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ImageAspirin is arguably one of the greatest drugs invented. Only antibiotics have saved more human lives than this wonder drug. In the history of cardiovascular medicine itself, aspirin has prevented more deaths than all bypass surgeries and angioplasties put together. Considering the low cost of this drug, and the immense cardiovascular benefits it provides, one is not exaggerating when aspirin is spoken of as a public health measure than a mere miracle drug.

The simplicity of the aspirin’s action lies in its ability to prevent platelets, small blood cells, from clumping together and forming clots within blood vessels. Typically, it is these clots in the arteries that cause heart attacks and paralytic brain strokes. Needless to say, both heart attacks and strokes are often fatal.

In patients who have already had myocardial infarction or stroke, aspirin treatment is mandatory to prevent recurrent events. This is spoken of as secondary prevention. Given the impressive cost-benefit ratio, doctors have always looked at aspirin as a potential drug to prevent first heart attacks and strokes in patients who have never experienced cardiovascular events. This ability to help in primary prevention has been a matter of study, now for decades.

The flip side to daily aspirin treatment is its side effect. By virtue of its ‘blood thinning’ effect aspirin is capable of causing unexpected bleeding. Often, the bleeding is from the stomach & intestine, (‘peptic ulcer bleeds’). But, any internal hemorrhage can result, including rare instances of brain hemorrhage in some patients. Some minor injuries, which may otherwise be well tolerated, can result in serious bleeding in patients on aspirin therapy.

Traditionally, patients who were deemed to be at a higher risk for developing heart attacks and strokes were put on aspirin on a regular basis. Typically, these were patients with diabetes, hypertension, high blood cholesterol, smokers and patients with family history of heart attacks. Higher the risk – e.g., a diabetic who is also a smoker with a family history, greater was the benefit provided by aspirin therapy. In an analysis published in 2011 (link), investigators from Brisbane concluded that the aspirin not only protected against heart attacks and strokes, but reduced overall risk of death.

However, a new meta-analysis of a number of previous studies, published in the Archives of Internal Medicine has contested this traditional wisdom. Prof Kausik Ray from St George’s University, London, who is the senior investigator of this analysis, has spoken extensively on the new conclusions arising out of this analysis about aspirin (link). The paper says that in most instances aspirin only protects against ‘non-fatal’ heart attacks. Regular intake of aspirin does not protect against mortality. And, the worst part of it all is that aspirin caused an increase in the risk of ‘non-trivial’ bleeding (translates as serious bleeding needing hospitalization, blood transfusion, necessitating surgery or leading to death).

With this the debate as to whether aspirin should be prescribed to patients who are perceived to be ‘at risk’ for heart attacks & strokes has come to a full circle. Traditional wisdom is being questioned.

But given its intuitively attractive risk-benefit ratio, as far as protection against heart attacks are concerned, my personal opinion is that one can’t be categorical about whether aspirin should or should not be used.
Individuals have varying risk of developing heart attacks based on their medical history. Some are at very high risk whereas some have a negligible risk. Likewise, bleeding risk too varies between individuals. The trick with preventive cardiovascular medicine is to identify patients at high risk of cardiovascular events but lower risk of bleeding and offer primary protection with aspirin. Higher cardiovascular risk can be identified with use of risk calculators which are recommended by experts in the USA or Europe.

In the practice of cardiovascular medicine ‘cure’ has never been cost effective with burgeoning hospitalization costs for angioplasties and by-pass surgeries. With cardiac disease prevalence assuming epidemic proportions, one can safely say that the day is not far when not enough hospitals and doctors will be available to treat all cardiac patients especially in a country like India. Thus, despite (?over)cautious observations such as this report, primary prevention with aspirin will continue to hold a key for the future.

(Image courtesy Harvard Health Blog)

Dr Chandrashekar

Being a cardiologist I am often called upon to give free advice to friends, family, newly made acquaintances, practically anyone around about nutrition. I have had to give opinions about various foodstuffs and eating practices and many times I have to make an effort to give sound advice and yet not scoff at many hare-brained ideas people seem to have.

This is about the time when I got terrific insights into certain aspects of nutrition by a well known medical practitioner, Dr Chandrashekar. Dr Chandrashekar is a pediatrician, physician and diabetologist by qualification (MBBS, MD, DCh, PGDDM) and in addition he is most passionate about dietetics.

The reason why I am writing about the good doctor is because, somehow I think his theory holds the key to the question as to why people in the Indian sub-continent and especially the south Indians are at such a high risk of developing diabetes, Dyslipidemia and heart disease.

Here’s his theory:

Dietary fibre is an essential part of human diet. Fiber is available from plant sources in two forms: soluble & insoluble. Both these forms of fiber are beneficial by modifying the processes of digestion and absorption of food in the stomach & intestines. The overall impact is stabilization of blood glucose and prevention of lipid absorption into the body.

Experts recommend that adult daily diet should contain around 30gms of dietary fibre. Dr Chandrashekar strongly argues that progressively Indian diets have been depleted of its fibre content. Rice is polished several times to give a ‘refined’ appearance, wheat flour is refined and re-refined to minimize fibre content. The blame for this transition from a fibre-rich diet to practically fibre-free diet should go to us, he says. We go to a restaurant and ask for rotis or naans (Indian breads) and if they are not extra soft we get annoyed. The softer the rotis, lesser will be the fibre content. Similarly unpolished or semi-polished rice would appear reddish brown and is not appealing in appearance to us. We prefer the fine white grains of rice and that has very less insoluble fibre content.

Dr Chandrashekar has numerous case examples to offer. I saw some patients requiring high doses of insulin. These patients were convinced to change over to unpolished rice and wheat flour straight after milling without putting it through a fine sieve. Insulin requirements have come down dramatically. In some cases patients requiring over 50-60 units are now requiring much less than 15-20 units. There are a few patients who have been taken off insulin completely and are doing well.

It seems quite a plausible hypothesis that if the dietary fibre is increased systematically in the diets the incidence of diabetes in general population and the severity of diabetes in diabetics will come down. Dr Chandrashekar has quite a number of other radical dietetic tips. Systematic study on these issues is highly relevant for our population which is getting more sedentary by the day and consuming more unhealthy diets each day.

In addition to this Dr Chandra is an avid teacher at PES Medical college. For details about his pathbreaking ideas on nutrition and dietetics you can write to him at drchandra59@yahoo.com.

Yesterday was revelation day. I met an old friend. Dr Suresh graduated from the same medical school as me. When I was a student, I was always envious of people like Suresh: his father ran a busy practice in his village and when Suresh completed medicine he would naturally join and later on fully take over daddy’s clinic. For students like us future was always uncertain and Sureshs and Rameshs who were doctors’ children left few opportunities of pointing this difference.

 

Things turned out a little different I guess. We sat together for dinner last night and I realized what medical practice is like in rural India. Suresh had a clinic in the village where he worked between 10 AM and 8 PM. He could walk home for lunch and coffee breaks etc., but only when he had no patients. There was no appointment system which meant whether or not there were patients he would have to sit in the clinic throughout the day. On an average he saw about 20 patients from within his village and the surrounding ones. I thought that was a good deal, till I heard how much he charged. He would charge each patient between 10 and 20 rupees! Some of the cab drivers in Bangalore earn more than that! But then, if he charges more, the patient will never return.

 

What about lab tests? What about pharmacy? Are these available nearby?

 

In the village clinic, Suresh explained, asking for a lab test is not practical because there is no lab in the vicinity. Also, the patient never had the money for the tests. If you advice a lab test, the patient simply moved to a different doctor. This means that practically all diseases are diagnosed presumptively and we all know how flimsy and dangerous such practice can be.

 

As far as the pharmacy is concerned, Suresh explained that he cannot prescribe medicines most of the time for two reasons: prescription medicines are costly and patients will not buy them. So, for the same fees that Suresh has collected, he is expected to dispense cheap, generic drugs to patients!

 

The other practical problem is if one patient in a family gets a prescription for, let’s say cough and cold, that prescription is never thrown away: anyone in that family has cough and cold next time, the same prescription is followed. Loss of revenue for the doctor! And if a child falls ill, half or one-fourth of the dose is administered out of the same prescription: can be dangerous too!

 

Medical practice in rural setting in India doesn’t seem as romantic and adventurous as James Herriot’s veterinary practice; or as humorous as Richard Gordon’s experiences amongst humans. Lack of doctors, paramedics, medicines, facility for safe surgery and child-birth, awareness of preventive healthcare all pose a humongous problem. Villagers, both patients and doctors seem to get a raw deal because of poor infrastructure, while plush corporate hospitals in the metros are trying to attract medical tourism.

 

Yet another irony of independent India!

 

 

 

 

Patients with blocks in the coronary arteries can suffer from the following problems

  1. 1. Chest pain – Angina Pectoris, stable and unstable
  2. 2. Heart attack – Myocardial Infarction
  3. 3. Reduced pumping capacity of the heart – heart failure
  4. 4. Sudden death due to cardiac arrest

 

Today we shall talk about stable angina pectoris. The reason for this is during the last year and a half, a clinical trial (COURAGE), published in the New England Journal of Medicine has stirred up the debate on how to treat stable angina.

 

Patients with stable angina get chest discomfort or pain on walking, running or other physical exertion. Pain is typically absent with minimal effort or at rest. Patients with angina at rest or very minimal activity have unstable angina (USA). USA is a more serious condition and we shall talk about it another time.

 

When body is at rest the workload on the heart is low. During exertion the heart has to pump harder and to supply higher energy for this pumping function, heart demands increased blood flow through the coronary arteries. Typically stable angina is due to blocks in the coronary arteries that are serious enough to hamper increased blood flow during effort, yet allow normal blood flow during rest. Which explains why symptoms occur only during effort.

 

Such patients get relief of symptoms by one or more of following treatments:

  1. Anti-anginal medications: medical treatment (MT)
  2. Coronary angioplasty with or without stent placement (PCI)
  3. Coronary artery bypass grafting surgery (CABG)

 

Even when PCI or CABG is applied the basic medications will continue. So if I mean CABG, it actually means that CABG is added on to MT.

 

It is no rocket science to understand that for patients with milder degrees of the problem, MT suffices and for more serious angina, PCI & CABG may be additionally required. Which patients will require PCI & CABG will depend on a number of clinical parameters: so-called indications. For instance in patients who have left main coronary blocks or serious reduction of heart pumping function or with multiple blocks in all 3 coronary arteries CABG is indicated. This is because it has been proven by scientific studies that such patients are at risk of developing heart attack and/or dying if left on MT alone.

 

There is a problem in applying this seemingly simple treatment principle to PCI: hitherto no scientific study has shown that PCI, i.e., stents can prevent death or heart attacks in patients who have stable angina when compared to MT. which means that if angina is well controlled, MT alone is enough. And if risk of death or Myocardial infarction (MI) is perceived, one should proceed for CABG.

 

Where do stents come in into this equation?

 

When stents were introduced PCI was applied to patients who had serious blocks and needed surgery. PCI was more convenient to patients and less expensive than CABG. As experience with stents grew, more & more situations that hitherto required CABG were being addressed by PCI.

 

In situations like heart attack and unstable angina, PCI is certainly life saving. In many circumstances, an assumption was made that in stable angina too stents would be life saving. This may account for the fact that a larger number of patients with stable angina undergo PCI than CABG. Consider this: in USA 7% pts of angina undergo PCI as compared to 2% every year. This accounts for over 100,000 PCI procedures each year.

 

COURAGE trial

This clinical trial compared the effects of MT & PCI: it was meant to see if use of stents benefitted by preventing deaths or heart attacks in stable angina patients. In this study it was observed that when used early during the course of angina, stents do not prevent death or heart attacks more effectively than medicines alone do. Medical treatment alone was good enough to protect patients against death or heart attacks. However, two additional facts were observed:

1. Stents provided quicker and more effective relief from angina

2. Many patients, in fact nearly a third, who were put on MT alone at the outset ‘crossed over’ and underwent a PCI procedure midway.

 

What this tells is that some patients have angina severe enough to warrant PCI or even a CABG. But mere fact that someone has angina does not mean that stents have to be inserted. In a large majority of patients medications can be just as good.

 

Close analysis of COURAGE trial will show that there were methodological and statistical problems. Following the publication of the trial there has been a spate of articles both in the medical journals and regular press about the trial. 18 months after the trial, the debate rages as to whether the trial was appropriately conducted, whether the results of the trial are wrong, whether stents should be used at all for treating angina.

 

Doctors who argue for COURAGE say that stents have been overused for treatment of stable angina. They feel that needless PCI procedures on patients who can be treated with medicines, causes an economic burden and puts patients to risk of the procedure. In fact, pro-COURAGE activists feel that stents are being inserted because it financially benefits hospitals and doctors involved.

 

Doctors who argue against COURAGE say that a reasonable number of patients cannot be satisfactorily treated medicines alone, yet their condition does not warrant a CABG surgery. These patients benefit from stents, and in fact need them. These doctors feel that COURAGE, with all its methodological flaws, has needlessly cast aspersion on the interventional fraternity.

 

Nevertheless, looking at the mass of medical literature even other than COURAGE trial, the following conclusions can be made about stents in stable angina

  1. Stable angina is not as dangerous as heart attack or Unstable angina. Still, all stable angina patients do not end up with uniformly safe outcomes. Some patients are truly low risk patients who are unlikely to die or have heart attacks in the coming years. Some, however carry a real risk of death or heart attack
  2. Identification of low or high risk depends on clinical parameters: age, gender, smoking status, diabetes, previous heart attacks or heart surgery, severity of angina etc.
  3. In addition an echocardiogram can be used to calculate the pumping efficiency of the heart. If the pumping is low, risk is high.
  4. Most patients of stable angina should undergo a stress test: either a TMT or a stress thallium. These tests can identify patients at high risk for heart attack or death
  5. For patients with truly low risk medical treatment alone is fine. Rarely do such patients need to undergo angiography, PCI or CABG if well treated with medicines
  6. All patients who fall in the higher risk categories should undergo coronary angiography
  7. Based on the coronary angio report many of them will undergo CABG surgery
  8. A proportion of patients who have severe angina not well treated by medicines alone, but whose angiography does not suggest need for CABG, maybe treated with stents

 

COURAGE or no courage, it appears that stents will continue to be used for treatment of severe stable angina. Improvement in angina and quality of life is unquestionable with stents. Better conducted trials will definitely address whether stents save lives in stable angina setting. Until then one difference COURAGE has made is that, unnecessary use of stents for trivial angina has certainly been minimized.

 

 

 

Two days ago a patient was brought into the hospital with a heart attack. Though he had raised the alarm that he had severe chest pain, and though his immediate family had recognized that this could be a heart attack, he took full two-and-a-half hours to reach our hospital emergency room, the nearest one, in the middle of the night when there was practically no traffic!

 

This is how:

 

First there was the transport issue: the family didn’t own a car. So they had to wake their neighbor and explain to him about the crisis and then it took some minutes for the neighbor to dress and take the car out of his house premises.

 

Then, the patient was driven to the house of a doctor within the same locality. The good doc was awoken, listened to the patient’s story, mercifully conducted a cursory examination in the car itself, without wasting much time. He also felt that this looked like a heart attack, and since he did not have the facility to perform an ECG test in his house, he suggested that the patient be taken to a nearby nursing home.

 

The nursing home was a short drive, the patient had to be put on a stretcher, carried into the casualty area, and an ECG was obtained. There was a junior doctor on duty who confirmed the family’s suspicion that this was indeed a heart attack. But since there was no ICU facility in the nursing home, the family was advised to shift the patient to a bigger hospital. This meant that the whole drama of lifting the stretcher, putting the patient into the car and driving around had to restart.

 

Mercifully someone had the forethought of calling up a friend and then after consensus they drove to the nearby tertiary care hospital, where we could attend to him. Though valuable time was lost patient survived with some damage to the heart muscle.

 

Things could have been worse: he could have had a cardiac arrest while being driven around or even inside the nursing home and might never have reached the tertiary care hospital at all! How could this have been bettered?

 

You know, if you walk into a hotel lobby or a high rise corporate office, you have detailed building evacuation plan in case of fire or some such disaster. Why can’t we have such disaster management plans for our homes? I’m suggesting one for cardiac emergencies. Make this plan today when all is well at home.

 

First, identify a hospital which has the facility of ECG and has an ICU to treat heart attack patients, which is the fastest to reach. Remember, fastest need not be the physically closest one. In many metros in India, during peak hour traffic some places are hard to reach in a hurry. In fact, you can identify different hospitals for day and night time when the traffic conditions are likely to be different.

 

Get the emergency contact numbers for hospital you are going to reach and write it down someplace handy: it can be a wall calendar in the kitchen (common middle class family practice in south India), or on a sticker on the undersurface of your telephone.

 

Next, pre-determine the mode of transport in case of emergencies. If a car and a designated driver are at home, then that is your transport mode. Call the hospital emergency that you are coming and the designated driver will drive.

 

If a car is unavailable, or if the designated driver is not at home or himself/herself is the casualty, then the best bet is to get an ambulance. The ambulance can be from the same hospital or from another nearby source. Get the emergency contact numbers of one or more ambulance services and write it down along with the hospital emergency numbers.

 

Keep aspirin tablets handy: 325 milligram tablets should be fine. In case someone has chest pain & you suspect it is heart related one tablet of aspirin should be chewed, not swallowed. Many of us are advised by friends or family that sorbitrate tablets should be given to patients for heart pain. Unless, advised by a doctor, this can actually cause blood pressure to drop and be dangerous.

 

The most important thing to do in a suspected heart attack to get good secondary care treatment as early as possible. Plan ahead and do not waste time in getting to the right place. The instructions to family members as to what to do in a crisis situation should be explicit and should be followed as a reflex even in the middle of the night.

 

Even organisations can have similar medical disaster management plans drawn up for their shop floors and facilities so when men (or women) at work are affected, things move fast.

 

That should save some lives!

 

 

 

In May, I started this blog when I was facing a dilemma: I wanted to bounce ideas off you as to whether I should send an old man for surgery or not (link). Now I am writing in to tell you that I did send him up for surgery and my worst fears came true.

 

No, my worst fear was not that the patient died during surgery. It was that the family holds me, atleast indirectly responsible for the sad outcome.

 

In May I wrote, ‘The family looks up to me to take a decision. “We trust you. Do whatever is best for him. But please make sure that he’s alright”. The last line is a killer!’

 

After the patient died, the family came back and met me. Sons came in first. It was not very difficult to say that I was sorry for the family’s loss of a parent and that we had done everything we could, and that some times it helps to be fatalistic. We went through the fact that both I and my surgeon had explained that the surgery carried a reasonably important risk of dying for the patient. The sons had actually signed the high risk consent after appropriate counseling. Perhaps they understood that we had not intended that the patient should die! They left thanking my fidgety self for taking care of their father during his illness and last moments.

 

Then the inconsolable daughter walked in. She did not and does not even now understand that 10% risk of dying during surgery meant that out of 10 such patients one will actually die. “I thought it’s just a 10% risk, but if you had told me that he is going to die during surgery, I would have convinced him against it”

 

Huh?

 

At a point of time I had to be a bit impatient. When we explained 10% risk of dying, we didn’t mean that 10% of his body will die and the rest will go home fine! We actually meant that there is a real possibility of dying…she told me that the family had trusted me because of the way I had taken care of her father for nearly two years. But the misgiving with which she finally walked away was that had I not advised him to go for surgery, he would have lived for some more time. Given the fact that he was quite sick the last few days, I was not sure of how long he would have lived but then how could I argue on that?

 

My point is not that it was after a truly sincere debate that I had resorted to surgical advice. I can’t tell the family that it was such an important dilemma that it turned me into a blogger!

 

My point is: Doctors are going to take hard decisions. Some of their patients are going to die. It never matters how much science or philosophy goes behind those decisions: if your decision was followed by death or disability, you will be held responsible for it!

 

People who develop blocks in the coronary arteries are often advised to undergo bypass surgery. During last quarter of 20th century coronary angioplasty saw dramatic improvements leading to a sea change in the kind treatment offered to patients with coronary artery disease (CAD). In the west, there has been a sharp decline in the number of coronary artery bypass grafting (CABG) surgeries and a phenomenal increase in the number of angioplasties.

 

Is that because angioplasty is better than surgery?

 

More importantly, is this situation applicable to India?

 

There are patients of CAD where CABG is the only solution. Angioplasty will simply not do. Similarly, there are patients where angioplasty and not surgery is the appropriate treatment. For the sake of this discussion, we leave out these unambiguous cases. The argument as to whether surgery or stenting is superior is relevant in cases where both treatments are equally feasible and a choice requires to be made.

 

The recently published Stenting versus Internal Mammary (SIMA) trial (conducted at multiple hospitals in Europe, Chief Investigator Dr Jean-Jacques Goy, MD, University Hospital, Lausanne, Switzerland) should serve as an ideal backdrop to this comparison between surgery and stenting.

 

Coronary block occurring at the beginning (proximal part) of the major blood vessel called Left anterior descending (LAD) artery of the heart are often fatal. This proximal LAD block is so feared that the artery is euphemistically known as the ‘widow maker’. Traditionally CABG surgery has been the main treatment of blocks in this location. There has been no direct comparison of long term results of surgery and stenting for treating blocks of this kind.

 

This new study has shown that patients who undergo stenting for proximal LAD blocks fare as well as those who undergo surgery, as far as protection against heart attacks and loss of life. The study also showed that in some patients whose blocks were treated by stenting, the blocks recurred. Such patients then required to undergo repeat angioplasty or CABG surgery.

 

In essence this means that:

 

1.         Patients with critical blocks in the widow-maker artery now have two options: Bypass surgery or stenting. Either way the risk of such a patient getting a heart attack or actually dying are quite low

 

2.         Stenting offers a convenience unbeatable by surgery. Patient is up and about in two or three days.

 

3.         In nearly 80% of patients, there is no recurrence of the block and patient will not need another procedure in his/her entire life for this block.

 

 

This study was begun over a decade ago and in those days the heart specialists used ‘Bare Metal’ stents (BMS). These BMS carried a risk of recurrence of the block in nearly 20% patients who were treated. On the other hand, bypass surgery is far superior in the long term if the internal mammary artery (IMA, the artery behind the breast bone) was used for grafting. Over 95% of patients with IMA graft to the LAD were free from problems even after 15 years of surgery! Because of this difference in risk of recurrence, surgery was always considered superior to stenting.

 

Cut to 2002: Johnson & Johnson released a new stent, CYPHER, known as Drug Eluting Stent (DES) essentially a BMS which was coated by a special medicine, which was intended to prevent the recurrence of the blocks treated. After several million of these DES having been implanted, we know that there is no recurrence in 90 – 95% of patients: as good as surgery with IMA graft. Soon after other DES have appeared in the market and look to be as good as CYPHER if not better.

 

Through SIMA study we know that stenting is safe even with BMS. Cardiologists are certain that with the use of DES even the recurrence rates are comparable to surgery, so stenting seems to be an effective alternative to surgery.

 

Caveats for the Indian patients:

 

1.         Several cardiac surgery centres in India especially in the tier 2 cities lack the expertise to offer IMA graft for the widow maker artery in bypass surgeries. Veins from the leg are used instead. Venous grafts are not as durable as IMA grafts and in fact nearly 20% of them occlude in the first 5 to 6 years. While venous grafts are acceptable in grafting of other arteries, in most cases IMA grafts must be preferred for the LAD. So before a patient decides on surgery it should be confirmed whether an IMA graft will be used.

 

2.         Many makes of DES are available in India manufactured in India, Europe, China and so on. Though none of these stents have been specifically compared in tests against bypass surgery, only few can claim really low recurrence rates. In other words all DES are not equal. So a patient offered stenting with a DES should not automatically assume that he will have a surgery-equivalent procedure unless he knows what DES is being used

 

3.         In the west, the leaning towards stenting is because stenting is cheaper than bypass surgery. Insurance companies prefer to go along cardiologists who advise stenting. Hospitals are happy because number of hospital days are less and so patient turnover can be more.

 

4.         In India, however, CABG is far cheaper than stenting with DES. So the western preference of stenting over surgery need not be automatically applied to India.

 

So what seems to be the right thing for the Indian patients with block in the widow maker artery?

 

1.         Stenting with a standard DES is as good as CABG with IMA grafting

 

2.         In case the stents fail, a second procedure would most likely be required.

 

3.         So, if you are short on cash (selling off a couple of cows or an acre of land to raise the money), perhaps surgery is a better choice because it is likely to be a once-in-a-lifetime procedure.

 

4.         If you have loads of cash and prefer to avoid surgery, stenting with a standard DES is fine: because there is a 95% chance that you actually get away!

 

5.         All this applies to the average patient: there are special circumstances in which these rules do not apply and the treating doctor is the best person to take the decision

From 'Unbreakable'

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Two days ago my good friend Ravi (Dr Ravindra Mehta, Critical Care Specialist) called me into his ICU to check out whether or not one of his patients had a heart condition. What I found there elevated my respect for human life and its unheralded custodians infinitely.

 

Here was a 20 year old patient, afflicted by a rare condition called Osteogenesis Imperfecta (OI, Brittle bones syndrome, the disease suffered by Samuel Jackson in Unbreakable, only much worse here in our man’s case). Mere application of firm pressure on his limbs would break his bones. If you hugged him hard, his ribs would crack.

 

Years of fractures & reunions of the bones combined with various other medical complications had rendered this young patient a four-foot dwarf, with his rib cage and lungs deformed. His limbs were in plaster-casts due to recent fractures which were yet to heal. He was admitted with a presumed lung infection and after examining this guy I concluded that there was no heart related problem.

 

Then I saw this amazing thing:

 

There was another twenty-something young man with the patient. Before even I embarked upon examining my patient, this youth asked me what I was going to do. Just as I was trying to reassure him that I knew the nature of the bone problem here, he proceeded to caution me, a little apologetically, that even a little more than gentle pressure on the patient will break more bones and could you please be gentle. Educated guy, spoke to me in decent English. He was doing this to every nurse, doctor or ward boy who came to attend to the patient. He appeared to know what movements, and how much pressure on the patient was safe. He would not allow anything that appeared out of the ordinary to be inflicted on his ward.

 

So my questions were natural: Who was this young man accompanying the patient? Was he there all the time, providing such tender care round-the-clock? To me clearly, in a country like India with the healthcare services being as they are, this fragile patient with such an incapacitating disease, had survived merely because of this kind of extraordinary care.

 

The answers amazed me even more.

 

This young man caring for the patient was not alone: there were 5-6 others. Two were distant cousins, others were well wishers but none were real siblings. All of them educated and productively employed. This army was around for the patient, whenever he needed them, caring for his life, nurturing his delicate body. I didn’t ask how the patient got around in his own home, but whenever he needed to go out to pray, to shop, to watch a movie, to a hospital, this group of angels went with him, making sure that he was protected from the jostling. There was no money in this, no selfishness. And this was not a one time voluntary work, we have all seen: visit cheshire homes once a year, donate money to the orphanage once a year, go clean Cubbon park once a year….this service was there night and day, each day that it was necessary and days on end and round the clock, on occasions like the present hospitalization.

 

 

Beats most charities I know.

 

Quickly images flashed in my mind: mindless killings in the name of borders, religion, and caste on one side. So many NGOs making quick bucks in the name of charity on another side. Young couples wanting to terminate unborn children because they are not perfect, on yet another side.

 

But above all were these unsung heroes celebrating life

 

 

 

 

An average elementary school student knows that carbohydrates provide instant energy, stored fats provide energy over longer durations of time and proteins are for building the cells, organ systems and the body itself. In addition we also learnt about micronutrients like minerals and vitamins for essential functions like generation of blood and vision. In societies where food is in abundance obesity is both a cosmetic and a genuine health problem. Dieting is a key step for weight control. However, there is no single dieting technique. What is good for the goose may not be good enough for the gander. In the absence of standardized methods, there hundreds of proprietary dieting techniques in the market.

 

Low carb diet, once almost synonymous with the Atkins diet has both proponents who swear by it and bitter critic. In general, the scientific community has been skeptical and some scientific bodies are openly against the concept of low carbohydrate diets.

 

What do believers say?

 

Diets that are rich in carbohydrate levels cause sharp surges in the blood sugar levels. In response to this, the body releases hormones like insulin into the bloodstream, which then act to bring down the sugar level. The net effect of this mechanism is to store excess energy as fats and this leads to obesity.

 

Foods are classified according to the level of blood sugar surge after their consumption. High glycemic index (GI) foods raise blood sugars to very high levels. Low GI foods are opposite. Most fruits and vegetables, meat, eggs, oils are low GI whereas processed sugar, sweets, white bread etc carry a high GI. Persons who consume excess simple sugars with high GI are at risk of developing obesity, diabetes, the metabolic syndrome, heart disease and strokes.

 

 

In addition to obesity, there are other dangers of carbohydrate-rich diets. Higher blood levels of insulin & insulin-like hormones can also lead to other problems. There are no simplistic explanations but there seems to be a cause-effect relationship between diet, GI index, insulin levels, genesis of diabetes and atherosclerosis.

 

Low carbohydrate diets contain very little carbohydrates and high content of proteins and fats. Consumption leads to lower glucose surge in the blood. Consequently there no extra energy to be converted to fats, thus leading to anti-obesity effect. In addition, the believers advocate this diet for combatig diabetes and high triglyceride levels.

 

What do the critics say?

 

Most medical experts believe low carb diets as non-physiologic. Two major arguments are put forward: one, lack of adequate instant energy and many micronutrients is a feature of many low carb diets and two, excess of proteins and fats in the low-carb diets are frowned upon. Though over a period of time, many professionals – especially those who treat diabetes have advised their patients to restrict carbohydrates to some extent. But in general experts have generally criticized low-carb, high protein & fat-unregulated diets.

 

What’s new?

 

A recent article in the New England Journal of Medicine compares three types of diets: a low-carb (20 grams of carbohydrate per day), a low fat diet (1500-1800 calorie diet with less than 30% energy coming from fats) and a more balanced mediterranean diet. This study showed that the low-carb diet produced the biggest weight loss and enthusiasts will be encouraged to note that none of the purported side effects were seen during the study period.

 

Obviously most western diets and many urban Indian diets have excess calories. The rise of modern epidemics of diabetes and heart disease in urban India may have to do something with this caloric excess. Low-carb diets, if proven completely safe maybe a preventive step.

 

Though not universally accepted yet as a physiological diet, low-carb diets are on the verge of capturing the physicians’ fancy with this study. Clearly, more clinical work is required so as to earn an official status to low-carb diets, certainly their advocates will be more confident now.

 

Cutting out carbohydrates maybe not as easy, especially in households where meat is not eaten or eaten on select days of a week. If not a stringent less than 20 gram carb diet is unfeasible, a more realistic moderate calorie restriction maybe the answer for our generation.

I am sure doctors, lawyers and human rights experts, all have their own opinions about the just cocluded drama-on-TV about the Mehtas’ plea with the courts to allow them to terminate the pregnancy because, the unborn child has a congenital heart defect. I am bouncing my thoughts off on you: if you have an argument or another opinion, let me know:

 

Anomaly scan, the ultrasound examination to detect major congenital defects in the fetus is reliable between 20 and 24 weeks of pregnancy. Prior to that period, the scans are inaccurate.

 

MTP law in India allows termination up to 20 weeks of pregnancy, but congenital defects in the unborn baby cannot be the reason for termination.

The first issue which needs to be resolved requires a full discussion on ethics: should pregnancies where the fetus has serious birth defects be allowed to be terminated? An analogy exists here: If during late pregnancy, baby is found to have anomalies like hydrocephalus (large water-filled head), often labor is artificially induced with drugs. One of the surgeries described involves decompressing the head of the baby before birth. Here, in fact the baby’s age of gestation is far more advanced than the 26 weeks of Mehtas’ baby. So a serious discussion is required which will address three questions

 

  1. Should MTP law incorporate birth defects for allowing abortions?
  2. If so, in view of the technical factors (anomaly scan being unreliable at 20 weeks, should the maximum limit for abortions be extended to 24 weeks?
  3. What defects are serious enough to merit abortion? Every minor defect cannot be considered just because everyone needs to have perfect babies

 

Before any of this can be seriously debated, one aspect needs to be kept in mind. In India, laws can be easily manipulated to ones’ advantage. For instance, what should prevent an unscrupulous doctor to issue certificates of congenital defect and terminate an unwanted female fetus? Unless, very serious checks and balances are in place, abortion laws can be easily misused.

 

If caution is not exercised, only healthy babies maybe born, but most of them maybe only boys!