Posts Tagged ‘bmj’

When we get contaminated with excess  knowledge , we lose our ability to think !   &  Common sense is the casuality . . .

Human beings differ from other forms of life by their sixth sense . Our planet is  few billion years old . Life came into existence over a million years ago .Our life has  evolved over many  thousands of years .The average life span of  human race   is  75 years . We need to realise , our life constitutes  only a fraction of our planet’s life (<.0000001% ) . A  may fly , which lives a life of  less than a  day ,   does it in style  , looking for the light  throughout  the night ,  says good bye ,  to earth by morning  leaving  it  unharmed . Actually ,  in terms of time , the life of the fly is  just a  fraction less than  human life span , when compared  to  our planet’s life !

When these children are  longing for food , some of  earthly humans go to  spend millions for  obesity surgery ! That is  the progress of knowledge driven society . . .

It is  extremely common to  experience the following  scenario  in any corporate hospitals of  both developing and developed country .A   uninsured  or half insured !  person is  refused entry into a hospital even for an  emergency care  while a wealthy person is lying comfortably watching TV in a five star suit of the same hospital after an inappropriate coronary angioplasty for  an   innocuous   lesion of his heart !

The irony is ,  in this short span  of  earthly life  ,  we want to prevail over the nature and conquer the planet . God is watching  this human  behavior silently . And he is smiling  . . .

With all our knowledge base ,  modern science  have done the maximum possible  damage to our  planet  .We have made many lives extinct. If  we  tend to  think , with the help of  6th sense  we can become immortal , it would be the ultimate foolishness. When every one of us ,  is  obsessed with our own  health  , we are deaf  to  the silent cries  of  our beloved planet earth .

Now , all of a sudden we realise all the accumulated knowledge & development has actually worked against us. We find our knowledge is dissociating our thoughts   and now , we are fighting  vigorously  over acquiring the rights to damage our planet  .

So it seems ,  the more we learn,  less wisdom we have  ! We may need to  learn important lessons  of living  from  all those  species   which  do not  boast to have  the  6th sense  !

Read a related article , excellent one published in British medical journal  nearly 2 decades ago

Knowledge disease BMJ. 1993 December 18; 307(6919): 1578.

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Pessimism, from the Latin pessimus (worst), is a state of mind which negatively colors the perception of life, especially with regard to future events.

Understanding pessimism is not that simple  . Some people argue  optimism   represents a strong mind while  a pessimism  is the domain of the weak . But it is not necessarily true.  Both pessimist and optimist are unreal , and playing the dangerous game of predicting the future. So realism is the answer .

In this era of information highways , commercial exploitation of science ,  our thought process is grossly determined by our perception of events.We hardly have an intention or time to analyse our thought process.

  • An optimist  ( Rather , unregulated optimist ! ) is a person who welcomes  any growth good or bad.*
  • A pessimist  is  a  person who welcomes only good growth.*

So how to identify good growth ? That is the million dollar question!

  • Many of the  optimists may not  bother about the final outcome of a treatment *
  • A pessimist bothers only about that .
  • An optimist  rarely asks questions, blindly accepts every thing !
  • A pessimist never believes any thing !

Actually the fundamental principle of scientific medicine lies in proving the null hypothesis null and void.Any treatment is useless until proved other wise .  So pessimist can be argued to follow true science , while  many of  the hardcore  optimists are blind believers ..

*It may be  a harsh   way of  interpreting an optimist  but  uncontrolled optimism  has played havoc in our  patients like many of the failed treatments (Some of them released prematurely into patient domain   has  killed many lives  . Power of positive thinking should be within the  realms of scientific feasibility !

So in  our  journey   to  conquer human health ,   we   may  proceed with  an optimistic mind and  a pessimistic eyes !

This understanding is all the more important in this era of contaminated science .It is a well known fact ,  now last 50 years of  planet earth has inflicted the maximum damage  to ourselves  than our ancestors did in 5000 years. That’s why we are compelled to meet at Copenhagen .(We never learn from our mistakes, that’s a different story !) .

There is definite and urgent  need for world summit  on  cleansing the medical science from  the clutches  of commerce  and ignorance . A medical green house effect, with dangerous holes in health care  is imposing on us (Another pessimistic thought . . . of course in the interest of human kind !)

World health organization ,  a sleeping giant has to be awakened on this issue

Final message:

Mankind has evolved over many millenniums ,  probably with a sole  purpose of living ,  that is reproduction and propagation of our genre without harming the environment and other species.

Unrestricted  and unregulated growth of any kind is dangerous we call it as malignancy in pathology .In science , we tend to call it a” great future ”

Our  sixth sense*  has  outgrown  miserably  out of  reality  , as have we decided to take on the nature and GOD .Now , many developing country men do not believe in death .They are fighting a losing battle against the God. And they suffer with escalating health costs of keeping the elderly ,  alive who are  knocking at the doors of heaven or hell . The same countries,  which deny funds for curable illnesses of the poor is a different story altogether !

The principle of modern medicine  would ideally  be

  • Reduce human suffering irrespective of economic status
  • Curing a illness if there is a cure
  • Prolonging life if there is useful purpose
  • Allow a good quality death if there is no cure.
  • Most importantly  , prey to god give us strength and capacity to identify which is good and which is bad for our patients  .

Read and learn for a  complete guide on optimism and pessimism

* It  is  important to recognise , the same sixth sense  has   made it possible to share our views through a great tool of  Internet  . So we should not be against the growth of science but against the misuses and wrong interpretations of it .



The traditional characters  of  a pessimist


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What are the fundamental  difference between randomised  studies and observational studies ?

New discoveries come from shrewed  observations made in bedside or labside  while ,  randomised studies evaluate these discoveries for it’s effectiveness or futileness  .

Let us realise ,  RCTs   primarily  never  contribute to  generation of  original  concepts or discoveries  ! .It is a  statistical tool to assess an observation .

Click below to reach the excellent knowledge  source on above  the issue .

PLoS Medicine: Observational Research, Randomised Trials, and Two Views of Medical Science

The fact that  observational studies are done with open eyes &  mind ,  it is  obvious it  demands  intense conceptualization and thinking .
Blinded studies  are  mechanical studies . It is pure statistical research . It requires  no thinking  , medical  mind , in fact one can do it with eyes closed as it is a strict protocol driven  , even a  non medical men  can do a  medical research , while it needs a  alert mind to do a observational study .

Observational studies , especialy  when done retrospectively  has  zero bias  as the case selection and  the potential intervention are completed even before the research question  is raised. In fact many of the  greatest medical breakthrough comes from retrospective analysis. Of course this has to be proved prospectively  preferably in a randomised fashion.

So , we the medical professionals ,  shall  do great observational  research with open eyes and mind and let the  the statisiticins do the outcome analysis blind folded .

If the core medical professionals are bothered more about  randomised blinded  studies ,which is  meant only for evaluation purposes , the  future of intellectual  medical research is  going to be in jeopardy!

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  1. Do 64slice MDCT  in all patients who has  a coronary event and follow it up with catheter based CAG.
  2. Use liberally the new biochemical marker ,  serum  B-naturetic peptide (BNP) to diagnose cardiac failure in lieu of basal auscultation.
  3. Advice  cardiac resynchronisation therapy in all patients  who are in class 4 cardiac failure with a wide qrs complex .
  4. As it is may be considered a  crime to administer empirical  heparin, do ventilation perfusion scan in all cases with suspected pulmonary embolism.
  5. Do serial CPK MB and troponin levels in all patients with well  established  STEMI .
  6. Open up all occluded coronary arteries irrespective  of symptoms and muscle viability.
  7. Consider  ablation of pulmonary veins as an  initial strategy in  patients with recurrent idiopathic AF. If it is not feasible  atleast occlude their left atrial appendage with watch man  device.
  8. Never tell  your patients   the  truths  about the  diet , exercise &  lifestyle modification (That can  cure most of the early hypertension) . Instead encourage the  use of  newest ARBs  or even  try direct renin antoagonists   to treat all those patients in  stage 1 hypertension.
  9. Avoid regular heparin in acute coronary syndromes   as  it  is a disgrace to use it  in today’s world. Replace all prescription of heparin with  enoxaparine  or  still better ,  fondaparinux  whenever  possible.
  10. Finally never discharge  a  heftily  insured patient   until  he completes all the  cardiology investigations  that are available in your hospital  .

Coming soon :  10 more ways to  increase cost of cardiology care . . .beyond common man’s reach

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                                                    Drugs are poisons , whenever it is administered without valid purpose. it can enter human body  in many ways (Oral, intravenous, percutaneous etc ) And now we have another route namely intracoronary !

                                                   In quest for prevention of restenosis, many of the anti cancer drugs are now delivered directly inside the coronary arteries .These drugs are secreted  like a sustained release  tablet from the drug coated stents.These drugs are expected to prevent restenosis within the stented segment.But, after years of  intense debate and research  , we realised that ,  drugs  eluted from the stent  could damage the distal coronary vascular bed and coronary microcirculation.( And thus came the epidemic of acute stent thrombosis ! )

                                                The tender and sensitive coronary microvasculature  is constantly exposed to  these  powerful anticancer and immmunosuppresive  drugs .It is a great surprise , no body thought of  this dangerous drug -coronary artery interaction ! It required the genius of Renu virmani and others to point out this.

But still , the cardiology community by and large , fails to consider  this an important issue.This is proven by the fact, usage of DES is  still increasing  and used mainly as an off label indication.

Read this land mark article from circulation




Questions that need to be answered

  • What is the long term effects of drugging a coronary artery ?
  • Is no reflow or slow flow  more common after DES , because of the adverse drug reaction in the distal vascular bed ?
  • If a patient  with  DES  undergoes a CABG later what  would be  the impact of the  drug on the graft ? Will the functional vasodilatation   affected ?

Final message

                                  A drug , to get a legal clearance it has to undergo  hundreds of rigorous tests . Finally it is cleared for that  specific indication for which it is tested  .Just because a drug is cleared for one purpose ( Paclitaxel for malignancy ) it does not mean it is safe to use for any other  purpose for which it is deemed to be useful . Exactly the  opposite is happening   in the  the field of interventional cardiology . No body wondered to think what would be the effect of these drugs on the normal coronary endothelial cells and vasculature.Is it not a crime ,  without analysing this particular issue  , dozens of drug eluting stents have been released in the market . And now,  sounds of crying  foul is heard world wide !

Let us thank  , the so called negative forces in cardiology  for making this an  issue . In science ,  the watch dogs should bark  at  times of danger not wag the tail !

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Drug eluting stents : A slap on the face of Evidence based cardiology . . .

Click the BMJ link or read below



It is often said science is sacred and unfortunately we forget ,  science is not a heavenly creation and it is the creation of scientist of varying grades of integrity fueled by the vested interest of medical industry . It has been a almost a daily affair , some of the devices and drugs are recalled or found to be unsafe on patients.

Now the big cat has come out .The Drug eluting stent has fallen from Hero to Zero in a short span of 5 years. It was projected to have zero percent restenosis in 2002 . And now we realize it is Zero percent truth.

What has started as anecdotal reports of late stent thrombosis has indeed become an epidemic in all DES patients. The five studies that has been published in the NEJM this month (March 2007) has convincingly proved how unsafe these stents are in most of the coronary population .

Millions of patients in whom this stent was implanted will carry an impending stent thrombosis and possibly an SCD . Who is to take care of them ?

The DES story is a clear cut case of getting premature approval for a dangerous form of treatment inside human coronary arteries.

It is amazing how the scientist’s eyes are shut by the illusion of knowledge and lure of wealth. How foolish they were to think drug which was administered via the stent will selectively prevent vascularisation and leave the normal endothelium intact . Now they realized , one should not suppress the endothelial growth around the stent and got the fundamental point wrong. Which was the key reason for the astonishing episodes of late stent thrombosis. When we play with biology of nature we have to be little more careful .God has created man and his heart for over a million years . One can not alter it by a 6 month follow up study of DES .

When ICDs were exposed last year , of similar disastrous outcome they were recalled and explanted . How are we going to unstent the millions of coronary arteries ?

Somewhere along the line the medical professionals have lost the battle against the Wall street and NASDAQ . Or how else we can explain repetition of similar events.

The wages for the modern technology , the patients have to pay a heavy price.

Let us all hope common man with common sense will reign supreme over the sixth sense of the uncommon man . . .

“Ignorance is better than illusion of knowledge”

Dr Venkatesan Sangareddi MD , Assistant Professor of cardiology , Madras medical college Chennai, India

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Anginal pain is a type of visceral pain.It is carried by type  C  unmylinated  nerve fibres.The perception of angina is a complex process.It is a combination of visceral and cutaneous referral pain.

How often is angina silent in diabetes mellitus ?

Presence of  diabetes per se does not make an angina silent. In fact,  if  one takes 100 patients with diabetes  , if angina occur in them , it is more often  , manifest than silent. So , only few of  the  diabetic patients who develop diabetic autonomic neuropathy fail to have angina.The exact incidence is not known.It could be around 20%.

If angina can be silent in diabteics , can they have anginal equivalents ?

This again is not answered in literature. Among the anginal equivalents , the most common is  dyspnea , which  can occur in diabetics.But now , we know dyspnea also needs thoracic nerve signals  from the intercostal muscle spindle and colgi organs.This can also be impaired in diabetics.

Can silent and mainfest episodes occur in a same  patient  ?


Once silent does not mean always silent, and similarly once angina is felt it  does not mean he is going to feel the next episode as well !

This  strongly reminds us medical science  is  much a complex  subject and what we know is very little in pain perception.

How is silent ischmia different from silent angina ?

There is considerable  overlap  between  silent ischemia and silent angina

The questions to be answered are 

Which is silent  ?  Is it the angina or is it the ischemia or both ?

Silent ischemia can occur in any individual ,  this is also called as silent CAD . When  ischemia occurs  but  fails  to generate pain it is silent ischemia .Undiagnosed  CAD in asymptomatic individuals is also called silent ischemia or CAD.In this population  Exercise stress testing detects  CAD which was otherwise silent and masked.These patients may develop angina during EST.

During exercise stress testing many times patient has significant ST depression  more than 2mm but still chest pain may not occur.These episodes may either be silent ischemia or  ngina. Many times the EST is terminated before angina is manifest .( Chest pain is the last to occur in the chain of events following ischemia- Concept of ischemic cascade )

What are the other situations where angina can be silent ?

  • Pain perception  and threshold  level is  high ,  so patient indeed has anginal  signals but fails to feel it .
  • Patients on  antianginal medication , fail to feel the angina.
  • Chronic betablocker therapy can exactly mimic  autonomic neuropathy

Is it a blessing for the patient  to have painless episodes of angina ? 

When their  ischemic colleagues , suffer a lot with chest pain it is tempting to think these diabetic patients  are blessed!

Scientifically , this could be true in at least in  some  especially in a patients  who’s coronary anatomy is known  and devoid of any critical proximal lesions. For example a small PDA  lesion can produce  severe angina  , but may be silent  in diabetic and be comfortable .This lesion is  insignificant other wise * !

It should  also be recalled , pain relief has been an important goal for treatment  of CAD .In olden days,  thoracic sympathectomy was done for angina . In fact ,  even in  CABG  , one of the the  mechanisms  for  angina  relief  is attributed  to cardiac denervation.

Caution: Even a small  episode of ischemia can trigger an electrical event .But it is rare.

 How common is silent infarct (STEMI) in diabetic patients ?

In a simple questionnaire we asked the diabetic patients in our CCU how they felt their pain during MI.Most felt it normally as do other non diabetic .  Diabetes  does not make  all anginal episodes  silent. Severe episodes of ischemia may be painful while less severe episodes may be painless. Diabetic autonomic neuropathy  is a  least recognized and  poorly understood complication of diabetes.Diabetes , involves  the vasanervorum of the autonomic nerves.

 The other mechanisms postulated in diabetic neuropathy are

  • Reduction in neurotrophic growth factors.
  • deficiency of essential fatty acids .
  • Reduced endoneurial blood flow and
  • Nerve hypoxia .

Is diabetic autonomic neuropathy treatable ?

Very difficult problem indeed.Controlling diabetes may partially correct  the neural dysfunction.Many add on neuro vitamins and aminoacids are having a good market !

If you successfully treat diabetic autonomic neuropathy will my patient  start feeling the  hitherto silent episodes of angina ?

We don’t know.Logic would answer ” YES”

What is the ultimate effect of cardiac autonomic neuropathy.

Cardiac denervation.  The manifestations  are

  • Tachycardia, exercise intolerance
  • Orthostatic hypotension

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