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Archive for the ‘Social medicine’ Category

Evidence-based medicine (EBM) is being projected as a scientific God’s secret specialty. Physicians who don’t follow EBM are considered unfit non-professionals. Presumably, in pursuit of truth, all those glamorous official bodies in cardiology bring out umpteen number of protocols, guidelines, advisories, and recommendations.

The blueprint for EBM

We have the famous 3 levels of recommendation backed up by different levels of evidence. Many of us trust these as the jury’s final verdict for most illnesses in cardiology. I would like to bring one particular issue about this hugely popular model of EBM. It is about one specific class of Indication referred to as 2b. The other day, there was an intense argument for an ICD in a young HCM patient and CRT in DCM based on this 2b stuff. Kindly request all of you to pause for a moment and introspect. We can realize, class 2b plays a mischievous game in EBM with the English language “may and may not”. It tries to push subconsciously an interventional bias from equipoise, in spite of lack of good evidence and clear divergence of opinion and a possible trend towards harm.

Further, there is widespread reluctance in many cardiac workgroups to refer class 3 recommendations as an absolute (or at least relative contraindication) It was strange to note one of my colleagues argued that,  class 3 is also a fair recommendation, to accept or reject is in our domain. I was initially shocked to hear that but had to agree with him ultimately as we realized a significant chunk of interventions we do, like delayed PCI > 24 hrs, CTOs, and chronic stable belongs to the proud class 3 recommendation. The debate came to a funny end when a senior cardiologist confessed somehow class 3 seemed to be a lesser evil than even class 2B.

Final message

For the sake of our patients, we need to bring an urgent reform in the EBM. Let us merge class 2b with class 3 and put it in a single basket and keep it out of reach to all tempting stakeholders. We shall display only class 1 in our therapeutic showcase.

Counterpoint

(*Dynamic recommendations is the norm in science, as we accumulate evidence with time.. Agreed, let us do this silently in research labs. Don’t bring it to practical guidelines. No, can’t agree. Freedom to indulge with an experimental modality in a no-option patient must always be there as we are able to give the benefit of doubt to these helpless patients. This is a valid argument but we must not forget even in dire situations  good option need not be a compulsive action, it can be in action as well)

 

 

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CokeMini_Happiness_03

  It costs just one Dollor !

Harvard school of Public health has  recently  published some  hard data about  the adverse effects of bad diet habits especially the impact of  soft drinks on long term cardio vascular health.

soft drinks and impact on healthAnother prestigious journal confirms it . . .

risk of soft drinks and coronary artery diseaseThe ultimate journal for the cardiologists Circulation reaffirms it .

soft drinks carbonated and coronary artery diseaseWe  have overwhelming evidence , prolonged use of soft drinks
increase CAD (Like tobacco ). Still , we haven’t added the customary caution on the bottles of these soft drinks ?

Why  ?

My guess would be, there are powerful forces in  modern society that would love to keep  the  threat of diseases high in the  human domain  so that all  stake holders  make a profit .

The poor , World health instigation(WHO)  and various public health forums  simply watch it .If they protest , they are at risk of sucked into the loop of deceit !

Failure to reverse public health hazards  may be a  lesser crime  in modern days  . . . But , here comes  a series of  advertisements in Indian media , that is a strong indicator that human  intellect and the sixth sense  is going nuts !

It suggests , Do you want  ever lasting happiness . . . Drink  it  . . . earnestly believe  in it  . . . and drink again  !

Coca-Cola-12

I was also told  a shocking fact that , The beverage war in India has  started and the soft drink giants have heavily Invested to take it into the rural markets .Their aim is to  provide  “health  for all Indians”  by 2020 !

Concluding question

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modern medicine ethics hippocrates

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News : In any developed nation , 90 % of  total  health expenditure is  exhausted in prolonging  final few days of  human  life !

When cost of dying   . . .  exceeds cost of living   . . . this world will go nuts !

The current real world  experience  from India’s  five star  hospitals  indicate,  many elderly rich men and women  spend their  last few days  before being buried or burnt  .They spent an average of 15 lakh Rs per death . This amounts to the entire  “life time” cost of living   of  majority of Indians .

modern medicine art living and dying

Image courtesy from Flicker/ Rachel sian photostream

When   human organ donation is considered  a greatest philanthropic act, there is one more excellent alternative for those who can’t do it .If only every super rich translate  their cost of dying  into  cost of  others living !   many new lives  will bloom .

The exorbitant rise in  cost of  dying  in India ,  is a recent development and reflects the affluence , honor , pride and of course lots of prejudice lack of wisdom ! Instead of filling the  deep  pockets of greedy  corporates why not the rich add new  lives   ?  !

Final message

Let all elders  with irreversible conditions , who have finished their life , shall  die peacefully at home .Why don’t we ( Affluent  .  . . would  be cadavers !)  cross sponsor their dying cost to a  public  health , nutrition or medical fund .

After thought

Oh America ,  . . .  Am I right  ,?  Obama thought it and implementing it too !  I would believe , his health care policy is  a  small first step in this  direction  !

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In the  2013 American diabetic association(ADA)  annual meet  a paper was presented   which raised  many eye brows ! . The  results were flashed across mainstream media. Published in New England journal of medicine online.

Look Ahead ADA lifes style  NEJM

It may be a  well conducted  trial  but  poorly interpreted  one . It reports one of  the dubious   observations  as a major conclusion  and  confuse the public.

Life style modification is the key to prevent  major diabetic  and cardiac events  . This is well  proved beyond doubt.

Epidemiological evidence  from various  global health  statistics  accumulated over a century will vouch for primary prevention of  diabetic and cardio vascular disease .

Link to Editorial on Look Ahead  : http://www.nejm.org

Why this study wants to make  a mockery of this fact ?  .Fortunately the accompanying  editorial  has  realistically  reported the implications of this study.

Final message

I argue the medical fraternity and patients to ignore this  study . It can be convincingly concluded something is seriously wrong with the outcome analysis  ,  however  modern may be the statistics. Some  groups are obviously worried about the natural and effective control of diabetic by good life style alone . It is a clear case of confusing the public .

There is huge collective evidence  and  common sense  for the  increased physical activity to reduce  cardio vascular risk  (INTERHEART)

Final Message

If life style modification is not going to help  . . . what is the alternative  to our patients ?

Drugs . . . yes  . . . one has to depend on it   . . . this study  seems to suggest .

To me, this is  a dangerous study   . It  plays a spoil sport on a great fact and  belief . This paper  should never have been published in a journal  like  NEJM . Atleast the conclusion  should  have  been re-written !

I guess this study would  promote the  Homo-sapiens  to  be inactive  and  make them diabetic and  consume drugs  perennially !

Reference

http://www.nejm.org/doi/full/10.1056/NEJMoa1212914?query=OF 

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It happens only in India

adventure

About  150,ooo people die in road accidents in India every year . . . highest in the world !  Myocardial infarction  kills  only slightly  more !

Image courtesy : Times of India , 18th April 2013 . Picture  by  S.L. Shanth Kumar .

 

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