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Archive for December, 2012

 

* Obfuscation:  hiding of intended meaning in communication, making communication confusing, wilfully ambiguous, and harder to interpret

This world can not be a perfect place and  it is foolish to expect the same !   What is published in medical literature is at best , an abstract thinking  of an unfinished agenda . Still public think  science is   . . . what doctors say ! They feel doctors can not simply watch a person  dying. They want us  act like  God. This is  how medical men became Demi-Gods  by default.

Here was a big opportunity . Who exploited it ? Obviously the greedy corporates  who embarked  on a dirty journey to en- cash this trust  and fill their coffers .This is the foundation  on which the  basics of medical market economy rides !

It is an un-pardonable on-going deceit among  modern human civilization . It has  spoiled  the trust between the patient and doctor and  probably  irreversibly  contaminated  in recent decades !

There are very few positives  though,  with occasional noble medical  souls (Like  BMJ,Lancet )   trying to keep the sinking ship afloat !

This sounding board article (Now we rarely  get to see )  from NEJM way back  in 1975  exposes a  shocking revelation  politely . Now, 40 years after ,  the importance of such article has grown  many fold . We are witnessing  every day ,  medical scientist break  stories ( Yes  . . . it is story )  in general media  with  absolute academic cowardice !

We expect more such  face bashing articles from NEJM . It would definitely  make   immense  good  for  our profession  which needs it  desperately !

Reference

I’m linking the original NEJM article ; Hope it does not violate copy right !

http://www.bumc.bu.edu/facdev-medicine/files/2011/03/Crichton_M_nejm1975_293_1257_medical-obfuscation_structure-function.pdf

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6 minute walk test is the simplest of all functional testing in cardiac evaluation . Though  walking  is  a routine day to day motion ,  it is  essentially  a hemo-dynamic stress for the  heart ,  especially so for an ailing heart . Even though  it appears  simplest  of all investigation  there are strict guidelines  available for performing  this .

It is  surprising  American thoracic society  has come out  with a  specific guideline for this .Many of us  are not aware of  existence of such guideline   ,  hence this post  , with courtesy of ATS I am  giving a link.

    Guyatt G. H.,Sullivan M. J.,Thompson P. J.,(1985)  The six-minute walk: a new measure of exercise capacity in patients with chronic heart failure. Can. Med. Assoc. J. 132:919–923.

Butland R. J. A.,Pang J.,Gross E. R.,(1982) Two, six, and 12 minute walking tests in respiratory disease. B.M.J. 284:1607–1608.

History and genesis of the concept

It was originally used in COPD in 1976 with a 12 minute walk .Cardiologists abbreviated it to 6 mts for their convenience.

McGavin CR, Gupta SP, McHardy GJR. Twelve minute walking test  for assessing disability in chronic bronchitis. Br Med J 1976;i:822-3.

In modern times we have an Android application  for 6 minute walk test

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This article   provides  you every thing  you  want to learn  about ASD device clsoure .The anatomy , the art of doing TEE in cath lab etc.Do not ever shy away from lesser known journals .It is simply amazing  to find  hidden treasures .Thanks to  Mr Tim BernersLee  invenor of the Internet !


mexican cardiology journal

 

Sample this arricle

 http://www.elsevier.pt/en/pdf/90140903/S300/

 

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Even though cardiologists consider themselves master of ischemic heart disease , their collective clinical acumen is  put into  acute stress test   when they  confront  a patient with dilated LV and severe  LV dysfunction.This is not  a  rare situation  in clinical cardiology we stumble upon such instances often .Most of them are conferred a  tag  of DCM .

The differentiation from ischemic  vs idiopathic or primary muscular is not a  wasted academic exercise  , since   ischemic  DCM  may get reversed with revascularisation .We have  various  tests to differentiate  ischemic from idiopathic like CAG,MRI, 3D RTE, etc . Still common sense would tell us   95 % of times we can  differentiate ischemic DCM from non ischemic by asking  two critical questions  in the  bed side  echocardiogram

  1. Is there a regional wall motion defect ?
  2. Does all 4 chambers of the heart is enlarged ?

Idiopathic DCM is primary disease of muscle hence  the cardiac   muscle as a  whole  fails  ( We know they are a single  folded  muscle sheet )

Since  Ischemic DCM  primarily affect left ventricle and left atrium  RV,RA enlargement  are terminal events.

* Please note the traditional dependence on CAG to  diagnose  ischemic DCM is fraught with a risk of missing small vessels  induced  DCM,

*** If atrial fibrillation is present longstanding it can dilate both atrium but still RV will be normal  in sized in  ischemic DCM until very late stages

Here is a  20  second flow  chart  to differentiate ischemic  DCM  from idiopathic

ischemic verses idiopathic dcm

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If you are a doctor  and  whatever  be your specialty   . . .  if you do  not read this article  and understand the nuances  probably you  will not become a   complete medical professional !

Master health check up futility general health check

master health check up geenral health checks bmj british medical journal cohcrane nordic

 

While  BMJ  struggles to  propagate  a vital truth , this  banner on a  Indian  high way   tempted the public  to go for 64 slice CT scan   . . .just like that !

Master health check up 2

Final message

Accruing medical knowledge and skills is only one aspect of medical profession. Applying it properly in our patient population is entirely  different ball game . Let us be disease curers and not disease hunters . This is important because disease  hunting is  a dangerous  game ,  where victims can be innocent  bystanders. This  is exactly same thing  Hippocrates  refered to as  Primum non nocere  1000 years ago.  It  has required  a huge statistical study to RE-INVENT  this universal fact !

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The  major  issue of contention is fear of conversion of pure ischemic stroke into hemorrhagic stroke .

But here is a catch if you worry about that  . . . who will worry about recurrent emboli from heart ?

References

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2678170/pdf/nihms104070.pdf


anti coagulation following cardio embolic stroke

aha stroke guidelines 2007

aha stroke guidelines

Recommendation for heparin

aha antiplatlet agent

Recommendation for anti-platelet drugs

I think  the 2007   stroke guidelines are the latest .Even after going  through the guidelines  I am not really clear about the answer for the question posed in this article.

One more thing   I  (mis) understood was  ,  In acute stroke thrombolysis seems to be safe  . . . Heparin seems to be dangerous ?  Is that true ?  It defies logic for  me !

One possible explanation is thromolysis is a emergency single shot salvaging  process . While prolonged heparin will ooze blood into Infarct ! This is exactly is the reason  in   tPA   should not be   followed up with heparin  in acute strokes.(unlike STEMI  where a follow up heparin is a must )

Regarding prevention of recurrent emboli , we need to bother about whether it is predominately platelet rich or RBC rich

Readers may contribute to find the exact answer !

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LVH is   a common ECG  finding .Classically  it should produce tall  R waves and deep S waves in V1-V3 .

But it is well known deep q waves also can occur in LVH  especially in severe  forms of pathological LVH.

Q-LVH INCOMPLET LBBB STEMI DIFFERENTIAL DIAGNOSIS

Why the septal R disappears in some is not clear .( due to  myocardial dis-array ? )

LVH  results in  secondary ST /T  changes either inherent or associated  conduction delay. (In-complete LBBB )

Final message

Errors  mistaking LVH for STEMI  is more common than we realise . Propagation of the  term  Q -LVH with ST elevation  will help  reduce this common error in coronary care units.

 

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