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Posts Tagged ‘lancet’

A forbidden quote in medical science

Posted in Uncategorized, tagged , , , , , , , , , , , , on September 14, 2024|

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Its time WHO,may declare CVD as a “communicable disease” equivalent

Posted in Uncategorized, tagged , , , , , , , , , , , on August 5, 2024|

*Lifestyle definition

 A set of attitudes, habits, or possessions associated with a particular person or group. and such attitudes, etc, are regarded as fashionable or desirable.

Final message

Communicable disease need not be an Infectious disease like covid. The word “Communicable” shall soon convey a new meaning, to the enlightened. Adverse life styles ,disseminated into the community that vigorously propagate CVD, has every reason to be referred to as a ‘Neo non-infectious pandemic”

Postamble

In the strict sense, CVD is not a communicable disease ,rather the risk factors are …but technically it is.

Reference

1.Rippe JM. Lifestyle Strategies for Risk Factor Reduction, Prevention, and Treatment of Cardiovascular Disease. Am J Lifestyle Med. 2018 Dec 2;13(2):204-212. doi: 10.1177/1559827618812395. PMID: 30800027; PMCID: PMC6378495.

3.A comprehensive narrative review

Click to access ijerph-20-04427.pdf

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Major research papers from NEJM in 2023

Posted in Uncategorized, tagged , , , , , , , , , , on January 25, 2024|

Here is a pleasant surprise, a collectors issue of NEJM year book 2023, is made available free (even for non subscribers, in its website) .It is fascinating to know how fast the Internal medicine has grown. For the busy cardiologists, this will a be refreshing reminder, that there are other important organs and specialties do exist in medicine , with equal breakthroughs and Innovations.

It is indeed an amazing , whirlwind tour of medicine for all those who see medical science as single holistic specialty. It has articles, ranging from from simple clinical studies on postpartum hemorrhage (E-MOTIVE study) from deep inside Africa by Melinda Gate foundation, to Dupilumab for COPD, a stunning monoclonal antibody inhibitor of IL-4 for COPD exacerbations. Shortening tuberculosis treatment with a strategy involving initial treatment with an 8-week Bedaquiline-linezolid regimen (TRUNCATE-TB study) is also a revelation.

Of-course, the mandatory cardiac topics do find a prominent place including the currently omnipresent drug GLP agonist Semaglutide for HFpEF (STEP-HFpEF study). Baxdrostat, an Aldosterone synthase antagonist for treatment-resistant Hypertension, appears promising (BrigHTN).

Final message

However, the crowning glory among all articles appear towards the end of the document, titled Combating misinformation as a core Function of Public Health.

Let me share the link to this PDF document here. Hope it allows open access and there are no copyright issues. Notable articles of 2023 from NEJM .

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Lancet : A 200 year old Idea and a process towards righteousness

Posted in Medical ethics, Uncategorized, tagged , , , , on January 4, 2024|

It was 1823, a genesis of a new thought process in medical publication began. The man who started it all, Dr.Thomas Wakley the founder of the most famous medical journal (Ref 1)

One of his peers described him what sort of an Image he had. “Thomas Wakley the editor as we find him—a courageous challenger of the medical establishment who was usually right and whose language, however tasteless it might seem today, was well suited to the rough and tumble of the time in which he wrote and spoke”

Lancet celebrates 200 year anniversary

On this 200th anniversary Lancet , looks back ,introspects and redefine the agenda of medical profession. We need more and more people like Wakley in the current era.

The Lancet editorial team has come out with two clips one podcast and other a brief video for a total of 28 minutes . If you have enough patience to hear to this , you are probably in the right direction to understand what exactly is the purpose being a Doctor.

After going through the history of medicine through the lens of Lancet, and understanding its original motto, one thing is very clear. Science and research are vital for progression medical science . But, the least important enemy to handle for a healthy planet and mankind is not diseases and afflictions as such, but the unkind behaviour of biased power centres, skewed knowledge, and unhealthy & unequal practices of health care invention and delivery.

Final message

Doctors are primarily healers, all right; more importantly, they are guardians of goodness and justice in healthcare. For this, we need to “Wakleyse the medical education“, meaning, keep a watch always on the true aim and action of medical establishment under which you work . I know, this post might sound pessimistic for many of you, … but that’s where optimistic goals are hidden deep .

Reference

Thomas Wakley (1795–1862): a biographical sketch

sharp2012Download

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Rosuvastatin or Atorvastatin , Which is good and safe ?

Posted in Uncategorized, tagged , , , , , , , , , , , , , , , on November 10, 2023|

Statins belong to a group of drugs, stolen and reengineered from the blueprint of natural Chinese red yeast rice (Monocoline K) in the late 1980s. The rest is the remarkable history in the pharma industry.

Statins directly interrupt the cholesterol synthesis by blocking HMG-CoA within the hepatocytes. It significantly lowers the LDL, fights human vascular atherosclerosis. It makes the plaque either regress, prevent progress, make it harder and in the process make them less vulnerable . There are innumerable studies that document the evidence. Statin has become a must-prescribe drug in any one with clinically established CAD or even in concealed CAD. Guidelines are available to prescribe statins various intensity, depending on the risk profile.

Which statin ?

There has been a long list of statins. Many of them have retired from the ring .Currently, the fight is between Atorvastatin, a Rosuvastatin. Like Pepsi vs. Coke.

Note the graphic ,A meteoric rise of one drug since 2005 . (Can you guess the reason ?)

ATRORVA or ROSUVA Which one should I choose ?

There is very little “one to one” comparison study between Rosuvastatin and Atorvastatin .The gap in the pros and cons are narrow. Following points are observed, without much dispute.

1.Rosuvaststin is more powerful.

2.Plaque stabilisation effect is not different((Satrun, study NEJM 2011 based on IVUS)

3.New onset diabetic risk is more likely with Rosuvastatin

4.Worsening of cataract is also more with Rosuvastatin

5.Atrovastatin has some additional benefits in lowering triglycerides. (Bakker-Arkema RG, JAMA. 1996)

No one is dare enough to give strong verdict . Surprised to find one this month. BMJ has come out with a possible answer. It is called LODESTAR trial (Ref 1)

Mechanism of new onset diabetes with statins (REF 3)

It can be 7% with Rosuvastatin (less with Atorvastatin). We think, statins act primarily within the hepatocytes where cholesterol synthesis takes place, but they also have an eye on the pancreatic β-cells as well. It down-regulates GLUT-4 in adipocytes, and results in compromised insulin signalling. Furthermore, statins’ impact on epigenetics may also contribute to statin-induced T2DM via differential expression of microRNAs.

Mechanism of cataract with statins (Ref 2)

The cells lining that line the lens are dynamic and require cholesterol on a day-to-day basis. Statins inhibit proper epithelial cell development within the crystalline lens, where cholesterol biosynthesis is critical to maintain transparency and structure of the lens.

Final message

So, is it Atorvastatin or Rosuvastatin? It is left to you.

Mind you, “no statin at all” is the best option if circumstances and risk profile allows. Statins are never considered life-saving staple drugs in our fight with CAD and atherosclerosis. We, along with our scientists might may make you feel like that. Lipids can be controlled within desirable means exclusively with diet and exercise in most of the population* .

(*Forget about statins in the last 5000 years of known human existence, so many great people have lived a long and successful life in this world, without even knowing there is an organ called the heart that is responsible for the circulatory system)

Reference

1.Lee YJ, Hong SJ, Kang WC, Hong BK, Lee JY, Lee JB, Cho HJ, Yoon J, Lee SJ, Ahn CM, Kim JS, Kim BK, Ko YG, Choi D, Jang Y, Hong MK; LODESTAR investigators. Rosuvastatin versus atorvastatin treatment in adults with coronary artery disease: secondary analysis of the randomised LODESTAR trial. BMJ. 2023 Oct 18;383:e075837. doi: 10.1136/bmj-2023-075837. PMID: 37852649; PMCID: PMC10583134.

2.Leuschen J, et al Association of statin use with cataracts: a propensity score-matched analysis. JAMA Ophthalmol. 2013 Nov;131(11):1427-34.)

3.Carmena R, Betteridge DJ. Diabetogenic Action of Statins: Mechanisms. Curr Atheroscler Rep. 2019 Apr 30;21(6):23. doi: 10.1007/s11883-019-0780-z. PMID: 31037345.

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Extreme “Knowledge + Skill” is a powerful stress test for our Intelligence

Posted in Uncategorized, tagged , , , , , on October 22, 2023|

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“World heart day” : Two conflicting messages

Posted in Uncategorized, tagged , , , , , , , on September 29, 2023|

World heart day is being celebrated every year on September 29th ,Initiated by the World heart federation with a genuine purpose, vision & goal. It has become big hit in recent times. In India, the theme has captured the imagination of the main stream media . Every one wants to propogate a message. I am not an exception. Please bear with this skewed message “One for the patients and the other for the self” !

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A potential new face of “Ethical dysfunction” is waiting to unfold !

Posted in bio ethics, Medical education, Medical ethics, medical satistics, tagged , , , , , , , , , , , , , , , , on September 8, 2023|

Postamble

This quote is being sent for the annual meet of “Right care movement” I know ,this can sound outrageous, permissble limits of abuse ? Up to 2% or 5% ? Let it be anything . Meanwhile try to enlighten yourself , the key differences between misuse & abuse.

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Testing times for EBM : NEJM gets ready & begins a new journey

Posted in Uncategorized, tagged , , , , , , , on January 19, 2022|

The New England Journal of Medicine (NEJM) the premier journal in medicine originated two centuries ago, in 1811, when  John Collins Warren, a Boston physician, along with James Jackson, submitted a formal prospectus to establish the New England Journal of Medicine and Surgery and Collateral Branches of Science as a medical and philosophical journal. 

Subsequently, the Massachusetts Medical Society (MMS) purchased the Journal for US$1 and, in 1928, renamed it to The New England Journal of Medicine.

NEJM’s New Journey

It is 2022, after 200 years of providing explosive knowledge in medical science, MMS  starts a new journal, fresh and bold. It is called NEJM Evidence. Can you guess, what is the need for such a journal now? I think the most battered word in science in current times is probably “ evidence”.  It has a unique character of appearing most sacred as well as scandalous at the same time.

NEJM has remained the torchbearer of almost all advances in the medical field seen in the last two centuries.  It is heartening to note the newborn is named as NEJM evidence. It has come at a critical juncture. I am sure, everyone will acknowledge that we are at difficult crossroads. Overwhelmed with unregulated scientific discoveries and publications, struggling to deal with self-inflicted knowledge pandemic. In the process, we have lost “not only” the ability to ignore trivial health issues “but also” failed to provide simple, cost-effective care to the real patients who desperately need it.

Let us hope, (& wish,) NEJM’s new prodigy will guide medical science towards a successful, meaningful, and ethically fulfilling journey for mankind. Meanwhile, let us pray for every medical scientist to be blessed with the required strength and courage to steer in the right direction, weeding off both academic and non-academic contaminants.

 

 

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Double blinded , prospective , multicentre , randomised nonsense !

Posted in bio ethics, Cardiology -Interventional -PCI, cardiology -Therapeutics, tagged , , , , , , , , , , on June 5, 2011| Leave a Comment »

Medical  research can be divided into few  broad  categories

  1. Basic science  research  in animal models
  2. Basic science  research   in Human
  3. Clinical : Bedside-  observational
  4. Clinical:  Epidemiological
  5. Community based long term data analysis
  6. Interventional -Drug /Device/Surgical

*Logically the  top 5  should  constitute  the bulk of research  ,  in reality    last one wins the race with considerable ease . Why ?

The important issues that  confront  today’s medical research  starts  right from the  “Aim” of the research ,  methods , materials statistics,  and  goes on  to   ethical issues , conflicts, futility ,  gimmicks  0f  publication  ,  marketing and ultimately left  for human assimilation .

(Read a related article in this blog   can  Aim of a study be wrong ?)

Data(s)  won’t  lie  . . .humans do  !

Science is nothing but collection of  facts ,  rechecking  the facts , and  finally confirming ,  they are indeed  facts. So medical  data collection becomes vital .  Data,  if  properly collected ,  wont lie.   Bias is always an issue in prospective trials. Further ,  and whenever and wherever  scientifically  motivated  human  beings interact with  data  the later   becomes a vulnerable  target and  get manipulated   for various reasons . (Read the famous article on data torturing  in  NEJM : I will link it soon  ) So blinding  becomes  mandatory   and it should  be total as some studies  tend  to  gain vision half way through !

Image courtesey : Jupeter images

Simplicity of observational studies.

We  give undue importance to RCTs . What we fail to understand is RCTs are required only  in selected situations in medical research (New drugs and interventions ) Meanwhile , we can do wonders with retrospective observational  data. These  data  can not be  manipulated  as the events  have occurred already and those people who collect or record the data  wouldn’t know this data is going to be utilized  for a study (This  , in fact  is  equivalent  to 100 % natural blinding and constitute a  real world study )

Observational  study can involve  patient behavior ,    disease behavior  , community impact, drug action, investigation modality , etc  . . .etc  . Your mind is the limit . Cost of doing a observational study is less but the impact on the society can be great .

Observing skills are the  biggest causality in modern medical times , This was  only scientific weapon of  our ancestors had , which they  used in an exemplary fashion .( Recall how Heberden described angina and Harvey taught us about circulation without even ECG and X RAY chest )

Fraud in medical research

Wherever big money is flowing corruption and fraud is unavoidable . . .at the  least . . .  we  should recognize it

( Many journals  just point out this possibility by simply displaying message of conflicts .They do not bother more than that  . . . just a warning message  )

Now in the modern scientific world  ,   even as the   genuine contributions   from our ancestors  left to  stare  the back of us  , we try to indulge in all sort  of unpleasant things.

In an audit against fraud in medical  research ,  it was found most of the fraudulent research happened with drug and device trials and few in basic science involving genetics and molecular medicine . It  was  rare to identify fraud in research involving purely clinical and  epidemiological  analysis .

Drug trials  need to be prospective . Vested interest can play  havoc in prospective data .There is a  thing called steering committee in all major studies   . . . we do not know what does the  word  steering really   mean .

There has been many  occasions  even well conducted studies turn out be  fraudulent . Now we realise many such studies are struggling to prove its worthiness .

In fact  it is argued every study before getting published   should undergo a  global ,  independent  trial   monitoring  board for genuineness  of the study . (Not the customary  peer review !)

Final message ( Sorry its  a  long one !)

We have a huge problem  here . I am afraid  we  haven’t even  understood ,  what  we  mean by medical  research !

For today’s   youngsters  medical  research means doing sophisticated  tests in nano- labs  , human genome  mapping ,  space age imaging modalities  or  involving a multi- billion dolor drug trials . This is absolute  falsehood.

What we need to do is   “search” , ” search”  ,  search again (That is   why it is called re-search )  for all those elusive  problems  our patients   face .Not only in their body , in their  home , in their community,  etc . Every  patient  teach us  few points,    observing and learning new things  and  publishing is  also an important aspect of  research .One can do  a instant   research in the crowded  OPD of a hospital   , in the wards , (What is the profile  of fever pattern in a winter season in your hospital ? does it reveal a new viral epidemic ?)

An ideal research  should  identify a problem and suggest a practical solution to a given problem .There are millions of such issue waiting for our attention in the bed side.  But what is happening  currently ? Current medical research is largely direction less ,  fueled by vested interest ,  makes  sure it avoids  all genuine problem areas !

Many studies  happen  based on  flimsy scientific   basis  .We are still  wasting our time to increase human HDL levels. ( Not with standing  the famous Torcetrapib fiasco  )   .Hundreds  of thousand of dollars   are pumped into this  research even after realising  only the  endogenous HDLs generated by natural methods like  exercise   are  the really  good HDL !)

While we do million dollar research   with a dubious risk factor called  high sensitive C reactive protein  ,   there is  no takers against number one killer disease of human kind  namely  “The  poverty” (WHO ICD codeZ59.5 )*

Let us prey   God  to instill common sense to all of us  . Patients  suffer with disease and we suffer from irresponsibility  or reduced responsibility ! It  makes us happy at-least few forces  like Lancet  , British medical journal etc are fighting lone war  against this  ailment  medical science is suffering .

*Please note :  http://www.icd10data.com   WHO labeled poverty as disease many years  back without much fanfare ! It is rarely mentioned in  any  graduate student**  medical text  in whom our future lies .  I do not know whether  Wars  and terrorist acts  been included as disease  or not !

**Our students  rattle about  about the  exotic  tick borne  Lyme disease happening once a year in remote hills ,    while  most will stare blank   when asked  how to diagnose and  treat  nutritional  anemia with  which millions suffer  every day !

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