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Archive for September, 2010

Mankind’s  elusive pursuit of happiness  has an  interesting relationship with human physiology.The recent research  from  Princeton  university has confirmed a concept about the relation between  happiness and the economic well being .It was strange it exactly mimicked a famous physiological concept involving hemoglobin and oxygen.

Two simple questions were asked

  1. Can money bring happiness to life ?
  2. Is there a linear relationship  between money  and happiness ?

The answer to the first question is  “yes” it can.

The answer to second  looks complicated but , it is actually simple !

The relationship between money and happiness is  linear initially  , till it  hits the flat  section of  the curve  at 75000$ /year . (In India it may at 12,0000 lakhs/year)

Like hemoglobin , which   gets saturated  with oxygen  at  Pa o2 of  90  %  ,

Beyond  a particular point , however much you increase  your salary , the  mind can not be enriched with further happiness !  , as all the happiness receptors  get  saturated !

Link to Princeton university paper

Another  curious phenomenon is ,  the more time you spent  in pursuit of happiness less likely you get it  !

(The following  illustration  is from the original Princeton paper which i got from  NDTV  website )

http://profit.ndtv.com/news/show/the-odd-relationship-between-money-and-happiness-102103

Hemoglobin Oxygen dissociation curve

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Cardiology is probably the most rapidly growing field  in medicine. Radiology is closely following .When both combine together there is  bound to be  plenty of action ! That’s what is happening with this journal .

Knowledge is power , do not bother if you do not have such  a machine in your work place.Just know what is happening in the world of cardiac imaging.

http://jcmr-online.com/

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  • Endothelium is the largest vascular organ in the body .
  • It is constantly being serviced by both the circulating blood  from the luminal side as well as from the abluminal plane.

  • The discovery of nitric oxide and endothelin  was a breakthrough .
  • They are under neural, mechanical and endocrine control .
  • Negative emotions like anger and depression has a high correlation with hypertension and cardiac event
  • Positive emotions like laughter and happiness is expected to have good vascular tone

This fascinating  study from Japan and USA (Texas)  published  in American journal of cardiology , discusses how a comedy movie possibly releases nitric oxide profusely from our endothelium

Link placed with the courtesy of AJC

http://www.ajconline.org/article/S0002-9149(10)01050-7/abstract

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The world of  medical science is  moving in a alarming speed.In any field , speed is always dangerous ! That’s why we have speed breakers , traffic police , speed cameras , etc etc . The medical world  is flooded with new devices, drugs , procedures . Though the mankind is benefited with many of them , a equal number could do the opposite.

How to identify which is causing benefit and which doing harm ?

It is a horrible fact , this is the most difficult exercise  for the  medical academia   . . . Still worse , harm will masquerade as benefit ! Further ,  beneficial concepts are  often buried alive if  it lacks  glamor  or  commercial value (Eg: The Digoxins,)

Lay public (as well as )  the physicians   are fed with half-baked ( Often quarter baked !) medical information .Many  of the medical journals,  guidelines , sponsored  seminars  ,  some times  even text books do a clandestine  campaign  . Even after a completion of major trial,  real truths rarely  come out . Funnily ,  they call them aptly , as blinded study ! Who is blinding whom is a different issue .

So ,  in  this  new millennium , thousands of innovations are on the pipeline. These pipes are often  infested with trivial , duplicate or even  harmful  concepts waiting for a grand release into human domain.

Take the story of coronary stents

In 1977 , Gruntzig mastered the  opening  of  the obstructed coronary  arteries with a simple balloon without any add ons . That patient is still alive  without  angina  . In the next 30 years we have ridiculed (Rather , we were compelled  to ridicule it ! * Read the related article  Is  there a role for  plain balloon angioplasty ?

Technology made  it  possible to introduce a  gamut of intra coronary  devices .We used (?abused ) all sort of anticancer drugs within the tender human coronary arteries .In 2002 , we claimed to  have climbed the summit and conquered  the restenosis with DES. And in 2010 , every one knows  what is happening to DES .

The malaise is  deep rooted  in every specialty . Next  came the  Stem cell fiasco ? and more  recently huge  conflicts of interest exposed  in the  vaccines  against H1NI

Final message

Who is going to regulate the menace ?  Hmm . . . . then  . . . Who will regulate the regulators ?

Is there a way out for our patients ?  or  they  have to suffer with it  along with the disease . The later is  more realistic option !

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In 1960 , exactly 50 years ago , a group of doctors from Jhon Hopkins published their observation in 20 cases. It went on to become , one of the most remarkable discovery  in the history of cardiology .

They taught us how to use  a pair of hand  ,  as an  artificial  heart and save lives

They are . . .

  1. Dr Kouwenhoven*
  2. Dr  James R. Jude, and
  3. Dr G. Guy Knickerbocker .

* He was not a medical doctor but an electrical engineer at Hopkins but he worked in the medical school as well .

They meticulously documented , each patient’s case history ,  whom they were able to successfully revive , (It was in the same  period , the  AC/DC shock was also invented  in the  Hopkins ) .One of  the  highlights of their paper was ,  with each chest compression  they were  able to elevate the carotid pressure  up to 90mmhg and was recorded in a pressure tracing .

We have to thank the  JAMA (Journal  of American medial   association )  for  making this  original  article   available  free in their website .

Must read for every cardiologist

http://jama.ama-assn.org/cgi/reprint/173/10/1064?ijkey=33bb40fe3062331bae50e10c8a04263f3e26b317

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We owe a lot  , to  our ancestors for making our  journey   smooth  and purposeful   in  our  pursuit ,   of   healing the   mankind  . It is because of their  meticulous  clinical acumen , passion  , dedication ,sacrifice we are enjoying  the fruits  of success .

Though there are thousands of them , one life that always fascinates  me is that of Harvey Cushing. His fame went  to dizzy heights  after his publication of  biography of William Osler .

A book every medical  professional must read and cherish especially the elite cardiologists !

I wonder  ,what  Harvey Cushing  ,  if alive would make  a difference  in the current  world of medical  science contaminated with commerce ,  hyped up technology ,  and  the near extinct bed side clinical skills.

Links to life of Harvey Cushing http://www.med.yale.edu/library/historical/cushing/peter.html

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We now understand , heart rate reduction  could be the single most important factor  in the management of heart failure .Beta blockers have proved this time and again.We know heart rate has a linear relationship between survival .

SHIFT trial has  proven  that  Ivabradine  has a major role in the management  of chronic heart failure therapy .It is an If current blocker .  No hemodynamic  side effects was noted.

How does Ivabradine act ?

It acts on the phase 4 diastolic depolarisation in SA node by slow I f  currents.

SHIFT trial Link to lancet

SHIFT study official website

In this trial , the usage of  optimal Beta blockers  was  only in 25 %  . Patients  who received   complete beta blockade did show much benefit with Ivabradine . Further, the usage of  digoxin was only around 20% .This does not represent  the realistic  population of  cardiac  failure in many  countries  .In India , almost 70-80 % receive  it . Digoxin , the wonder drug does have an important vago mimetic action, to  reduce the heart rate .

Another  contentious issue   in SHIFT study  is , the Class 4 patients constituted <2% of the study population .It is ironical , these are the patients , one would  like to try a new rate control drugs like Ivabradine  , because we  are worried about beta blockers in this population  .A great opportunity was  lost as Ivabradine could have  been tried in this population.

We need a study  like this .

  • One to one comparison   of  beta blocker  and   Ivabradine  in cardiac failure  . Such a study will ever happen ? My guess is , it is  next to impossible !
  • Efficacy of  Ivabradine in patients with class 4  failure  , where beta blockers were contraindicated  or could not be administered.

Final message

Ivabradine , a new generation  negative chronotropic agent  is a great concept drug. But , the worthiness of this drug  is questionable , when we have  proven , well tolerated  drugs namely , the beta blockers to reduce the heart rate.. However , if the beta blockers are poorly tolerated  Ivabradine may be tried.Last , but not the least, never under-estimate the greatness of digoxin in heart failure.It is the only drug that has a positive  inotropic  properties coupled with  negative chronotropic action . Both benefits patients in CHF  . It can do wonders than any other drugs .(DIG trial was the most misunderstood by cardiologists!)

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