Tuesday, 29 March 2011

Get your legs looking beautiful for the Summer!

We have all seen them, we all hope we don’t get them, but unfortunately varicose leg veins are a common problem which affects a high proportion of people. Varicose veins are more common in women than in men and related factors include pregnancy, obesity, menopause, prolonged standing, leg injury and abdominal straining (constipation, prostate enlargement or excessive lifting !). There also seems to be an inherited component to the development of varicose veins, which results in some young people developing the condition, however the prevalence increases with age.
So what exactly are varicose veins?  Put simply, they are swollen, enlarged and tortuous veins resulting from incompetent (damaged) leaflet valves within the vein. As blood is pumped around the body, it flows from the heart via arteries through the organs and limbs and returns to the heart via the veins. In medical circles, the term varicose can be applied to veins in many areas of the body including the abdomen and gullet, but generally people recognise the term as referring to large swollen veins in the legs and thighs.
In the legs, the latter part of the circulatory cycle is facilitated by walking and movement. When your calf muscles contracts they squeeze deep veins within them forcing blood along the veins. Essentially your own legs pump blood up the veins and back to the heart. This is why airlines encourage you to move your legs whist you are sitting on an aeroplane flight, simply to move the blood around your legs and prevent the blood clotting and forming a deep vein thrombosis or DVT.
To stop backflow of blood when the muscle relaxes, veins are equipped with a series of one way leaflet valves which keep the blood moving in a forward direction. As we spend most of our time in the upright position, the valves in the leg veins may have to hold back a column of blood up to 1.5 meters high (the distance between the ankle and the heart). If we didn’t have them, blood would pool in our ankles and we would have to stand on our heads to get blood back to the heart! If for any reason the veins stretch and the leaflet valves fail to close properly, blood flow reverses when the muscles relax and the superficial veins under the skin overfill and bulge.
Once the veins are weakened, blood refluxes backwards further stretching the vein and thus a vicious cycle ensues and the pressure within them rises. Fluid escapes from the veins into the tissues making them ache and feel heavy and lumpy veins can be felt just under the skin. Besides cosmetic problems, varicose veins can cause a great deal of stress and are often painful, especially when standing or walking. Whilst serious complications are rare, if untreated serious conditions such as phlebitis, bleeding can occur. At the ankle where the intravenous pressure is at its highest, blood cells and proteins can  leak into the skin. Iron is released from the breakdown of red blood cells which discolours the skin and causes varicose eczema. This often itches, and trauma or scratching the area can cause ulcers (which in rare cases may become malignant). Fortunately, if treated early and properly the leg can be restored to normal.
Although varicose veins may seem to only affect one leg, detailed investigation often shows early problems in the other leg. Many doctors will simply assess leg veins in the outpatient clinic by sight and a few tourniquets, but these days this is considered an incomplete test and the leading centres in the UK and USA advocate the use of Doppler ultrasound to assess all symptomatic veins. An inaccurate diagnosis may result in inappropriate surgery and some studies have shown that varicose veins can come back in up to 60% of such cases. At the Specialist Medical Clinic the latest ultrasound diagnostic equipment enables our specialist team to accurately identify the cause of your varicose veins and their stage of development. Ultrasound is painless and identifies the vein and areas where valves have failed. Visual examination on its own cannot achieve this. Ultrasound technology identifies back flow in a vein through a damaged valve and in complicated cases or when previous surgery has been performed Colour Duplex Imaging (CDI) is undertaken.
Not all varicose veins require surgical treatment. For instance, people with only minor varicose veins which are causing no symptoms, the best option is to do nothing. If symptoms are limited to aching after standing for long periods, this can be relieved by wearing below knee graduated pressure support stockings during the day. These come in a variety of colours and are indistinguishable from ordinary hose. Unfortunately they don’t work if they are left in the stocking drawer!!
Spider veins are probably best treated with injection sclerotherapy a treatment which has been used to treat the condition for over 150 years. This gives good cosmetic results and may be all that is necessary to help reduce achy legs. Small unsightly veins arising from isolated sources of incompetence can also be injected or removed under local anaesthetic in the clinic. 

The major problems only arise if and when the varicose veins are due to incompetence of the major valves in the main superficial long or short saphenous veins. In these cases the underlying cause must be dealt with to avoid recurrence. Because most of the blood in the legs is returned by the deep veins, the superficial veins, which return only about 10 per cent of the total blood of the legs, can usually be removed or ablated without serious harm.

Traditionally surgeons have operated to strip out the damaged veins, a painful procedure which involves having a general anaesthetic, cuts in the groins and legs, at least one night in hospital and bandages for a number of weeks!! Anyone who has had the procedure will tell you that it is painful and that they didn’t get back to work for at least a week. For this reason surgeons have looked for less painful alternatives. About 7 years ago, foam sclerotherapy became popular. In this procedure a special foam mixture of sclerosant and air is injected under ultrasound guidance into the veins to cause inflammation and stick the walls of the vein together. Some surgeons still use this, but side effects are slowly relegating this to a support therapy to more modern occlusive techniques. In 1996 a report indicated the technique was successful in 76% of cases at 24 months.

These days however, the gold standard for treatment of the major superficial varicose veins is moving towards local anaesthetic percutaneous endovenous occlusion. These treatments are effective in up to 95% of patients at 5 years (against approximately 70 - 80% in surgically treated patients). Percutaneous endovenous occlusion is a walk in, walk out 45 minute procedure performed under local anaesthetic in the outpatient clinic. More nervous patients may wish for sedation, but generally this is not necessary. Following the procedure, patients walk out of the clinic and return to their normal activities often the same day. In the USA and UK, patients even book in to have their veins treated during their lunch hour and whilst learning the technique at the Cadogan Clinic in London, we treated one Consultant Surgeon, who after having the treatment returned to work in the afternoon, and did an NHS and Private operating list the following day!

The technique involves the introduction of a thin fibre under ultrasound guidance into the vein through a small hollow needle. Once placed in the correct position, the fibre is heated and withdrawn slowly. The heat from the fibre occludes the vein thus preventing backflow of blood and reducing the pressure and swelling in the veins. As there are no surgical cuts, and the vein is not stripped out, there is much less pain than the “old fashioned” surgical treatment.

The catheter is heated using either laser (light) or radio-frequency energy. The first technique to be widely used was Endovenous Laser Therapy (EVLT) in which laser energy is used to heat the vein up to over 800ºC. This boils the blood in the vein causing occlusion. The very high temperatures can lead to burn holes in the vein wall and some bruising and pain albeit much less than with surgery. Laser safety is a major issue and great care must be taken that patients and medical staff do not get eye injuries from the laser.

Over the last 18 months or so, a newer Radiofrequency ablation technique (VNUS Closure®) has gained in popularity and is rapidly becoming arguably the preferred endovenous occlusion technique in the UK and USA. As it works at much lower temperatures than EVLT, (120º), there is less risk of making holes in the vein which in turn results in less bruising and pain. As laser light is avoided, the technique poses no danger to patients and staff.

Varicosity recurrence with both techniques is about 5% at 5 years which compares well with conventional stripping, which in the best hands has a recurrence rate of 10 to 30%.Doctors must use ultrasound during the procedure to see what they are doing. Some practitioners also perform phlebectomy or ultrasound guided sclerotherapy at the time of endovenous treatment however recent evidence suggests that once the main veins have been treated less than 30% of patients actually require follow-up treatment.

EVLT and VNUS require specialized training and expensive equipment, however the surgical team at the Specialist Medical Clinic have been trained by the UK’s leading pioneer in this technique and have now started treating patients in both Gibraltar and Puerto Banus.

Thursday, 24 March 2011

Obesity and being Overweight


The World Health Organisation (WHO) defines overweight and obesity as abnormal or excessive fat accumulation that presents a risk to health.

Worldwide more than 1 billion adults are currently overweight with approximately 1/3 of these being clinically obese (BMI >30). This obesity epidemic is now a major contributor to the global healthcare burden. In individual countries obesity rates vary from 5% (China and Japan) to 66% in the US and 75% in urban Samoa.
More worrying is the 22 million children under five currently estimated to be overweight worldwide. According to the US Surgeon General, in the USA the number of overweight children has doubled and the number of overweight adolescents has trebled since 1980. In 2004 the American Medical Association placed obesity as the second highest cause of death in the USA.
USA Death Statistics 2004
(American Medical Association)
Obesity accounts for as much as 7% of total health care costs in several developed countries and in the USA and the UK the cost is even higher. In 1995 the US treasury estimated that $99 was million spent on treating obesity and its associated complications. Today the cost is more than double this. In reality however the true costs are much greater as not all obesity-related conditions are included in the calculations.
No mater how alarming the health economic data is, it is extremely important to not  forget the significant cost of obesity to the individual. These include:- 
l  Lost output due to reduced ability to work or cessation of productivity
l  Reduced quality of life
l  Increased morbidity (cardiac disease, diabetes and arthritis)
l  Premature mortality (heart disease, cancer, diabetes, liver disease)
l  Stigmatization within society
l  Decreased opportunity in education, housing and employment

How do we define obesity and overweight?

Obesity is assessed using body mass index (BMI) which is defined as the weight in kilograms divided by the square of the height in metres (kg/m2). Whilst BMI provides a benchmark for comparative assessment, risks of disease in all populations increase progressively from lower BMI levels.
In Africa and Asia, adult mean BMI levels are 22-23 kg/m2 whilst levels of 25-27 kg/m2 are prevalent across North America, Europe, and in some Latin American, North African and Pacific Island countries. BMI also increases amongst middle-aged elderly people, who are at the greatest risk of health complications. The distribution of BMI is shifting upwards in many populations.
WHO Body Mass Index (BMI) Classification
Less than 18.5
18.5 to 24.9
25.0 to 29.9.
30.0 to 34.9
35.0 to 39.9
40.0 to 49.9
Normal or Healthy Range
Severely Obese
Morbid Obese
Super Obese

Why is this happening?

The rising epidemic reflects changes in society and its behavioural patterns over recent decades. Undoubtedly, genetic inheritance is important in determining a person's susceptibility to weight gain however energy balance is determined by calorie intake and physical activity. Thus as incomes rise and populations become more urban, diets high in complex carbohydrates have given way to more varied diets with a higher proportion of fats, saturated fats and sugars. At the same time, shifts towards less physically demanding work, and moves towards less physical activity through the increasing use of automated transport, technology in the home, and more passive leisure pursuits have been seen worldwide. Put simply, 
“Energy balance is determined by calorie intake and physical activity”
Ironically, contrary to common belief, the obesity epidemic is not just restricted to industrialized societies and the epidemic is seen to be growing faster in some developing countries which are currently experiencing the rapid introduction of modern energy saving technology and western high calorie foodstuffs.  

How does excess body fat impact health?

The health consequences of obesity range from increased risk of premature death, to serious chronic conditions that reduce the overall quality of life.  Obesity is a major risk for life threatening related chronic diseases including type 2 diabetes, cardiovascular disease, hypertension, stroke, certain forms of cancer (breast, colon, prostate, endometrium, kidney and gallbladder) and gallbladder disease.
Being overweight can lead to adverse metabolic effects on blood pressure, cholesterol, triglycerides and insulin resistance. Other non-fatal, but debilitating health problems associated with obesity include respiratory problems (sleep apnoea), chronic musculoskeletal problems (including osteoarthritis – a major cause of disability), skin problems, infections and infertility.
Obesity should probably be considered a disease in its own right as together with smoking, high blood pressure and high blood cholesterol it is a recognised key risk factor for many other chronic diseases. In the analyses carried out for World Health Report 2002, approximately 58% of diabetes and 21% of ischaemic heart disease and 8-42% of certain cancers globally were attributable to a BMI above 21 kg/m2.
Economists with RTI International, a non-profit research organization in Research Triangle Park, N.C., analyzed national data on 366,000 people. Among the findings published online in the journal Obesity, they found that:
•Overall, excess weight was responsible for the loss of roughly 95 million years of life in the USA in 2008.
•Non-smokers who are obese (about 30 or more pounds over a healthy weight) have a shorter life span by a year or less.
•Smoking takes a toll, too, and very heavy smokers are affected most. An 18-year-old white male who is normal weight and does not smoke can expect to live to age 81. If he's extremely obese and a smoker, his life expectancy is 60, a difference of 21 years.

What can society do about it?

Inside every obese person there is a small person trying to get out”

Effective weight management for individuals and groups at risk of developing obesity involves a range of long-term strategies. These include prevention, weight maintenance, management of co-morbidities and weight loss. Key elements include:
  • Creating supportive environments through public policies that promote low-fat, high-fibre foods, and that provide opportunities for physical activity.
  • Promotion of healthy behaviour to encourage, motivate and enable individuals to lose weight by
    • eating more fruit and vegetables, nuts and whole grains;
    • engaging in daily moderate physical activity for at least 30 minutes;
    • cutting the amount of fatty, sugary foods in the diet;
    • moving from saturated animal-based fats to unsaturated vegetable-oil based fats.
  • Promoting medical treatments for the existing burden of obesity and associated conditions with effective support for those affected to lose weight or avoid further weight gain.
Medical and Surgical Options
Whilst lifestyle changes, low calorie diets, increased exercise and some medical treatments remain the ideal way to loose weight, some patients are unable to achieve the weight loss necessary to return to a health BMI.
Many surgical techniques have been developed and today interest in obesity (Bariatric) surgery is a growing at a faster than ever before. Broadly speaking three surgical options exist.
The water filled Intragastric (BIB®) Balloon is placed in the stomach using an endoscope passed through the mouth under sedation. The procedure takes about 15 minutes and does not require surgery. It is effective in patients who are overweight (BMI 25.0–29.9). It is sometimes used in special circumstances for patients with very high BMIs to rapidly reduce the liver fat content prior to surgery. The balloon is removed once the target weight is reached.
For patients with BMI’s greater than 30, the balloon is not so effective and two surgical treatments are available.
Gastric by-pass surgery including the gastric by-pass and duodenal switch are major irreversible operations which reduces the size of the stomach and short circuit the small intestine to create a permanent state of malabsorption. The operation is very effective but involves cutting and joining the intestine in a number of places. It is associated with a significant surgical complication rate and post operative biochemical problem including vitamin, iron and calcium malabsorption which can occur in up to 30% of patients. This requires lifelong supplements to be taken.
The adjustable laparoscopic gastric band (Lap Band®), is a device which is placed around the neck of the stomach using keyhole surgery and which can be intermittently adjusted to restrict the amount of food that can be eaten. The Lap Band is as effective as the gastric by-pass techniques at helping a patient loose weight, however the technique has the distinct advantage of not altering the intestinal tract and not dividing the bowel. The surgical complications are much lower with this procedure and there are no associated vitamin, iron or calcium nutritional problems. The device can be removed once the patient reaches their target weight.
When considering what way to best loose weight, the preferred option is by reversing the “energy in / energy out” imbalance by diet and exercise. If you opt for one of the surgical options, to ensure the best long term results, your team should be able to offer you dietetic, surgical, endocrine medical and fitness training support an be committed to working with you towards your goal.   

Wednesday, 9 March 2011


The current economic uncertainty and resultant commercial anxiety, has seen a surprising increase in the number of medical consults by executives who have hitherto not been to a doctor for years. In the UK and USA, previously healthy businessmen and women have been presenting to their GP with palpitations and stress related exacerbation of existing conditions such as asthma, migraine, diabetes, hypertension, irritable bowel syndrome, and heart disease. Whilst many symptoms may have simple explanations others may indicate more serious underlying problems. For instance relatively benign symptoms such as poor sleep, insomnia or early morning wakening surprisingly may be signs of depression. On the other hand, symptoms such as chest pain don’t always indicate heart disease and may simply indicate heartburn, gastritis or ulcer disease (particularly if not related to exertion or stress). Medical self diagnosis is not advisable, particularly when it is remembered that serious problems can arise if individuals simply ignore early warning signs. In these days of high stress, the discerning individual should be seeking medical advice and getting “checked out” firstly to have new symptoms investigated and diagnosed, and secondly to screen for early signs of cardiac, respiratory, mental and malignant disease.

Certainly, many executives will have experienced one of those old fashioned medicals where a physician does some basic blood analysis and subjects one to a variety of tests. These have typically involved shining a torch down the throat, into the ears and eyes, hitting knees with a hammer and possibly running an ECG tracing of the heart. Although this may suffice for many, the more discerning patient with access to the internet, will be aware that these medicals leave a lot out and serious illness can be missed. I recently heard of a 45 year old lady who had one of these a few years ago, and was deemed medically fit at the age of 45, only to be diagnosed with bowel cancer 6 months later and have to undergo major surgery in order to remove the disease. Certainly a more thorough health check may have picked the disease up 6 months earlier. Another story involves a 49 year old runner who despite having regular “normal” medicals and being able to run 10 miles in 1hr 20 mins, had a cardiac Magnetic Resonance Imaging “MRI” scan which unexpectedly found him to have a completely occluded coronary artery which required urgent stenting

Sadly a healthy external appearance is no guarantee that all is well inside ones body. The fact is that the only way to truly gauge and understand your own “inner health” and that of your executives and employees relies on a modern, comprehensive health check. These days, such checks should include state of the art imaging (ultrasound and MRI scans) of your major organs and blood vessels, in addition to patient and disease specific blood testing and a thorough clinical examination. The recent trends seen in the UK and the US suggest that increasing numbers of executives are now volunteering for these comprehensive full body MOTs, first in order to ensure their fitness to do their job but more probably more importantly, to ensure their wellbeing for their family and children.   

So what can you do to comprehensively analyse your own health? Furthermore what can a company do to ensure that its key men and women are healthy and fit enough to endure the stress and anxiety of modern day business pressures?

These days, to a greater extent than ever before, control of your life expectancy and health wellbeing (and that of your employees) lies in your own hands. Modern “Well-Man and Well-Woman” screening packages are much more far reaching and comprehensive that even 5 years ago and represent a true value for money investment.  These typically begin with routine urine and blood tests, and depending on age, medical history and gender, disease specific blood tests are also included to look for cancer and chronic disease markers.  Cardiovascular fitness is then tested by a resting and exercise ECG (and ECHO cardiogram if necessary) and this is followed by an extensive ultrasound examination of the major organs (including prostate, abdominal organs, ovaries as well as the carotid arteries and aorta). The assessment should also include hearing and a glaucoma tests. Thereafter the most comprehensive screening packages include MRI scans. These are scans taken by a very powerful magnetic scanner, which computer manipulates thousands of images of the body to produce incredibly detailed images of the heart, brain, kidney and entire body arterial tree. As they utilize a magnetic field rather than x-rays, MRI scans have the advantage of being radiation free (unlike CT scans) and thus completely avoid the recognised significant lifetime increase risk of cancer associated with CT scanning. MRI brain scans check for tumours and abnormalities in blood circulation (in order to assess stroke risk), whilst a MRI heart scan assesses the function of the cardiac muscle and clearly analyses the pumping action and microcirculation of your heart. Scans of the main arterial tree looks for potential aneurysms, narrowing of arteries and plaque deposits and evidence of increased vascularity within the major organs may be the earliest indication of cancer. The process takes about 1 hour in total and is completely painless. There is no better example of using modern day technology to help save or prolong lives.

As the recession unfolds, more and more executives will have to endure increased stress levels resulting from longer working hours and increased pressure to succeed in more and more challenging markets. Combined with the fear or experience of unemployment or business failure these conditions are fertile grounds for heart attacks, strokes and even cancers. By ensuring that your health and that of your senior workforce, is good for its age (and that your company personnel have no apparent short term illness concerns) clearly offers a real benefit to any director.

It is often said that a business is only as healthy as its leaders but in these challenging times, company directors and senior executives can be so focussed on the health of their business that they risk neglecting their own. Why is it therefore, that we willingly invest money and time on the maintenance of our high performance chattels such as cars and houses, yet rarely invest the same time, money or effort into monitoring the well being and condition of most important non replaceable possession - our bodies?