Posted in Infrequently asked questions in cardiology (iFAQs), myocardial disease, tagged cardiology table, DCM, ischemic and idipathic dilated cardiomyopathy, ischemic vs idiopathic dialted cardiomyopathy on July 31, 2011| Leave a Comment »
This seemingly straight forward question is often asked in cardiology boards.
The answer to this question is important in the bedside as well ! Ironically , with sophisticated diagnostic modalities the complexities has also multiplied .
The following table attempts to simplify it. ( Mostly written with a personal knowledge and ignorance !)
Please click on the table to visualise a high resolution image.
Posted in cardiology-ethics, tagged error in judgment, errors in medicine, ethics and doctors, hippocrates, medical errors, medical mistakes, medical negligence, procedural complication, side effects of drugs vs doctors on July 29, 2011| 1 Comment »
This is because . . .
Answer
Though all the above contributes for this behavior . It is the response 2 that plays havoc on patient care !
Discussion
It is a well-known fact millions of medical mistakes happen every year across the globe .Most of them are committed by medical professionals and equal number of them result from untoward effects of drugs, complications of procedures and surgeries.
Apart from these , laboratory errors in reporting and interpreting diagnostic tests happen on hour to hour basis in any hospital . Many of them could have serious implication in patient outcome . Though doctors do periodic auditing the incidence continue to galore and there is very little data to suggest the overall incidence has reduced in any significant fashion .
In many sense doctors do share some similarities with drugs and devices . Like the ubiquitous drugs and devices , diagnostic tests, , doctors too cause side effects by their action or inaction . It is referred to as , undesired response, complications, error in judgement , negligence , ignorance etc ( Read a related article in my site)
Like the famous quote of ( Osler I think )
A drug which causes no side effect will not have the desired effect as well . . . a doctor who has not caused any injury to their patients can never be considered as an accomplished doctor !
Drugs like statin which is supposed to reduce cholesterol in blood misbehaves with liver and can even result in fatality .We accept it .The matter ends with a FDA box warning .
If a ventilator crashes due to a soft ware problem , we accept it . We can boldly admit medical errors if it is a fault of a drug or machine. But , errors by doctors are rarely pardoned ! So it is natural they are swept under the carpet.
When doctors do delicate cardiac surgeries , it takes only a fractional loss of concentration to cut the aorta and that could cause serious after effects .
These can be called as errors, mistakes or negligence in whichever way you like to call it. The problem is , these minor events (Which occur in thousands every day ) are not recorded, logged , or disseminated to our patients . Even medical law makers and judiciary is blinded to most of thing that happen inside the medical institutions.
So , the world will never know the reality .When we want transparency in all walks of life , we should at least fight for a minimum transparency from doctors.(Why cant they conduct the customary internal auditory meeting in the public domain !)
If only doctors admit their mistakes with courage medical profession will get more respect .Living behind veils never liberates . This traditional suppression of facts make the medical professionals high risk for guilt when truths unfolds .There is one Tamil proverb which says A half doctor is the one who has killed at-least 1000 patients . Still , a minuscule of doctors are ready to accept their mistakes .(Especially to their patients and their relatives , though they admit in private !)
Final message
Coming soon
Posted in cardiology -ECG, tagged left ventricular hypertrophy, lvh, normal voltage lvh, pathological lvh, physiological lvh on July 28, 2011| Leave a Comment »
Mechanism for LVH without high voltage
Read a related topic in this blog
Posted in Cardiology -Interventional -PCI, cardiology -Therapeutics, cardiology journal club, Cardiology-Land mark studies, tagged academic research consortium, classification of stent thrombosis, sub acute stent thrombosis on July 27, 2011| Leave a Comment »
Want answers for all these ? Your search ends here . . . The academic research consortium criteria committee provides everything free .
A must read for both mature and immature cardiologists . http://circ.ahajournals.org/content/115/17/2344.full.pdf+html
Here is a cartoon for classifying stent thrombosis (Time based )
There is another etio-pathological /Geographical classification for stent thrombosis that will be discussed later.
( Entry block , exit block , diffuse thrombosis etc Read -Geographical miss.)
A word about Academic research consortium
ARC is a consortium of clinical research from the Harvard medical school and their associates . The aim of which is to bring clarity in the definition of medical terminologies and study endpoints.A universal criteria is being prepared so that the study results are comparable which currently use different criteria and end points.
For cardiology ARC came out with standardized definition in the year 2007.
Posted in cardiology-ethics, tagged commerce in medicine, ethics in medicine, hippocrates, hippocratic otah, patien doctor relationship, pressure for prescribing, the hindu paper article on doctor patient relationship on July 25, 2011| 1 Comment »
It is heartening to read a series of open page articles in the India’s national news paper recently which started a lovely debate about how the medical profession and doctor’s behavior is being perceived in this country . It all began with this article by Dr Araveethi with serious criticism of the ways and means , by which doctors indulge in forbidden unethical acts . (mainly involving financial benefits ) Click on the Image to read the article.(Hope it works)
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While most agreed with his observation surprisingly one response by Dr. Manoramma Gadde tried to justify it ! promptly evoked strong reactions for and against.
And this response from Dr .A.R Antony to Dr Manorama Gadde CAME A WEEK LATER seemed a best one. Read for yourself
I enjoyed the entire article by Dr Antony , especially when he observes ethical doctors are a rare breed and even be a laughing stock among their colleagues. This is very much true but as he rightly points out , the majority of goodness should prevail over the minority of evil . ( Let us hope it is not vice versa , as evidence is mounting against this assumption )
What is the role of modern science in making medical profession into a self less service to service only for self ?
Read on this article : Truths when silent are not heard in consultation rooms
Is there acceptable level of unethical acts for doctors ?
100 % perfection is never possible in any field .
Like permissible carbon levels in environment and permissible contaminant in tinned foods one can suggest doctors can also be allowed a quantum of immorality ! (This is akin to making corruption legal still the ultimate aim is to control it ) .Probably this is what Dr Manorama tried to convey in his article !
What is the patients role in the perpetuation of un-ethicalness of doctors ?
A patient with half-baked ( internet fed ) medical knowledge asking for various tests is quiet common phenomenon . This is termed as pressure prescription . Patient interference in medical decision-making and doctors yielding to it is also a rampant phenomenon. Empowering patients beyond a level is unreasonable or not a desired goal.
Why doctors continue to be noble but many hospitals are not ! How is this possible ?
We have willfully accepted medical care to become an industry .When corporate hospitals are listed in stock exchange what do you expect of them ? I do not know how the current generation of prepaid medical professionals manufactured from various medical education factories in our country side will behave . It is them , who are running these dubious hospitals and nursing homes . In my observation a genuine and meritorious medical student is never interested in starting a hospital or nursing home . He lacks both the business sense and also the resources . Hence he or she often becomes an employee of a hospital or institution run by capitation fee fed neo- medical graduates with Dalal street mentality.
Counter point
There are thousands of doctors especially in primary health centres and emergency wards working round the clock in all those ill equipped poorly staffed Govt hospitals trying to save lives desperately . Similarly many private practitioners sitting in the remote towns and villages spending their precious evening caring for the sick.
So , the problem lies mainly in the proliferation of pseudo – modern medical science in an unregulated fashion mushrooming into the urban and semi urban areas .
Solution ?
Never believe the private sector in the present form (*Total chaos) will provide an inclusive health care to our population. The recent WHO statistics say India is the only country where permanent assets like houses , livestock are sold by people to get a seemingly modern and scientific health care .(Poor villagers are asked to spend their entire monthly salary to do a costly PCR test (Now proved useless) to diagnose a AFB positive open tuberculosis !)
The current model of health care in most developing countries especially India , which our corporates are actively pursuing is counter productive for both rich and poor.
A rich old man is simply not allowed to die a natural death without spending a chunk of his accumulated wealth , while a young , active poor men of our country die for want of those same facilities which goes futile those dying elite bodies !
*Let me drift to a different topic . The private sector health care is totally disorganized , lies in complete chaos though enriched with infrastructure and other resources. What they lack is the terrible common sense. While the Govt sector has a organised administrative and functional model with huge expertise which lies mostly dysfunctional due to various reasons. Which is causing more danger to society ? The answer is tough one It would a close race between hyperfunctional private sector or dysfunctional Govt Sector .
I dream a day when these private sectors take over the Govt hospitals and vice versa so that both can complement the best between them.
Final message
Most doctors are really noble in their thinking. In few ,their action may occasionally touch the lines of immorality .( The definition of immorality or unprofessional acts are often reset according to our convenience ) .
Even if a conscious doctor wants to do genuine work in the existing system , he is rarely allowed to pursue it . So , in the current situation most doctors are at risk of tasting the bad fruit every day with or without their knowledge.
The doctrine of hospitals lack ethical code , while it is expected from individual doctors is the single important factor that is responsible for the present chaos in medical care delivery
So in my final analysis I agree with many of the arguments on both sides .Even though ethical doctors are available they are in a very short supply . We need much , much more . . . I am afraid the future looks bleak ! . . . with humble excuses to all optimists out there.
What is your take on this issue ?
Posted in Cardiology - Clinical, cardiology -ECG, Cardiology -unresolved questions, tagged eatly repolarisation in women and men, ers pattern in ecg, ers uncommon in women, gender and repolarisation, incidence of ers in women, K channels in women, pottasium channels and repolarisation, qt interval and gender, t inversion in women, tall t waves in men women, why long qt in women on July 23, 2011| Leave a Comment »
Possibly yes !
In a preliminary analysis of 50 consecutive ECGs with ERS pattern, only 3 were females .An astonishingly low incidence of 6 % is it not ? . The 94 % exclusivity in males demands a detailed EP analysis of this entity.
How often you see an ECG such as this one in young women ?
This finding may not be a surprise , if we link another fact namely , the longevity of QT interval in women. Repolarisation begins when rapid sodium channel extinguishes and potassium channel starts firing and efflux this cation from within the cell .This happens during interface between phase 0 and phase 1. This point corresponds to the onset of repolarisation.
The onset of repolarisation is not entirely related to K+ efflux (Rather K + determines largely the duration of repolarisation).QT interval is prolonged in females because repolarisation is slow in women .In men it is early , short and swift .
The mysteries surrounding the ion channels especially the K+ with vast genetic and gender heterogeneity is yet be unraveled. Influence of sex hormones on right from the early days of fetus could be one such area for research.
Other related gender specific ECG findings include
Link to another article on Early repolarisation syndrome from this blog
Final message
It is a well recognised fact , repolarisation is brisk in men and slow in women .It is now realised , the onset of repolarisation is also earlier in most men . This has a direct bearing in the impact of ischemia on fibrillation threshold . Arrhythmias induced by EADs are logically more common in persons with ERS.
Statistics again reveal men are more likely to have primary VF during STEMI . ( Male Gender by itself a CAD risk factor !) .Recently Hassagure et all elegantly documented , ERS is indeed a risk factor for primary VF at times of ischemia
Reference:
In the above article , the incidence of ERS was 72% in males , considerably lower than our observation . Still , the male dominance is confirmed. We still feel in our country true ERS occurs in a negligible minority of women. This finding need to be confirmed with data from other centers .
Posted in Cardiology - Clinical, Cardiology -Interventional -PCI, cardiology -Therapeutics, Cardiology -unresolved questions, cardiology-ethics, tagged gimmicks called statisitcs, impact factors in journals, limitations of study, modern scientific papers, original research, randomised controlled studies, rct on July 22, 2011| Leave a Comment »
“Limitations of a study” column appear in scientific articles because . . .
I fail to understand , why even good articles are rejected for minor errors in methodology by many journals.
Meanwhile , how on this earth it’ s possible ? for some articles to appear in top journals ( with questionable conclusions ) embellished
with major errors in methodology , but has a proud declaration and confession about the flaws of the study in the “Limitations of study” column !
So , in this modern scientific world , it suggests to me , one can can write whatever you think as science , as long as you declare it and able to impress the editors to shift the errors into limitations column , you are likely to be excused and also rewarded !
Posted in Cardiology - Clinical, cardiology -ECG, Cardiology -unresolved questions, tagged benign st segemnt changes, benign t wave inversion, early repolarisation syndrome, ECG, ers pattern, flat st segment, flat t wave, flattish st segment, non ischemic st segemnt, non specific st segment, st elevation, T WAVE INVERSION on July 21, 2011| 7 Comments »
Often general practitioners refer ECGs with abnormal resting ST/T wave patterns to cardiologists .
Following are few of them
The commonest( benign) abnormality is T wave inversion in women and tall ST /T waves reflecting early repolarisation pattern in men. A flat ST segment is an occasional finding in general population.
ST segment is inscribed during the most important time of cardiac cycle.This is the period the ventricle is doing its prime function , namely ejecting the blood in systole .Hence it is subjected to maximum stress . During times of ischemia ST segment gets elevated or depressed depending upon the severity of ischemia. For the same reason , even subtle changes in this segment is frowned upon by cardiologists. Most of them would receive a EST.
It is ironical to note , few normal people show almost silent electrical activity during this crucial phase of their ECG .ST segment is often a flat line in them . This is a ECG of a women referred as CAD. She was asymptomatic . Echocardiogram was normal . She was asked to do a EST.
This asymptomatic women was refered for ECG opinion
The peculiar thing about T waves are , a 10 mm upright as well as 5 mm inverted T wave , both can be normal. So . there is no element of surprise to note absent T waves or a flat T wave to be called as normal .
The curious case of lost ST segment !
* T waves are recorded when K+ efflux occur rapidly out of cells . Hypokalemia can be an important cause of flat T waves.
It is still a mystery to me why some people inscribe a tall T when potassium comes out of cell and an equal number (Esp women) record a down ward T wave for the same event ! I wish I get an answer to this lingering question from any of the readers !
Is a flat T wave represent a T wave in transition to become inverted T wave later ?
Possible .But we are not sure ! A static T wave is safer than a dynamic T wave .
Final message
Flat ST segment and absent T waves represent a same spectrum of ECG findings which are referred to as non specific ST segment changes in clinical practice .Generally , they have little clinical significance.* In our experience we have found , female patients, Anemia hypothyroidism are often associated with flat ST segments . If CAD is suspected exercise stress test should be done. Some believe a flat ST segment is more likely to result in EST positivity (Not necessarily true positive !)
* Non specific ST/T changes by itself is a huge topic. Ideally the term non specific ST /T changes should be avoided , as it primarily came into vogue to denote non ischemic ST segment (Still , other pathologies are very much possible) It is estimated there are about 50 causes for non specific ST/T changes , right from a benign situation like deep respirations , to significant myocardial disorders. However , it still makes good clinical sense for a general practitioner , to refer to a cardiologist , whenever ST segment deviates without any reason .
Posted in Cardiology - Clinical, Cardiology -Interventional -PCI, tagged complications of coronary stenting, coronary stenting, edge lesion, exit block in cath lab, geographical miss, plaque stent dissociation, stent lesion mismatch, tips and tricks on July 21, 2011| Leave a Comment »
Landing an aircraft is a high precision job. A pilot and co pilot with the help of air traffic control must do this job meticulously every time .They are not afford to make any mistake .Number of lives are at stake.
In cath lab something similar happens every day although a single life is at stake ! We call this coronary stent landing . If it lands wrongly it is referred to as geographical miss , a descriptive terminology for a poorly deployed coronary stent ! ( In strict terms it should be called as failed PCI !)
But there are few vital differences between the two . . .
If an aircraft overshoots the runway it is visible to every body and it becomes a national news next day !
If you deploy a stent away from a lesion it is usually a silent event . Only a few alert fellows and staffs know it ! Patient often gets discharged next day (of course after paying the bills ) and the consequence is often delayed by weeks or months when he comes back knocking the ER doors with an ACS !
Final message
The stent -plaque dissociation is much more common than we perceive , for the simple reason cardiologists have learnt to accept luminal shadows as surrogate markers for plaques . ( Coronary blindness !)
It is imperative to apply all our senses properly in the cath lab , like our pilots do while they land . Be prepared for turbulent weather which is common in cath lab as well !
http://www.sciencedirect.com/science/article/pii/S0735109701011123
Posted in Uncategorized, tagged diabetes and statins on July 20, 2011| Leave a Comment »
This article is from the journal JAMA July 2011 , and “The Telegraph” breaks the News in general media because of the immense importance it has for the public.
http://www.telegraph.co.uk/health/8589168/High-dose-statins-increase-Type-2-diabetes-risk.html
http://jama.ama-assn.org/content/305/24/2556.abstract
HMG COA reductase has a new side effect when used in high doses. It is now official , it is confirmed by this meta analysis.
According to this study the risk is mainly with 80mg of Atrovastatin . But the dose at which the diabetic risk develops is highly variable.
In simple terms . . . It all depends upon how a person’s liver responds to ingested statins.
Statins are not divine molecules that can heal atherosceloris. It mercilessly blocks the vital cholesterol synthesizing enzyme HMG COA* located in every cell , especially it has a virulent action in the hepatocytes . We know liver is the major metabolic hub which co ordinates glucose and Lipid metabolism and to certain extent amino acids as well . These statin infested hepatocytes can interfere with glycolysis , neo-glucogenesis and lipolysis in a complex fashion . It would not require great brains to understand how diabetes can be induced by statins !
* Which also has a indirect cell/ lipid servicing action.
Final message
It is becoming increasingly clear , statins should be used judiciously in whatever dose . We need to be in constant vigil even as the human lipid is under siege from the corporate board rooms , who are primarily worried about the decline in the per capita consumption of these ubiquitous molecule !
Dr.S.Venkatesan MD 