Your heart condition monitored while at home or holidaying in Yala...

by Dr Hemantha Wickramatillake

Can you believe it? It is true. Some of us have heard of the "so called" Telemedicine technology. Using this new medical technology one can carry out an ECG (electrocardiograph) examination, if one experiences a mild or severe chest pain, while watching the tele at home or while relaxing at the Buthuwa bungalow in Yala.

This is just one type. Telemedicine (also referred to as "telehealth" or "e-health") allows health care professionals, and now, even, non health persons to use "connected" medical devices in the evaluation, diagnosis and treatment of patients in other (remote) locations; this could be land, remote situations in the sea or even in air (many airlines use Telemedicine now).

Tele-technology is so advanced that more disease diagnosing information can be transferred from the remotest places in the world (author had designed the data transferring format from European Union flagged ships to Telemedicine centres ashore) to Telemedicine Centres in hospitals and big cities.

For example, technology can be used to transfer lung function status information in case of acute asthmatic attacks or temperature charts in case of undiagnosed fever, and more sophisticated formats transfer X'ray (Teleradiology) and scan images or even microscopic slide pictures (Telepathology).

Many radiologists are installing appropriate computer technology in their homes, so they can have images sent directly to them for diagnosis, instead of making an off-hours trip to a hospital or clinic.

Dermatology also uses store and forward technology (although practitioners are increasingly using interactive technology for dermatological examinations). General practitioners can take images of skin conditions, and send them to a dermatologist for diagnosis.

In these advanced settings, patient could also be seen and spoken to (Teleconferencing function), and in many countries clinics for chronic, long term illnesses are now conducted via Telemedicine, providing easy access to health care in remote areas.

As mentioned above, advanced forms of Telemedicine equipment needs a surgery, the software and equipment, at least a laptop and a Telemedicine centre, while some user friendly types focusing on some illnesses per se (heart conditions) need only a laptop and the small-sized equipment.

In Sri Lanka, with internet facilities being available in most parts of the country (with the President's "Nanasala concept"), one may only need the equipment; data can be taken to the nearest Internet cafe, downloaded and transferred to a centre in Colombo via a computer.

The simplest Heart disease equipment can be as cheap as just over Rs. 5,000 and the slightly sophisticated type, yet, costing under Rs. 50,000 a piece. Thus, with access to internet, these diagnostic cardiac (heart) equipment can be used at home or, even if one is holidaying in remote places like Yala or Wilpattu.

A slightly advanced, but yet simple, form has facility to measure lung function; this could be used in case of asthmatics or in those who have a cardiac (heart) condition complicating the lung function.

The devices are enhanced through the use of telecommunications technology along with computing, network technology; video and video conferencing systems.

The use of specialized application software, data storage devices, database management software, and medical devices capable of electronic data collection, storage and transmission are all key components of Telemedicine infrastructure. Today, with the further advanced technological marvel some of the facilities can be used from home and without the presence of a healthcare professional.

Telemedicine customarily uses two methods to transmit images, data and sound - either "live", real-time transmission where the consulting professional participates in the examination of the patient while diagnostic information is collected and transmitted, or "store and forward" transmission, where the consulting professional reviews data asynchronous with its collection.

"Store and forward" technology is used for transferring digital images from one location to another. A digital image is taken using a digital camera, ('stored') and then sent ('forwarded') by computer to another location.

This is typically used for non-emergency situations, when a diagnosis or consultation may be made in the next 24 - 48 hours and sent back. Some other investigations (e.g. ECG recordings) can be downloaded to a computer and sent to another computer elsewhere immediately. ECG tracings and lung function readings are more needed in emergency situations.

The other widely used technology, two-way interactive television (IATV), is used when a 'face-to-face' consultation is necessary. The patient and sometimes their provider, or more commonly a nurse practitioner or telemedicine coordinator (or any combination of the three), are at the originating site; medical assistants in ships and some airline staff are now trained to carry out this function.

The specialist is at the referral site, most often at an urban Tele-medical centre. Videoconferencing equipment at both locations allows a 'real-time' consultation to take place. The technology has decreased in price and complexity over the past five years, and many programs now use desktop videoconferencing systems.

There are many configurations of an interactive consultation, but most typically it is from an urban-to-rural location. It means that the patient does not have to travel to an urban area to see a specialist, and in many cases, provides access to specialty care when none has been available previously.

Almost all specialties of medicine have been found to be conducive to this kind of consultation, including psychiatry, internal medicine, rehabilitation, cardiology, paediatrics, obstetrics and gynaecology and neurology.

There are also many peripheral devices which can be attached to computers which can aid in an interactive examination. For instance, an otoscope allows a physician to 'see' inside a patient's ear; a stethoscope allows the consulting physician to hear the patient's heartbeat.

Many healthcare professionals involved in telemedicine are becoming increasingly creative with available technology. For instance, it's not unusual to use store-and-forward, interactive, audio, and video still images in a variety of combinations and applications. Use of the Web to transfer clinical information and data is also becoming more prevalent.

Wireless technology is being used for instance, in ambulances providing mobile telemedicine services, and more and more airlines now use Telemedicine technology.

(Dr Wickramatillake was the Project Coordinator of the European Union Telemedicine project NIVEMES, for ships and remote sites, and the software he had designed is being used in EU ships - [email protected])

Good and bad dietary fats - Part II

by Dr. Nimal Ratnayake, Ph.D. (Head, Metabolism Section, Nutrition Research Division, Health Canada, Ottawa, Ontario, Canada )

Coronary heart disease (CHD) is the primary cause of death in both developing and developed countries. It is a complex disorder, several modifiable and non-modifiable factors contribute to its development.

Among the modifiable factors, high levels of total blood cholesterol and low density lipoprotein (LDL) cholesterol constitute major risk factors for CHD. LDL is the major lipoprotein fraction that carries cholesterol in the blood.

Generally, LDL transports cholesterol from the liver and small intestine to cells and tissues which are taking up cholesterol. Because LDL transports cholesterol to the arteries, increased levels are associated with atherosclerosis, and thus myocardial infractions, strokes and peripheral vascular disease. This is why LDL cholesterol is called bad cholesterol.

The American Heart Association recommends that LDL-cholesterol should be maintained below 100 milligrams per 100 decilitre (mg/dL) of blood to minimize the risk of coronary heart disease..

In recent years lower levels of high density lipoprotein (HDL)-cholesterol have also been implicated as risk factors for CHD. HDL is another class of lipoproteins that remove cholesterol from the body's tissues to the liver and from which a portion of cholesterol is put back into the circulation and the remainder is excreted after conversion to bile acids.

Because of this process, in which HDL can remove cholesterol from atheroma within arteries, and transport it back to the liver for excretion or re-utilization, they are sometimes called "good cholesterol". High level of HDL particles serves as protection to the body's cardiovascular health (in contrast to "bad" LDL cholesterol).

Men tend to have noticeably lower HDL levels than women. Men also have an increased incidence of atherosclerotic heart disease. High concentrations of HDL (over 60 mg/dL) have protective value against cardiovascular diseases whereas low concentrations of HDL (below 40 mg/dL for men, below 50 mg/dL for women) are a positive risk factor.

From the vast number of human feeding studies conducted over the last 50 years in many parts of the world, in healthy volunteers and people with heart disease, it is very clear that the type of fat in the diet plays an important role in heart health.

There is little evidence to suggest that moderate changes in total fat without a change in the type of fat has any beneficial effects and might actually produce a more detrimental effect on cardiovascular disease. From these studies some common conclusions can be drawn.

Saturated fats increase LDL and HDL cholesterol but have their greatest effect on LDL. Monounsaturated and polyunsaturated fatty acids both decrease LDL cholesterol. Except at exceptionally high intakes, polyunsaturated fatty acids does not decrease HDL and monounsaturated fatty acids may actually increase it.

The net effect is that saturated fatty acids increases the LDL/HDL-cholesterol ratio whereas monounsaturated and polyunsaturated fats decrease the ratio.

Thus, any incremental increase in the intake of saturated fats increases the risk of coronary heart disease, whereas monounsaturated and polyunsaturated fats produce a favourable blood lipid profile and decrease the coronary heart disease risk. Therefore, intakes of saturated fatty acids should be as low as possible while consuming a nutritionally adequate diet.

Trans fatty acids also increase LDL cholesterol, similar to that of saturated fats. However, unlike saturated fats, trans fats decrease HDL cholesterol and therefore trans fats increase the LDL/HDL cholesterol ratio to a greater extent than saturated fats.

In other words, trans fats are more dangerous than saturated fats. Many western countries have taken steps to reduce the trans content in processed foods and margarines to the lowest level possible.

Tips for consumers

1. Since saturated fatty acids are associated with increased risk of cardiovascular disease, avoid using oils in cooking that are high in saturated fats, such as coconut oil, palm oil, palm oil, butter, lard (pork fat) and other animal fats.

2. Choose vegetable oils with the best nutritional profiles - those with a healthy amount of monounsaturated fat and the two essential n-6 and n-3 polyunsaturated fats and low in saturated fat.

Of all the vegetable oils, canola, and to some extent soybean, are the healthiest oils. Use these oils as salad oil, cooking oil and to stir-fry vegetables or saute foods.

3. Other vegetable oils such as olive oil, sunflower, safflower, and corn are also low in saturated fats. However, canola and soybean oils are far superior to other vegetable oils, because they can provide both n-6 and n-3 polyunsaturated fatty acids.

Other vegetable oils contain primarily n-6 polyunsaturated fatty acids and almost no n-3 polyunsaturated fatty acids. Excess intakes of n-6 polyunsaturated fatty acids are not recommended because large levels of n-6 fatty acids in blood may have some negative effects on heart health.

On the other hand, the n-3 fatty acids counteract the negative effects of the n-6 fatty acids and provide protective effects on cardiovascular risk. They may also improve other cardiovascular risk factors such as platelet function, blood pressure, blood flow and inflammatory processes.

Thus, it is imperative to have a good balance of n-6 and n-3 fatty acids in our diets. In this respect, canola oil is the best vegetable oil, because it provides n-6 to n-3 in a desirable ratio of 2:1. Soybean oil can also provide both n-6 and n-3 fatty acids, but the disadvantage is that it contains too much n-6.

4. Choose soft margarines that are low in saturated and trans fats instead of butter, hard margarines, lard and shortening.

5. Substitute unsaturated oils (such as liquid oils or soft margarines low in saturated fats and trans fats) in recipes that call for shortening, butter, hard margarines, lard or beef fat..

6. Use a small amount of oil to saute or stir fry foods rather than deep-frying in oil. Deep-frying uses a large amount of oil, which is soaked up by the foods, thereby increasing the overall caloric content of those foods.

7. Although deep frying is not a healthy choice, if you have to deep fry, choose a hard fat such as coconut oil, palm oil are or palm kernel oil. These oils more stable than unsaturated liquid vegetable oils. Because of their high saturated fat content, they do not break down during deep frying.

Although fried foods are more tastier than non-fried foods, because of the negative effects of saturated fats on CHD, it is best to limit eating deep fried foods on a regular basis.

8. For pan frying, it is not necessary to have a highly stable oil. Oils containing high levels of monounsaturated fats have a stability intermediate to that of saturated oils and polyunsaturated oils and are healthier than saturated fats.

For pan frying, use any of the very high monounsaturated oils, such as canola or olive oil. Once you use the oil for frying, do not use it again for frying or cooking. Polyunsaturated fatty acids tend to break down when they are exposed to high temperatures for long periods. Therefore, always use fresh oil for deep frying.

In summary, oils containing large amounts of saturated fats or trans fats are considered as bad fats. Bad fats include coconut oil, palm oil, butter, various animal fats and hard margarines prepared using partially hydrogenated oils. Polyunsaturated fat, along with monounsaturated fats are good, healthy fats and they can be found in oils such as canola, soybean and olive.

Polyunsaturated fats are necessary for the body and protects against illness.