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Archive for the ‘history of cardiology’ Category

William Withering the British Botanist of 18th century now laid to rest in the St Barthomlew Churchyard ,Edgbaston is known for his astonishing isolation of the wonder moelcule Digoxin from Foxglove. (Of course, let us not forget original old lady Ms. Hutton from Shropshire who was treating epidemic dropsy with a concoction of herbal Tea ) He reported this in the seminal paper “An account of Foxglove’ in the year 1750 and subsequently became a fellow of Royal college of science.

(The story of Withering and Digoxin is extensively researched and written by Dr Dennis M, Krikler in a classic review article of 1985 JACC )

Near-death experience of Digoxin

After 250 years , saving millions of life, modern science has killed this warrior (inadvertently ?) by a minuscule study with serious flaws called DIG trial *published in NEJM 1997. It exposed the truth that science in flimsy forms can misrepresent fact. Actually many wouldn’t agree its a bad study. But , everyone realised , the conclusion was misinterpreted and disproportionately given weight to one aspect.The conclusion was worded in such a fashion, which sort of implied a negative bias.

*Yes , flaws were discussed in one of our detailed journal club meeting .

DIG trial

This one study was good enough to smear this drug with a knockout punch as if we are administering poison to a patient with heart failure.Thus a grand old drug became an object of ridicule in academic forums. Subsequent offline real-world scrutiny clearly indicated reduced hospital rate admissions and preventing worsening of HF was directly improving the mortality for which there were no takers. At least occasionally we need to realize there is foolish face for statistics. Now we are beginning to restore some lost sense.

 

What’s happening in 2019

The same scientific methodology finds Digoxin to have great value . JACC.  Awais Malik from Veterans Affairs Medical Center, Washington DC and others try to  dig out a truth.

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Whoever is blaming this as a withdrawal study are requested to go through the basics of how adding a drug doesn’t help but stopping it worsens. Another group has a different issue. There is a tendency among the scientific community, to look down on studies done in VA hospitals as if they have lesser academic value. I strongly object to that if it’s true. Never have preformed opinion about a study by its source.

How does Digoxin act?

Mind you, Digoxin was working all alone in CHF in the past without the help of all-powerful loop diuretics which was discovered 200 years later, This adds more credit to Digoxin since it has a combined the action of diuretic, anti sympathetic and vagal modulating action, and AV nodal regulation. The only issue with Digoxin could be its safety profile, which if carefully taken care can be overcome. (Afterall, we are trained for this job ) One may call it a most comprehensive drug amongst others in cardiac failure.

Final message

Ignore the greatness of old drugs at your own peril. Foxglove blossoms again, after a gap of 30 years. Please don’t crush it this time! Let Willaim Withering smile from deep inside his resting place at Barthomlew Church along with millions of heart failure patients.

 

Reference

1.

2.History of William Withering

3.Ahmed A, Rich MW, Love TE, et al. Digoxin and reduction in mortality and hospitalization in heart failure: A comprehensive post hoc analysis of the DIG trial. Eur Heart J. 2006;27(2):178-186

Postamble 

A funny business Idea

I guess Parke Davis those days had wholesome rights for Digoxin. May I suggest few tips for the industry how to capitalise this newly generated enthusiasm. Please ensure this drug sounds anything other than Digoxin which seems to have a stigma attached for the modern guys.

Try renaming this drug , a sodium-potassium ATPase blocker, as DiNaKatban and patent  it as a unique weekly depot Injection with an attractive  499$ price tag. Another option is to add Digoxin ,Neprilysin and Frusemide,  possibly an ARB  ( Dinephrimab) and project it as polypill for HFrEF . Publish it in NEJM with a huge non Inferiority trial,break it in  ESC or ACC .Consider selling it on all heart failure clinics with a special launch. I am sure, the same guys who ridiculed this drug for so long, will ask their patients to stand first in the queue. Call me, if this new generation Digoxin doesn’t vanish like hot cakes from these pharma malls.

 

 

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Charles river esplanade ,Boston* : A healthy middle-aged man who was jogging quietly, while his heart was under intense scrutiny by the bionic eyes of Apple i-watch’s smart patch electrode. Suddenly, it detected some bizarre ST segment fragmentation (Seems it can predict in advance , Ischemic signals 10 minutes prior to onset of ACS ) The built-in cosmos direct GPS instantly alerted & summoned a titanium powered Space X drone that pulled the patient from the riverside to the nearest human wellness port .

EHANG 184

It dropped him through a remotely accessed split glass roof right inside the hybrid heart lab, to find , men and women chatting with flattish Artificial intelligence panels who readily allowed the robotic arms to hug the patient which engaged the coronary artery pushing radiation free magnetic gas found nothing inside and what would become a perfectly normal human coronary artery .

An amused resident robot gently plucked the patient from the cath table with sheepish laughter and called for another drone to drop the patient exactly in the same place from where he was picked up.The healthy hearted patient thanked the doctors profusely and continued his routine evening jog across the Charles of course with a 16-minute delay!

Next day . . .

Event auditing firm medi-logic mind congratulated the entire cardiac team and its digital health hub for the quality of the network and completing this daring coronary rescue mission in 16 minutes. While the drone to hospital roof time was 3 minutes, the coronary artery visualisation time was perfect.The auditing team had a special mention about the astonishing capability of Apple time watch algorithm that made sure that the patient’s evening routine was unaffected in spite of this life-threatening non cardiac pseudo-emergency. The crowning glory was, the entire expenses amounting to 250000 dollors (after a special money back discount coupon for the first false alarm) were taken care by the patient’s virtual insurance blockchain payment gateway.

*You have just read the news that wasn’t – January 2030 AD

Now, back to reality,

Stumbled on this news clip from pages of Times of India, (20-6-2019) months after I wrote the above piece. I wondered the chase between fact and fiction is becoming  really a close race.

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Indian subcontinent has a grand old history with a great civilization that began even before the ancient Greek and possibly Egyptian pharaohs .Post renaissance Europe made the British monarchy enter the country in early 1600s .This could be perceived as a new journey of modern India.In the early days of British colonization through East India company , the province in southern Indian Coramandal coast called Madras (Currently named Chennai) was a key economic and power center. Since the hospitals were the prime requirement to take care the Incoming officers ,Govt general hospital is the first major health care center to appear in India more than 300 years ago (In which the author of this blog is currently associated for over two decades) !

history of madras medical college government general hospital elihu yales

Though we currently call it as GGH , the original name was MGH* Madras General Hospital .

Originally built for the sick soldiers of east India company which functioned in the present St George fort premises.Then president of Madras fort Elihu Yale allotted the adjoining land and was instrumental in building the Govt general hospital in the year 1664 .The academic limb of the hospital the Madras medical college came more than a century later in 1835 .

elihu yale madras medical college

Few decades later in 1718 a Governor of New heaven Connecticut , Cotton Mather from far way North America wanted to start a small hospital who was short of money.He requested through his American contacts of British east India company for a donation from a successful British businessman Yale from Wales who making a fortune in the Indian county of Madras . Since, Yale had an American connection by birth in Boston, was willing to donate the money through Indian gifts worth of 560 pounds which was good enough to build the legendary hospital in New Haven which was named later after his name.

*It should mentioned the first seed of this hospital was planted by another British Sir Edward winter (1622-1686) , the Madras agent for the East India Company .

An article which appeared in Yale journal recently recalled the link between these two institutes.

history of madras medical college yale university drsvenkatesan dr s venkatesan cardiologist

Yale, of course carried a tag of being a controversial leader of British empire for misusing his power, still has his name permanently etched in the history of two great medical institution located far across the globe.

His life ended in 1721 , was laid to rest inside the quiet compound of church of Wales .The dark black concrete letters telling to the occasional visitors about the extraordinary life he lived over 300 years ago.

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Elihu Yales 1641 -1721.Born in Boston , Lived in Madras died in London. This memorial is found just outside St.Giles Church Wrexham , Wales .UK

st giles church elihu yales memorial Wrexham 2 wales

St.Giles Church Wrexham , Wales .UK

Click here : How to reach Wrexham ?

Another MGH . . .

The MGH as we know today is Massachusetts General hospital which was stated 150 years later than MGH senior in 1811 in Boston. It some times pains me to compare the growth of two . In terms of science , technology and research they are poles apart But in terms of equitable service , care , and social impact I think the senior MGH would still prevail over. !

Postamble

It is fascinating to know origins of college that taught us medicine.I wonder how many of the current students and the alumni know the grand old history of their Alma mater.I wish they pay a visit to St Giles church Wrexham , Wales once in life time. As we stand in-front of the Yale’s memorial one will definitely get that unique feel of travelling to the vintage past when Chennai GH was born with a baby cry !

Reference

1.http://en.wikipedia.org/wiki/Elihu_Yale

2.http://en.wikipedia.org/wiki/Yale_University

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Great men dream , but they just do not sit idle. They do what they are passionate about .History just follows them or they create it.Here is a brief story of an ordinary man born in a small European country Lithuania in 1921  ,lived much of his  life in the east coast of USA ,transformed into a brilliant cardiologist  based in Brigham Hospital , Boston.

He is Dr Bernard Lown , best known as a founder of what is used in every coronary care unit and cardiac surgical theaters around the world . Yes, the DC cardioversion was invented by Lown in the year 1961.(Of course,  it was an Improvement  upon the  pioneering work of Zoll’s AC power line  for defibrillating   the heart  which was impractical and caused much injury )

 

drlown_history

Dr.Bernard Lown (Born 1921) ,With his Invention of DC Cardioversion machine Currently  working in  Harvard University

 

He was also the brain behind the  conversion of local anesthetic agent Lignocaine to cardiac anesthetic  which revolutionized the treatment of ventricular arrhythmia.(What a simple  but a path breaking  idea to use membrane stabilising action of local anesthesia to sedate the heart when it behaves erratically !)

We can also credit him for  rediscovering  Digoxin and found the secret that potassium supplementation can largely overcome  toxicity of this drug which was otherwise lifesaving in dilated , failing hearts  running amok with delirium tremors (Surname for Atrial fibillation in those days !)

While the Invention  of DC cardioversion had  a dramatic impact all over  world , he simultaneously popularized the concept of coronary care units along with Julian in London and Dr Day in Kansas city.

Its said great men’s mind  are perennially restless.Accordingly ,he was worried about the impending nuclear war with USSR and other global powers then. He collaborated with Russian cardiologist Dr. Eugene Chazov. It became a hugely popular peace organisation  International Physicians for the Prevention of Nuclear War (IPPN) for which he got ultimately the Noble prize for  in 1985.

 

bernard-lown-dc-cardioversion-lown-institute

During one of his Noble lectures (Linked to video)

 

 

It turned out to be “lovely Irony” for a man who probably should have got a Nobel prize for medicine for inventing DC cardioversion ,  ended up with Nobel peace prize for  his fight against a man made disease called  “Nuclear proliferation”.

Its heartening to note he has visited my country(India)  and was  awarded with Mahatma Gandhi peace prize  as well.He is now 95, active in Harvard   currently turned his vision towards eradicating Inappropriate medical treatment from the noble profession .I wonder , for a man who fought against a  nuclear war, what does this new Initiative mean ? Does he equate the medical profession in its current form and the direction in which travels to something that’s  grossly unacceptable ?

Whatever it is , I humbly endorse his views and has since dragged me to  his Institute.

lown-image

I just joined the institute and signed  a declaration . I wish every physician who take oath on Hippocrates should strengthen Dr Lown’s Doctrine .

Reference 

Link to Wikipedia

nobel-prize-in-medicine-cardiology-drsvenkatesan-venkatesan-madras-medical-college

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The field of cardiology has seen great men over the centuries. Few women have permanently stamped their presence  in that history .Jane Somerville can be termed mother of pediatric cardiology along with Maude Abbott She has a fascinating life history , having  worked  in Royal Brompton  , Imperial  and Guys London.She was mentored  by  pioneers like  Paul wood , Blalock and others .She is primarily interested in the pediatric cardiology especially congenital heart surgeries .The classification  of pulmonary atresia with VSD  goes with her name.

jane somerville

Dr. Jane Somerville : British cardiologist , (b-1933 )

She carries the credit  of  starting  the Pediatric cardiology world congress in 1990 ,is the founder of GUCH (Grown up children with congenital heart disease.) .

Here is a rare  interview  from he  to Dr Robert Califf  for Heart.org. For  those,who like to  have a glimpse of  cardiology in its vintage  times , don’t miss it.Dr Jane addresses the past treasures , explores specific issues of facing pediatric cardiology  and frank expression about the issues of women being a cardiologist  in a man’s world.

 

She has a foundation in her name that helps the children and adults with congenital heart disease.

somerville foundation

Reference

The landmark paper in BHJ 1970

pulmonary atresia

 

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Men are from Mars , and  Women are from Venus  ” . . . Do you agree ?

Many probably witness the much talked  differential behavior among the gender  every day. Its argued , men take more risk in life ( often  senseless !) , some go to the extreme to  suggest  Men are Idiots and decorate them with a  provocative title  MIT (Men Idiot Theory ) (Mcpherson 2011).Risk taking is important in life, but at  what cost ? Does women (Who  are caring by nature )  help themselves  and the society by less risk taking behavior ?

I stumbled upon this rare piece of writing from BMJ which  would demand  in depth analysis  into this gender phenomenon based on  evolutionary biology and genetics.

This article concludes, Yes, men  . . . indeed  tend to take some foolish risks in various life situations that result in potential harm.

Gender difference in medical outcome men are from mars women venus male idiotic theory darwin theory

What is the influence of MIT on medical profession and patient outcome ?

Now , Iam compelled to ask  a hypothetical question .Does women medical professionals take  less aggressive stance and low risk taking behavior  and in the process result in less mortality and morbidity to our patients  ?

I would think the answer to that question  would be in affirmative .I wish  BMJ or anyone  should design a study on this issue.

Reference

1.Harris CR, Jenkins M, Glaser D. Gender differences in risk assessment: why do women take fewer risks than men? Judgm Decis Mak2006;1(1): p. 48-63.

2.Eckel CC, Grossman PJ. Men, women and risk aversion: experimental evidence. In: Plott CR, Smith VL, eds. Handbook of experimental economics results. Vol 1. North-Holland, 2008:1061-73.

3.McPherson J. Women are from Venus, men are idiots. Andrews McMeel, 2011

4.Northcutt W. The Darwin Awards: The official Darwin Awards: 180 bizarre true stories of how dumb humans have met their maker. Orion, 2004.

 

 

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William  I am Harvey first discovered human circulatory system in the year 1628 .Published his work in  De Motu Cordis” (otherwise known as “On the Motion of the Heart and Blood”) as a 72 page booklet in Frankfurt book fair. The world of medicine changed  forever , and new system of human circulation was born.

Read this now

Who first invented human circulation william harveyExcerpts  from   Chinese classic of Internal medicine , written  2000 years before William Harvey,

All the blood is under the jurisdiction of the heart .Twelve blood vessels are deeply hidden between the muscles and cannot be seen.Only on the outer ankles are visible because there is nothing to cover. All other blood vessels that are on the surface are  veins. The harmful effects of wind and rain enter the system first through the skin , being conveyed to the capillaries. When these are full , the blood goes in and turn empty into the big vessels .The blood current flows continuously in a circle and never stops

Post-amble

Of course , this in no way takes credit away from any body .William Harvey collected  every data on circulation available at that time , and  came with that classic De Moutu Cordis ,  the importance of which is undisputed. But ,history time and again tell us there are silent restless brains pondering over important  concepts all over the globe .Whoever has the access to scientific  facility , proves the same  point ,  publishes first and gets attention . After all thoughts are never rewarded in human domain ! (God , does it I guess  !)

Reference

1.Hume E.H Medicine in china ,old and new,American medical history 1930; 2;272-280

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