lost and extensive damage has been done to properties, including the heritage ones. The aim of the terrorists is to create panic, cripple the economy and divide the people. Even though there is temporary loss of great magnitude, our Government has shown the terrorists that there is no room for negotiation and terrorists will be dealt with firmly. We applaud the role of our brave police force, army, navy and NSG Commandos in the fight against terrorists, a number of whom have sacrificed their lives in the process. We deeply mourn for them.
Friends, we are concerned with the social issue as well apart from medical activities. At this hour of grief and loss, we request you all to contribute generously to the Fund created for the families of the deceased policemen in our Suburbs. Your contribution will be duly acknowledged in our Circulars and the next issue of ‘IMAGE’. Let it be known that by their dastardly act, the terrorists have only united us together instead of dividing us.
Together we stand united in this period of grief and pledge that no act of terrorism can shake our loyalty and faith in our democratic country. We are determined to root out the evils of terrorism.
JAI HIND, JAI MAHARASHTRA
LONG LIVE IMA MULUND
Dr. V. Seetharaman
ONE DAY TOKEN STRIKE & SILENT PROTEST MORCHA ON 10TH OCTOBER 2008
On 7th October 2008, a meeting of all local IMA Branch representatives was convened at Mumbai IMA office at Haji Ali. President Dr. V. Seetharaman and Secretary Dr. Nilesh Pandya represented Mulund IMA. In the meeting it was conveyed that a one-day token strike be undertaken by all local IMA Branches on 10th October 2008, as directed by IMA – Maharashtra State to protest against attacks on Doctors by hooligans. We were also requested to organize peaceful protest ‘Morchas’ to pressurize the Government to pass a Bill making attacks on Doctors a non-bailable offence. Such an act already exists in states like Andhra Pradesh and IMA MAH wanted the State Government to pass an ordinance and sign a bill at the earliest to this effect. It was also decided to launch a mammoth protest ‘Morcha’ from St. George Hospital to the Collector’s office on the same day afternoon to submit a Memorandum to the Government officials.
In spite of very short notice, the office bearers of Mulund IMA worked hard to get maximum support for the strike and protest march. Pamphlets announcing the strike were distributed, Protest banners made in many languages, Black Bands distributed , Mass SMS contact made, personal phone calls & visits to colleagues followed ! Police permission was obtained for the protest march & media was informed. All this was done on a public holiday, Dussera with limited man power !
Despite the short notice of one-day, the response to the strike was tremendous, with approximately 200 Doctors ( including many senior ones ) assembling at our Presidents Hospital, wearing black bands and displaying the Banners. The Secretary Dr. Nilesh Pandya briefed the members about the strike and the protest ‘morcha’ followed by President’s address.. The Members were requested to stage a silent protest ‘morcha’ to the Police Station in groups of three. The ‘Morcha’ started from Devidayal Road and moved towards ‘Panch Rasta’ and then along M.G. Road towards the Mulund Police Station. Many Senior Members joined the ‘Morcha’ all along the route. The Members were escorted by the Police who were helpful all throughout. The media and the press kept interviewing the Members all along the route. Neither the traffic was disrupted nor the pedestrians inconvenienced all along the route .
The ‘Morcha’ ended at the Mulund Police Station where a Memorandum, regarding violent attacks on doctors with an appeal for timely action against miscreants was submitted to the Police authorities. The officials were requested to do the needful in the matter eventually paving way for passing a Bill making attacks on Doctors a non-bailable offence.The police officers accepted the Memorandum and offered us full co-operation and assurance to maintain law and order.
The President briefed the members about the meeting with the police officials. The members appreciated the co-operation and support of the police officers towards our cause. Senior members like Dr. Mukhi, Dr.Davda, Dr. Upasani & others shared their views on the issue. The Senior Police officer also addressed the members and offered his departments full co-operation. Members were assured of immediate police action at any time of the day in case of assault by hooligans. The Senior Police Officer’s talk was well received. Thereafter the press and media coverage was given by the office-bearers for the public to know the details about the strike and the protest ‘morcha’.
The morcha ended with the Secretary Dr. Nilesh Pandya offering a vote of thanks. He requested the members to join the main ‘Morcha’ of Maharashtra IMA at Mumbai. Accordingly a group of members led by the President Elect left with protest banners to represent Mulund IMA at the State level. Members were requested to keep their OPD and routine work closed for the day; emergency work was permitted wearing black bands of protest. Overall, the response to the call for the strike and protest ‘Morcha’ was excellent. We sincerely thank the members of the Mulund Branch of IMA for co-operating with us despite a very short notice and making it a grand success.
JAI HIND JAI MAHARASHTRA
LONG LIVE IMA MULUND
In spite of very short notice, the office bearers of Mulund IMA worked hard to get maximum support for the strike and protest march. Pamphlets announcing the strike were distributed, Protest banners made in many languages, Black Bands distributed , Mass SMS contact made, personal phone calls & visits to colleagues followed ! Police permission was obtained for the protest march & media was informed. All this was done on a public holiday, Dussera with limited man power !
Despite the short notice of one-day, the response to the strike was tremendous, with approximately 200 Doctors ( including many senior ones ) assembling at our Presidents Hospital, wearing black bands and displaying the Banners. The Secretary Dr. Nilesh Pandya briefed the members about the strike and the protest ‘morcha’ followed by President’s address.. The Members were requested to stage a silent protest ‘morcha’ to the Police Station in groups of three. The ‘Morcha’ started from Devidayal Road and moved towards ‘Panch Rasta’ and then along M.G. Road towards the Mulund Police Station. Many Senior Members joined the ‘Morcha’ all along the route. The Members were escorted by the Police who were helpful all throughout. The media and the press kept interviewing the Members all along the route. Neither the traffic was disrupted nor the pedestrians inconvenienced all along the route .
The ‘Morcha’ ended at the Mulund Police Station where a Memorandum, regarding violent attacks on doctors with an appeal for timely action against miscreants was submitted to the Police authorities. The officials were requested to do the needful in the matter eventually paving way for passing a Bill making attacks on Doctors a non-bailable offence.The police officers accepted the Memorandum and offered us full co-operation and assurance to maintain law and order.
The President briefed the members about the meeting with the police officials. The members appreciated the co-operation and support of the police officers towards our cause. Senior members like Dr. Mukhi, Dr.Davda, Dr. Upasani & others shared their views on the issue. The Senior Police officer also addressed the members and offered his departments full co-operation. Members were assured of immediate police action at any time of the day in case of assault by hooligans. The Senior Police Officer’s talk was well received. Thereafter the press and media coverage was given by the office-bearers for the public to know the details about the strike and the protest ‘morcha’.
The morcha ended with the Secretary Dr. Nilesh Pandya offering a vote of thanks. He requested the members to join the main ‘Morcha’ of Maharashtra IMA at Mumbai. Accordingly a group of members led by the President Elect left with protest banners to represent Mulund IMA at the State level. Members were requested to keep their OPD and routine work closed for the day; emergency work was permitted wearing black bands of protest. Overall, the response to the call for the strike and protest ‘Morcha’ was excellent. We sincerely thank the members of the Mulund Branch of IMA for co-operating with us despite a very short notice and making it a grand success.
JAI HIND JAI MAHARASHTRA
LONG LIVE IMA MULUND
SLEEP AND CARDIOVASCULAR DISORDERS
Sleep is essential for life and for physical, mental and emotional well being. Sleep has a close relation to cardiovascular system scientifically and emotionally.
There are several risk factors for hypertension,diabetes,coronary heart disease etc, but Sleep disorders as a risk factor has not been highlighted.
NORMAL SLEEP AND CARDIOVASCULAR CHANGES
In Non Rapid Eye Movement (NREM) sleep there is generalized decrement of mean heart rate and blood pressure with marked autonomic stability with parasympathetic dominance.( Stable blood pressure and overall cardiac homeostasis giving an opportunity for metabolic restoration). However there is a risk for further ischemia in patients who suffer from severe coronary disease.
During transition from NREM to (Rapid eye Movement) REM sleep there is heart rate acceleration
pauses in heart rhythm or even frank asystole and shifts in posture resulting in autonomic activation. With aging these shifts are more frequent.
At the initiation of REM sleep there is increased excitability resulting in profound bursts in sympathetic activity.These bursts trigger intermittent increase in heart rate and blood pressure. Breathing patterns become irregular and can result in oxygen desaturations. REM sleep therefore has the capacity to disturb cardiorespiratory homeostasis. However cardiovascular homeostasis must be maintained in sleep and this is achieved by close co-ordination of respiratory and cardiovascular systems.
ABNORMAL SLEEP AND CARDIOVASCULAR DISORDERS.
Sleep is generally beneficial and protective but not in subjects suffering from respiratory and cardiac disease as it can precipitate cardiac arrythmias, myocardial ischemia, breathing disorders and even death.
SLEEP DISORDERS :
Obstructive sleep apnea (OSA), Central sleep apnea (CSA), Chronic sleep deprivation ( CSD ), Nightmares are some of the sleep disorders with adverse effects on the cardiovascular system. OSA is a common disorder but is usually not recognized in clinical practice. The disorder is characterized by repeated pharyngeal collapse pharynx in sleep resulting in cyclical hypoxemia. Sympathetic stimulation coupled with release of stress hormones and endothelin impose a significant burden on the cardiovascular and metabolic systems. OSA is a risk factor for the development of hypertension, ischemic heart disease, strokes, type 2 diabetes mellitus,dementia and others. Habitual snoring (often loud) and excessive daytime sleepiness are the two prominent symptoms of the disorder. The other nocturnal symptoms witnessed apneas, choking, dyspnea (can be mistaken for dyspnea of cardiac origin) restlessness manifested by frequent change of posture, nocturia due to release of atrial natrureticpeptide gastroesophageal reflux, diaphoresis and drooling. Some subjects may just complain of insomnia (patient unable to continue sleep due to repeated arousals) and may compel a physician to prescribe an hypnotic. Sedatives, hypnotics and antianxiety medicines are often prescribed in cardiology practice. Such drugs increase the hypotonia of pharyngeal muscles and therefore should be avoided in patients of OSA. Alcohol is used as sleeping aid by some patients and it also carries similar risk. It is not uncommon to observe patients have choked themselves in sleep after consuming such medications/ alcohol before retiring to bed. It is also important to note that OSA patients are often REM sleep deprived. Chronic REM sleep deprivation results in anxiety, excessive eating and hypersexuality. Excessive eating promotes obesity which in turn aggravates sleep apnea. It is therefore necessary to treat sleep apnea in obese individuals to achieve optimal body weight.
Daytime symptoms of OSA includes sleepiness, fatigue, morning headaches, poor concentration, decreased attention, depression, decreased dexterity and personality changes. Subjects of OSA often exhibit mood swings behaviour and may seek psychiatrist’s opinion. Although obesity is risk factor for development of OSA it is not uncommon to observe OSA in low and normal body weight subjects due to anatomical factors (narrow upper airway). Polysomnography is the gold standard to diagnose OSA.
The apneic hyponeic episodes of OSA have the capability of disrupting myocardial perfusion even in individuals without cardiac disease. The resultant effects are manifested by nocturnal myocardial ischemia, arrythmias and hypertension. A greater prevalence of cardiovascular complications is seen throughtout the spectrum of sleep disordered breathing which consists of snoring, upper airway resistance syndrome and obstructive sleep apnea.
Sleep apnea and hypertension
OSA is an established risk factor for hypertension. In fact it is one of the common and important causes for reversible hypertension.
The chronic usage of continuous positive airway pressure (CPAP) in patients with hypertension and obstructive sleep apnea results in reduction of hypertension both while awake and during sleep..
Sleep disordered breathing in pregnancy may have adverse effects both on the mother and foetus( pregnancy induced hypertension and small for gestational age birth). It is interesting to note that approximately 28% of children born in India are of low birth weight and low birth weight is associated with elevated levels of glucocorticoid in later life. A story from womb to the tomb.
Cardiac medications and Sleep
Lipophilic beta-blockers pinidolol, propanolol and metoprolol increases the number of awakenings and period of wakefulness as compared to placebo and non-lipophilic betablockers like atenolol. Betablockers in general do cause daytime lethargy possibly due to sleep disruption. Melatonin is also depleted by beta-blockers. Beta-blockers and calcium channel blockers may provoke nightmares.
SLEEP DEPRIVATION AND CARDIOVASCULAR EVENTS
Chronic sleep deprivation (CSD) is associated with cardiovascular events by more than one mechanism.viz (1) Sleep deprivation induces or aggravates snoring by increasing muscular hypotonia and delaying contraction of the dilator muscles of pharynx. (2) By causing an autonomic imbalance. (3) CSD in young healthy volunteers has been reported to increase levels of proinflammatory cytokines decrease parasympathetic and increase sympathetic tone, increase blood pressure, increases cortisol levels as well as elevate insulin and blood glucose levels.
Coronary Artery Disease ( CAD ) and sleep apnea.
Several studies have suggested that there is a greater risk of CAD in sleep related breathing disorders. There is 20 fold risk of developing myocardial infarction in untreated OSA. It is therefore important to screen all patients of coronary artery disease for sleep apnea. Treatment of sleep apnea is rewarding in multiple ways viz good quality of sleep, daytime alertness ,normal physical activity which helps in reducing body weight, good cardiovascular function and better glycemic control. Continuous positive airway pressure( CPAP) is the widely accepted mode of treatment of OSA.
Diabetes is a cardiovascular disease There is a close association between OSA and insulin resistance. The nocturnal events in OSA ultimately culminate in cyclical hypoxia, cylclical hypertension release of catecholamines & stress hormones , insulin resistance and diabetes Recently we have reported favourable results in glycemic control in 4 patients of type 2 diabetes who had associated obstructive sleep apnea with regular usage of CPAP. The beneficial metabolic effects of CPAP has been discussed recently and has been documented. There is a close association between diabetes, hypertension, ischemic heart disease, sleep disorders particularly sleep apnea.
Sleep Apnea and atrial fibrillation
Sleep apnea and atrial fibrillation frequently coexist. OSA has been implicated in the recurrence of atrial fibrillation..
OSA and Congestive Heart Failure (CHF)
Central Sleep apnea (CSA) is frequently observed in patients with congestive heart failure (CHF). The condition affects cardiovascular function adversely by causing tissue hypoxia , arousals from sleep and activation of the sympathetic nervous system. It also independently increases the risk of death.Studies have demonstrated beneficial effects of CPAP in CHF. Polysomnography is mandatory in all subjects of CHF.
In conclusion sleep disorders are common in clinical practice. It is time that we took cognizance of this in various cardiovascular disorders since patients usually do not attach much importance to sleep while narrating the history. Society in general has held the view that snoring is a sign of sound sleep. In literal terms sound sleep needs to be differentiated from healthy sleep. A close association exists between anatomical factors in the face, life style, sleep deprivation, sleep disorders, eating, obesity, hypertension, coronary heart disease, metabolic syndrome, cardiovascular morbidity and mortality. It is important to record sleep history in all patients suffering from hypertension, metabolic syndrome and coronary heart disease . Premature death in OSA patients is most often due to cardiovascular disorders. It is now accepted that treatment of OSA by CPAP is rewarding since it can prevent or improve hypertension, reduce abnormal elevations of inflammatory cytokines and adhesion molecules, reduce excessive sympathetic tone, avoid increased vascular oxidative stress, reverse coagulation abnormalities and reduce leptin levels. It is often argued sleep studies may not be economically feasible but given the benefits and properly placed before the patient in question would definitely improve compliance for the test.
Dr.S.Ramnathan Iyer, M.D.(Med) Dr.Revati.R.Iyer, M.S.( OBGY)
(9820143970) (9819598570)
There are several risk factors for hypertension,diabetes,coronary heart disease etc, but Sleep disorders as a risk factor has not been highlighted.
NORMAL SLEEP AND CARDIOVASCULAR CHANGES
In Non Rapid Eye Movement (NREM) sleep there is generalized decrement of mean heart rate and blood pressure with marked autonomic stability with parasympathetic dominance.( Stable blood pressure and overall cardiac homeostasis giving an opportunity for metabolic restoration). However there is a risk for further ischemia in patients who suffer from severe coronary disease.
During transition from NREM to (Rapid eye Movement) REM sleep there is heart rate acceleration
pauses in heart rhythm or even frank asystole and shifts in posture resulting in autonomic activation. With aging these shifts are more frequent.
At the initiation of REM sleep there is increased excitability resulting in profound bursts in sympathetic activity.These bursts trigger intermittent increase in heart rate and blood pressure. Breathing patterns become irregular and can result in oxygen desaturations. REM sleep therefore has the capacity to disturb cardiorespiratory homeostasis. However cardiovascular homeostasis must be maintained in sleep and this is achieved by close co-ordination of respiratory and cardiovascular systems.
ABNORMAL SLEEP AND CARDIOVASCULAR DISORDERS.
Sleep is generally beneficial and protective but not in subjects suffering from respiratory and cardiac disease as it can precipitate cardiac arrythmias, myocardial ischemia, breathing disorders and even death.
SLEEP DISORDERS :
Obstructive sleep apnea (OSA), Central sleep apnea (CSA), Chronic sleep deprivation ( CSD ), Nightmares are some of the sleep disorders with adverse effects on the cardiovascular system. OSA is a common disorder but is usually not recognized in clinical practice. The disorder is characterized by repeated pharyngeal collapse pharynx in sleep resulting in cyclical hypoxemia. Sympathetic stimulation coupled with release of stress hormones and endothelin impose a significant burden on the cardiovascular and metabolic systems. OSA is a risk factor for the development of hypertension, ischemic heart disease, strokes, type 2 diabetes mellitus,dementia and others. Habitual snoring (often loud) and excessive daytime sleepiness are the two prominent symptoms of the disorder. The other nocturnal symptoms witnessed apneas, choking, dyspnea (can be mistaken for dyspnea of cardiac origin) restlessness manifested by frequent change of posture, nocturia due to release of atrial natrureticpeptide gastroesophageal reflux, diaphoresis and drooling. Some subjects may just complain of insomnia (patient unable to continue sleep due to repeated arousals) and may compel a physician to prescribe an hypnotic. Sedatives, hypnotics and antianxiety medicines are often prescribed in cardiology practice. Such drugs increase the hypotonia of pharyngeal muscles and therefore should be avoided in patients of OSA. Alcohol is used as sleeping aid by some patients and it also carries similar risk. It is not uncommon to observe patients have choked themselves in sleep after consuming such medications/ alcohol before retiring to bed. It is also important to note that OSA patients are often REM sleep deprived. Chronic REM sleep deprivation results in anxiety, excessive eating and hypersexuality. Excessive eating promotes obesity which in turn aggravates sleep apnea. It is therefore necessary to treat sleep apnea in obese individuals to achieve optimal body weight.
Daytime symptoms of OSA includes sleepiness, fatigue, morning headaches, poor concentration, decreased attention, depression, decreased dexterity and personality changes. Subjects of OSA often exhibit mood swings behaviour and may seek psychiatrist’s opinion. Although obesity is risk factor for development of OSA it is not uncommon to observe OSA in low and normal body weight subjects due to anatomical factors (narrow upper airway). Polysomnography is the gold standard to diagnose OSA.
The apneic hyponeic episodes of OSA have the capability of disrupting myocardial perfusion even in individuals without cardiac disease. The resultant effects are manifested by nocturnal myocardial ischemia, arrythmias and hypertension. A greater prevalence of cardiovascular complications is seen throughtout the spectrum of sleep disordered breathing which consists of snoring, upper airway resistance syndrome and obstructive sleep apnea.
Sleep apnea and hypertension
OSA is an established risk factor for hypertension. In fact it is one of the common and important causes for reversible hypertension.
The chronic usage of continuous positive airway pressure (CPAP) in patients with hypertension and obstructive sleep apnea results in reduction of hypertension both while awake and during sleep..
Sleep disordered breathing in pregnancy may have adverse effects both on the mother and foetus( pregnancy induced hypertension and small for gestational age birth). It is interesting to note that approximately 28% of children born in India are of low birth weight and low birth weight is associated with elevated levels of glucocorticoid in later life. A story from womb to the tomb.
Cardiac medications and Sleep
Lipophilic beta-blockers pinidolol, propanolol and metoprolol increases the number of awakenings and period of wakefulness as compared to placebo and non-lipophilic betablockers like atenolol. Betablockers in general do cause daytime lethargy possibly due to sleep disruption. Melatonin is also depleted by beta-blockers. Beta-blockers and calcium channel blockers may provoke nightmares.
SLEEP DEPRIVATION AND CARDIOVASCULAR EVENTS
Chronic sleep deprivation (CSD) is associated with cardiovascular events by more than one mechanism.viz (1) Sleep deprivation induces or aggravates snoring by increasing muscular hypotonia and delaying contraction of the dilator muscles of pharynx. (2) By causing an autonomic imbalance. (3) CSD in young healthy volunteers has been reported to increase levels of proinflammatory cytokines decrease parasympathetic and increase sympathetic tone, increase blood pressure, increases cortisol levels as well as elevate insulin and blood glucose levels.
Coronary Artery Disease ( CAD ) and sleep apnea.
Several studies have suggested that there is a greater risk of CAD in sleep related breathing disorders. There is 20 fold risk of developing myocardial infarction in untreated OSA. It is therefore important to screen all patients of coronary artery disease for sleep apnea. Treatment of sleep apnea is rewarding in multiple ways viz good quality of sleep, daytime alertness ,normal physical activity which helps in reducing body weight, good cardiovascular function and better glycemic control. Continuous positive airway pressure( CPAP) is the widely accepted mode of treatment of OSA.
Diabetes is a cardiovascular disease There is a close association between OSA and insulin resistance. The nocturnal events in OSA ultimately culminate in cyclical hypoxia, cylclical hypertension release of catecholamines & stress hormones , insulin resistance and diabetes Recently we have reported favourable results in glycemic control in 4 patients of type 2 diabetes who had associated obstructive sleep apnea with regular usage of CPAP. The beneficial metabolic effects of CPAP has been discussed recently and has been documented. There is a close association between diabetes, hypertension, ischemic heart disease, sleep disorders particularly sleep apnea.
Sleep Apnea and atrial fibrillation
Sleep apnea and atrial fibrillation frequently coexist. OSA has been implicated in the recurrence of atrial fibrillation..
OSA and Congestive Heart Failure (CHF)
Central Sleep apnea (CSA) is frequently observed in patients with congestive heart failure (CHF). The condition affects cardiovascular function adversely by causing tissue hypoxia , arousals from sleep and activation of the sympathetic nervous system. It also independently increases the risk of death.Studies have demonstrated beneficial effects of CPAP in CHF. Polysomnography is mandatory in all subjects of CHF.
In conclusion sleep disorders are common in clinical practice. It is time that we took cognizance of this in various cardiovascular disorders since patients usually do not attach much importance to sleep while narrating the history. Society in general has held the view that snoring is a sign of sound sleep. In literal terms sound sleep needs to be differentiated from healthy sleep. A close association exists between anatomical factors in the face, life style, sleep deprivation, sleep disorders, eating, obesity, hypertension, coronary heart disease, metabolic syndrome, cardiovascular morbidity and mortality. It is important to record sleep history in all patients suffering from hypertension, metabolic syndrome and coronary heart disease . Premature death in OSA patients is most often due to cardiovascular disorders. It is now accepted that treatment of OSA by CPAP is rewarding since it can prevent or improve hypertension, reduce abnormal elevations of inflammatory cytokines and adhesion molecules, reduce excessive sympathetic tone, avoid increased vascular oxidative stress, reverse coagulation abnormalities and reduce leptin levels. It is often argued sleep studies may not be economically feasible but given the benefits and properly placed before the patient in question would definitely improve compliance for the test.
Dr.S.Ramnathan Iyer, M.D.(Med) Dr.Revati.R.Iyer, M.S.( OBGY)
(9820143970) (9819598570)
MIGRAINE
A migraine headache is the most common primary headache syndrome. The term migraine is derived from the ancient Greek word hemikranios which means "half head". Attacks are often recurrent and tend to become less severe as the migraine sufferer ages.
Migraine headaches are more common in females usually before the age of 40 years.
Majority of Migraine cases are without aura, only one third of cases being with aura. Less common types include, Ocular migraine, Menstrual migraine etc.
The cause of migraine is unknown. There is often a family history, in 90 % of cases.
Triggers : Commonly identified migraine triggers include the following:
Alcohol , Foods that contain caffeine (e.g., coffee, chocolate), monosodium glutamate (MSG; found in Chinese food), and nitrates (e.g., processed foods)
Environmental factors (e.g., weather, altitude,) ; Glare, contrasting patterns
Hunger, Lack of sleep , Exertion & Stress ; Hormonal changes in women
Medications (over-the-counter and prescription) ; Perfume
MIGRAINE PHASES :
1. Prodrome: Consist of alterations in mood or energy level, excessive yawning, or food cravings.
2. Aura: It is experienced 10 to 30 minutes before the headache. Most auras are visual (scintillating scotomas, zigzag lines or castles- fortification spectra) in nature.
3. Headache: Migraine headache is often described as throbbing or pulsating pain that is intensified by routine physical activity, coughing, straining, or lowering the head.
There may be accompanying symptoms such as nausea, vomiting, sensitivity to light, sound or strong smells.
4. Postdrome: Left feeling tired and weak once the headache has passed.
Diagnosis : Diagnosis is mainly based on symptoms with a near normal neurologic examination.
CT/ MRI, CSF Examination, EEG may be performed to rule out other neurological conditions, including meningitis, intracranial bleeds, vascular malformations etc.
TREATMENT : The goals of treatment are to prevent or reduce the number of migraine attacks (prophylactic treatment) and to alleviate symptoms and shorten the duration of the migraine attack (abortive treatment).
A. Abortive Treatment : Mild, infrequent migraines may be relieved using over-the-counter medication. During a migraine headache, people often prefer to rest or sleep alone in a dark, quiet room.
1. Analgesics, e.g., aspirin, ibuprofen should be taken at the first sign of a migraine.
2. Ergots ,e.g., Ergotamine maleate (MIGRANIL) along with anti emetics. Not effective if the headache has moved into the throbbing stage.
3. Triptans: Sumitriptan, Ritzatriptan are fast-acting, usually well- tolerated medications commonly used to treat migraines. They are available in oral, injectable (subcutaneous Suminat) and nasal spray forms and can be taken any time during the headache.
4. Steroids: Used in those with severe, refractory or frequent headaches.
B. Prophylactic Treatment : indicated for Frequent headaches (more than 1/ WEEK) or uncommon migraine conditions .
Start with monotherapy), but a combination of medicines may be necessary.
1. Beta blockers (e.g., Propranolol , atenolol) are the preferred medications. To be avoided in asthmatics.
2. Calcium-Channel Blockers prevent spasm of arteries by inhibiting contraction of smooth muscle. Flunarizine ( [FLUNARIN, SIBELIUM] is the most commonly used.
3. Tricyclic antidepressants (TCAs; e.g., Amytriptyline [TRYPTOMER], nortriptyline are also useful for migraine prophylaxis especially in those with associated tension type headaches.
4. Anti Epileptic drugs (AEDs): Valproic acid , Topiramate, Gabapentin.
There are other prophylactic agents to be used selectively like Cyproheptadine in children.
Prevention : There is no cure for migraine but avoiding triggers, managing stress, and taking prophylactic medications can help prevent migraine headaches. Keeping a migraine journal can help identify triggers and gauge the effectiveness of preventive measures.
Stress management techniques (e.g., biofeedback, hypnosis) and stress-reducing activities (e.g., meditation, yoga, and exercise) may help prevent migraines.
Migraine headaches are more common in females usually before the age of 40 years.
Majority of Migraine cases are without aura, only one third of cases being with aura. Less common types include, Ocular migraine, Menstrual migraine etc.
The cause of migraine is unknown. There is often a family history, in 90 % of cases.
Triggers : Commonly identified migraine triggers include the following:
Alcohol , Foods that contain caffeine (e.g., coffee, chocolate), monosodium glutamate (MSG; found in Chinese food), and nitrates (e.g., processed foods)
Environmental factors (e.g., weather, altitude,) ; Glare, contrasting patterns
Hunger, Lack of sleep , Exertion & Stress ; Hormonal changes in women
Medications (over-the-counter and prescription) ; Perfume
MIGRAINE PHASES :
1. Prodrome: Consist of alterations in mood or energy level, excessive yawning, or food cravings.
2. Aura: It is experienced 10 to 30 minutes before the headache. Most auras are visual (scintillating scotomas, zigzag lines or castles- fortification spectra) in nature.
3. Headache: Migraine headache is often described as throbbing or pulsating pain that is intensified by routine physical activity, coughing, straining, or lowering the head.
There may be accompanying symptoms such as nausea, vomiting, sensitivity to light, sound or strong smells.
4. Postdrome: Left feeling tired and weak once the headache has passed.
Diagnosis : Diagnosis is mainly based on symptoms with a near normal neurologic examination.
CT/ MRI, CSF Examination, EEG may be performed to rule out other neurological conditions, including meningitis, intracranial bleeds, vascular malformations etc.
TREATMENT : The goals of treatment are to prevent or reduce the number of migraine attacks (prophylactic treatment) and to alleviate symptoms and shorten the duration of the migraine attack (abortive treatment).
A. Abortive Treatment : Mild, infrequent migraines may be relieved using over-the-counter medication. During a migraine headache, people often prefer to rest or sleep alone in a dark, quiet room.
1. Analgesics, e.g., aspirin, ibuprofen should be taken at the first sign of a migraine.
2. Ergots ,e.g., Ergotamine maleate (MIGRANIL) along with anti emetics. Not effective if the headache has moved into the throbbing stage.
3. Triptans: Sumitriptan, Ritzatriptan are fast-acting, usually well- tolerated medications commonly used to treat migraines. They are available in oral, injectable (subcutaneous Suminat) and nasal spray forms and can be taken any time during the headache.
4. Steroids: Used in those with severe, refractory or frequent headaches.
B. Prophylactic Treatment : indicated for Frequent headaches (more than 1/ WEEK) or uncommon migraine conditions .
Start with monotherapy), but a combination of medicines may be necessary.
1. Beta blockers (e.g., Propranolol , atenolol) are the preferred medications. To be avoided in asthmatics.
2. Calcium-Channel Blockers prevent spasm of arteries by inhibiting contraction of smooth muscle. Flunarizine ( [FLUNARIN, SIBELIUM] is the most commonly used.
3. Tricyclic antidepressants (TCAs; e.g., Amytriptyline [TRYPTOMER], nortriptyline are also useful for migraine prophylaxis especially in those with associated tension type headaches.
4. Anti Epileptic drugs (AEDs): Valproic acid , Topiramate, Gabapentin.
There are other prophylactic agents to be used selectively like Cyproheptadine in children.
Prevention : There is no cure for migraine but avoiding triggers, managing stress, and taking prophylactic medications can help prevent migraine headaches. Keeping a migraine journal can help identify triggers and gauge the effectiveness of preventive measures.
Stress management techniques (e.g., biofeedback, hypnosis) and stress-reducing activities (e.g., meditation, yoga, and exercise) may help prevent migraines.
Dr Rajesh Benny
Consultant Neurologist (DM)
Consultant Neurologist (DM)
GUIDED TOUR KOKILABEN DHIRUBHAI AMBANI HOSPITAL
DATE: 16/11/2008 (SUNDAY)As per the planned program, Members of Mulund IMA started assembling at Shree Ram Eye Care Centre at 10.30 a.m. Tea was served to Members present. Sixty Three Members who approached in time were accommodated in two Buses which started at 11.00 a.m. We reached our Destination at 12.30 p.m., where every Member was given a rousing Welcome with Flower Bouquet. We were then escorted to Food court and served Welcome Drink. In order to manage the Event properly, two Batches were formed. The Hospital has four Gates. The Emergency Trauma Centre has one attached O.T. to take care of Urgent Cases for Surgery. Special provision is made for transfer of Blood Samples, Drugs and Records. Thus, whatever we want to transfer have to be inserted in specially designed Capsules which will travel through Duct till Destination. All the beds in the Hospital have attached Suction, Oxygen, Bells, irrespective of Class. The Seven Hundred Bedded Hospital is housed in 16-storied Building serving Vegetarian Food only. Each Floor has attached Hotel Room for relatives. It has Five Hundred Seating Capacity Hall for Conference. At the end of the program, all the Delegates were given attractive Gifts. Lunch was served to all. We were dropped back again at Mulund. We thank Mr. Vaishnav Pravin C., Relationship Manager, Kokilaben Dhirubhai Ambani Hospital and Medical Research Institute, for arranging the Tour meticulously.
Dr. Nilesh Pandya
Secretary, I.M.A. Mulund
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