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The sweeping allegation of corruption against doctors in Aamir Khan’s talk show was something that was waiting to happen. Too many people believe that a good number of doctors are out to get their money, by hook or crook! Clearly the show itself was one-sided: there are a large number of doctors that are not corrupt; even where individual cases of alleged wrong practice was projected on the show, the accused were given no chance to defend themselves. Aamir was judge, jury and the executioner. Despite this, the criticism of the manner of the show is not to say that all doctors are honest.

This piece is not about whether or not doctors are corrupt. This is not even about why they are forced to be corrupt. A chain email is already doing that job of condemning ‘Satyameva Jayate’, and extolling the greatness of doctors toiling under adverse educational, vocational and financial circumstances. I am just examining how some doctors end up indulging in malpractices and dishonesty in their professional lives.

Most of the doctors I know are personally fine people. There is far less lying, adultery, cheating, scandals and financial scams involving doctors than say, film actors! Yet, like any government clerks, private IT managers and bankers, some doctors are unscrupulous in their work.

Root cause analyses will lead us to two factors: Comparatively poorer remunerations across the nation and across private or government sectors are given to doctors when you consider their age, qualification and training. A 30 year old MD who puts in six and a half years in graduation and another three years in post graduation is offered thirty thousand rupees (less that $600) a month in private hospitals. Government service provides even less! A ‘software engineer’ even without a post graduation, a CA who is much younger earns at least twice this amount in Metros at start up. A professor in the prestigious AIIMS who teaches life-saving skills to younger doctors while actually treating Governors and Supreme Court Judges would barely receive a 6 figure salary at retirement. Compare this with the professors at IIMs and you will realize, similar skills do not yield similar remunerations.

In smaller towns and villages the situation is worse. If an MBBS doctor charges Rs five for a consultation (very frequent in rural Karnataka), imagine the number of patients he has to see just to bring home groceries worth Rs 4000 a month! The examples can actually go on, but the fundamental issue is doctors feel, and often justifiably so, that they are underpaid, while the world around them seems to have a great time!

Of course, that you have less money is no excuse for turning to burglary or kickbacks. But, on the other hand, when has affluence prevented greed & gluttony? All around us, we see people who are illegally wealthy, yet continuing to indulge profiteering. The mining scam in Karnataka or the 2G controversy are huge examples. This brings us to the other fundamental point:

Some doctors are corrupt, not just because they are underpaid, but corruptibility is in the grain of our society. I would really like to go back in time and see if during the time of Lord Rama, people in India were honest and just. But at least, during my own lifetime – I’m 45 now – I haven’t seen many Indians around me that are honest or transparent! Our society seems to be full of people whose only aim is climbing up the social and financial ladders at any cost. Morality and honesty are sacrificed at the altar of selfish personal gain. How, then, do you expect the doctors alone to be clad in pure white? Have you ever waited at midnight for the traffic lights to turn green, when all around you, others are driving through the red light, just because there are no cops? How long can you hold on to your principles there, without looking like a moron who is not ‘smart’?

After all, when a doctor finishes medical school, he doesn’t come out trained in malpractice. It is the community around him that urges him to issue a bogus medical certificate, offer kickbacks for referring tests to a laboratory and even abort a female foetus! So the society reaps as it sows. In fact, it is a testimony to the doctor community’s integrity that only a few among them succumb to these temptations!

It is very fine for people like Aamir Khan to want doctors to put patients before themselves, others before their own families and to feel that doctors must serve and not think of money! But doctors too live in the same society which demands bribes and kickbacks. No registrar gives a discount to the doctor on the bribe amount for registering a property! Shows like Satyameva Jayate appeal to the viewer by ‘sensational’ expose’s but fail to address more fundamental issues. If you look close enough, you realize that when it comes to the moral fabric of the society, it is only Mithyameva Jayate! Given the size of that problem, it is well nigh impossible for medical practice to totally rid of dishonesty and corruption. So, don’t expect this problem to go away. It will only change with society. Or Armageddon! Also be thankful that despite so much pressure to be otherwise, a large majority of doctors are actually honest and incorrupt!

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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.

Firstly, apologies for not blogging regularly. No excuses, but have a new resolution to be more frequently at the keyboard.

The one issue which has forced me out of my cocoon will be debated in the coming months: often in hushed tones in the medical and pharmaceutical circles. That is the newly renewed guidelines to the medical doctors about their relationship with the pharmaceutical industry. The text of the “Indian Medical Council (Professional Conduct, Etiquette and Ethics) (Amendment) Regulations, 2009 – Part-I” (Ref: No.MCI-211(1)/2009(Ethics)/55667) is available in the Indian Gazette, but I first read it here and gratefully acknowledge the author of the blog.

The summary guidelines say:

“In dealing with Pharmaceutical and allied health sector industry, a medical practitioner shall follow and adhere to the stipulations given below.”

a. Gifts: A medical practitioner shall not receive any gift from any pharmaceutical or allied health care industry and their sales people or representatives.

b. Travel facilities: A medical practitioner shall not accept any travel facility inside the country or outside, including rail, air, ship, cruise tickets, paid vacations etc. from any pharmaceutical or allied healthcare industry or their representatives for self and family members for vacation or for attending conferences, seminars, workshops, CME program etc as a delegate.

c. Hospitality: A medical practitioner shall not accept individually any hospitality like hotel accommodation for self and family members under any pretext.

d. Cash or monetary grants: A medical practitioner shall not receive any cash or monetary grants from any pharmaceutical and allied healthcare industry for individual purpose in individual capacity under any pretext. Funding for medical research, study etc. can only be received through approved institutions by modalities laid down by law / rules / guidelines adopted by such approved institutions, in a transparent manner. It shall always be fully disclosed.

e. Medical Research: A medical practitioner may carry out, participate in, work in research projects funded by pharmaceutical and allied healthcare industries. A medical practitioner is obliged to know that the fulfillment of the following items (i) to (vii) will be an imperative for undertaking any research assignment / project funded by industry – for being proper and ethical. Thus, in accepting such a position a medical practitioner shall:-
(i) Ensure that the particular research proposal(s) has the due permission from the competent concerned authorities.
(ii) Ensure that such a research project(s) has the clearance of national/ state / institutional ethics committees / bodies.
(iii) Ensure that it fulfils all the legal requirements prescribed for medical research.
(iv) Ensure that the source and amount of funding is publicly disclosed at the beginning itself.
(v) Ensure that proper care and facilities are provided to human volunteers, if they are necessary for the research project(s).
(vi) Ensure that undue animal experimentations are not done and when these are necessary they are done in a scientific and a humane way.
(vii) Ensure that while accepting such an assignment a medical practitioner shall have the freedom to publish the results of the research in the greater interest of the society by inserting such a clause in the MoU or any other document / agreement for any such assignment.

f. Maintaining Professional Autonomy: In dealing with pharmaceutical and allied healthcare industry a medical practitioner shall always ensure that there shall never be any compromise either with his / her own professional autonomy and / or with the autonomy and freedom of the medical institution.

g. Affiliation: A medical practitioner may work for pharmaceutical and allied healthcare industries in advisory capacities, as consultants, as researchers, as treating doctors or in any other professional capacity. In doing so, a medical practitioner shall always:
(i) Ensure that his professional integrity and freedom are maintained.
(ii) Ensure that patient’s interests are not compromised in any way.
(iii) Ensure that such affiliations are within the law.
(iv) Ensure that such affiliations / employments are fully transparent and disclosed.

h. Endorsement: A medical practitioner shall not endorse any drug or product of the industry publicly. Any study conducted on the efficacy or otherwise of such products shall be presented to and / or through appropriate scientific bodies or published in appropriate scientific journals in a proper way.

It was time that these guidelines were issued and adhered to. Medical profession has too much into disrepute because of the various enticements the drug companies offered and are accepted. The freebies include gifts ranging from pens to motorcars, local and foreign trips to local and international destinations often thinly disguised as academic tours (“conference”), cash and sundry other goodies. A very innovative medical company once offered to start an SIP in my name in return to what they called an ‘exclusive support’ to one of their products.

I have no doubts that any sane person, which includes most doctors, would welcome these restrictions, but I have a couple of points to make:

  1. Along with all the greedy, unscrupulous medical practitioners, genuine academicians have been needlessly restricted by these guidelines. For instance, in my own field of interventional cardiology, the premier academic conferences which propagate new techniques and technologies are held in Europe and the United States. In the absence of any structured training or opportunity to dabble with emerging technologies, this restriction will now condemn us to archaical practices. Of course, since I’m in private practice and because of the pressures of learning new technologies I personally will fund my own training abroad. But with typical conference expenditure between Rs 150,000 to Rs 200,000, how does a typical cardiology faculty member from AIIMS or PGI manage to go to these conferences? True, the government sponsors few faculty members with lots of limit on the expenditure, no of days of attendance, no of times one could go attending conferences, but that kind of scanty attendance would hardly suffice for learning on a large scale. Moreover, governmental funding, already abysmal on research will further fall because huge increases in conference funding.
  2. While the guidelines exhort the doctors to stick to ethical conduct, there doesn’t seem to be any directive towards the pharmaceutical industry. The New Year has started and I am already tired of refusing gifts and overseas conference offers. Representatives of various companies go around asking doctors as to which conference they would like to attend ‘this year’ so that their companies can plan their ‘annual budgets’. Strangely, they don’t seem to acknowledge the existence of these fresh laws to the doctors. So many doctors who are unaware of the laws may accept gifts or conference invitations and may be later on punished.
  3. Despite the MCI formally coming up with the guidelines, the average neighborhood doctor is unlikely to be aware of the existence of the rules and the type of reprimand or punishment they are likely to face in the event of a violation. These laws were reported in some sections of the media. I personally am not aware if the MCI is making any attempt to make doctors aware of these laws. It should. If it has already done it, then there should be more visibility of the awareness program.

Comments are welcome.

bcpRecently, Hema my niece sent me this chain mail and asked my opinion about it

“PASS THIS ON EVEN IF YOU DO NOT USE IT

Recently this past week, my cousin Nicole Dishuk (age 31…newly graduated student with a doctoral degree about to start her new career as a Doctor…) was flown into a nearby hospital, because she passed out.

They found a blood clot in her neck, and immediately took her by helicopter to the ER to operate. By the time they removed the right half of her skull to relieve the pressure on her brain; the clot had spread to her brain causing severe damage.

Since last Wednesday night, she was battling… they induced her into a coma to stop the blood flow, they operated 3 times… Finally, they said there was nothing left that they could do… they found multiple clots in the left side of her brain… the swelling wouldn’t stop, and she was on life support…

She died at 4:30 yesterday. She leaves behind a husband, a 2yr old Brandon and a 4yr old Justin… The CAUSE of DEATH – they found was a birth control she was taking that allows you to only have your period 3 times a year… They said it interrupts life’s menstrual cycle, and although it is FDA approved… shouldn’t be – So to the women in my address book – I ask you to boycott this product & deal with your period once a month – so you can live the rest of the months that your life has in store for you….”

The mail goes on to name the products by trade name and asks people to boycott them. Hem wanted me to opine on this. Here is my reply to her:

Every drug has side effects. But in general, modern drugs will undergo many checks and tests in order to be extremely safe. So it is unlikely that hundreds and hundreds of women who take birth control pill drugs are dying such horrible deaths regularly.

Let me illustrate safety of important drugs with an example. A patient of mine, who has a serious heart disease,  is on aspirin for many years. We know that aspirin prevents death due to heart attacks and strokes. So, it is possible that this guy lives on thanks to aspirin.

Now, the other day this patient started vomiting blood and was rushed to the hospital almost in an unconscious state. Fortunately we were all there and despite the fact that he had vomited over one and a half litres of blood we managed to transfuse blood to him and take him up for a test called as endoscopy. This test showed that he had a huge ulcer in the stomach which was continuously bleeding. That bleeding was controlled by endoscopic treatment and the patient went home after 3 days of recovery time.

I can easily make a huge story about this and send a chain email which says: Aspirin causes big bleeding ulcers and you can die of a horrible death, so all you heart patients please stop taking aspirin! And also I could request ‘everyone who cares about your near and dear ones to forward this mail to as many people as possible and prevent hundreds of deaths!’ Yet I prescribe aspirin to literally hundreds every month because it saves too many lives

If you ban birth control pills based on such sensational stories then you will have a billion people in each state of India and we will all die because there will not be enough food to eat for all of us!

It is possible that this story is true. But whoever wrote it up made it look so  gruesome to you tend to vilify the drug. And when you read this, you are not reading the positive side of this drug. Worse, people maybe forwarding such mails to their contacts without even verifying if it was true thus causing panic and misinformation about drugs.

As I said at the beginning, every drug has side effects. Thanks to research and regulations modern drugs are very safe and serious side effects are extremely rare. Rather, far more lives are saved by the good effects of drugs than are lost due to their adverse effects. Patients who take medicines should consult doctors and learn about the positive and negative effects of drugs, balance the possible risks with possible benefits and then take the decision to use the drug or not, rather than being tricked by such mails!

If you have more chain mails on medical stuff, send them to me. Let’s look at them objectively.

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!

 

 

 

 

security1After the chilling incidents in Mumbai during the last few days, we are all ‘limping’ back to normalcy. Meaning, we are now turning away from page One to the sports columns and page 3s faster than the last couple of days. For a change, ‘important’ heads have already rolled or on the block this time, but honestly the pessimists amongst us do not expect major changes except that after all the political chess moves, I think finally India will be under lot of pressure, ironically!

 

Which is not the point of the blog: this is about two incidents that left me with no doubts that we are a nation of fools.

 

Incident One: My boss went to a very reputed scientific organization in Bangalore on Friday to give a lecture on how to prevent heart diseases. The august audience consisted of some of their top scientists. This organization was recently in the news for carrying out successfully a very prestigious mission, thus enabling India to join an exclusive club of nations who have carried out similar feat.

 

On reaching the gate in his private car, my boss’ driver lowered the glass and the security guard peeped inside and asked the driver who deing driven. He was told that so-and-so doctor from such-and-such hospital was there to deliver a lecture. The guard must have had this info earlier and must have been expecting the good doctor, who incidentally is very reputed. But still, no identification papers were asked for and the car was allowed to pass without even a symbolic security check of the boot and the undercarriage!

 

The doctor was then accompanied by some scientists to the director’s office. The director was very courteous and they both had coffee together. All this while my boss was carrying his laptop which remained unchecked. Later on when he finished off the lecture at a hall below, my boss suddenly remembered that another leather bag which he had carried was accidentally left behind in the director’s office and it remained there during the entire time of the lecture!

 

I shudder to imagine the security consequences if at all this visitor were a turncoat or someone in disguise or simply a different guy. And this monumental negligence was on Friday when we were still fighting the terrorists holed up in the hotels.

 

Incident Two: I drove to a reputed hospital in town to visit a sick relative admitted there on Sunday. The security guy handed me a parking ticket and waved me in. I asked if there is going to be any security check. The guy’s face was blank and I instantly realized two things: one, there is going to be no increase in security at many such places. Two, it struck me that this security guard was probably not even aware of what had happened in Mumbai, and why I had asked him if there was going to be a security check of the car!

 

Just after such an attack on my motherland, half of us don’t seem to care and the other half is not even aware. Do we still expect 26/11 to bring about a change in our attitude? Forget about it..

 

 

vac1This was an unusual dilemma for me. My second child was due for routine vaccinations & my wife planned to take my first child along. Our pediatrician, incidentally a dear friend, suggested that Hepatitis A vaccine be given to my first born. Wife consulted me & with whatever knowledge of hepatitis A and various vaccination programs, I said no. But my wife & our pediatrician together decided otherwise and the vaccine was given anyway. They somehow tried to justify their stand by saying when it comes to children’s health one should not mind spending, as if I was worried about that! In fact the kind pediatrician, offered to pay for the vaccine! Thanks a lot doc!

 

This blog is in response to that event. I’m bouncing my thoughts off you, random reader. This has now got nothing to do with my daughter’s bygone vaccination.

 

Hepatitis A is a viral infection which is transmitted by feco-oral route (Don’t say yeeash!). Fecally contaminated water contains viral particles and when such water is consumed infection occurs. Now there is a difference between Hep A infection & Hepatitis A disease. In a large majority (nearly 90%) of children who ingest Hep A contaminated water the virus enters the system, goes into the liver cells, is recognized by the body immune system and is cleared by the body’s policemen. In the process the child develops permanent immunity against future Hep A infection.

 

In less than 10%, children exposed to Hep A virus, the virus actually damages the liver cells leading to ‘jaundice’, before the body’s immune system is activated. Eventually immune system wakes up and clears the virus from the body, damaged liver cells heals, thus jaundice goes away. Extremely rarely, liver damage is severe enough to be fatal. Unlike Hepatitis B or C, hep A never causes chronic liver disease.

 

In adults on the other hand, it is a little different. Nearly 30% of those exposed to Hep A suffer from jaundice. And the illness is clinically little more severe in terms of symptoms and duration in adults than in children. Even in adults fatal liver damage is very very rare.

 

So it appears that it is better to have Hep A exposure during childhood than later.

 

In endemic regions like India, water contamination is so rampant that practically everyone is exposed and immune to Hep A before they are 10. On the other hand, in developed world, exposure is rare. So it makes sense for a child in the US to be vaccinated against Hep A.

 

Early vaccination (my child is 3yrs), prevents natural infection and immunity and if the vaccine acquired immunity wanes in late adulthood, the individual is at risk for developing clinically more serious hepatitis. So WHO does not support routine vaccination in endemic areas where Hep A exposure is universal and natural immunity is lifelong.

 

Any thoughts on this?

 

P.S., this kind of argument does not apply to diseases like Diphtheria or measles where the clinical illness is severe as well as life-threatening. What I’m saying is I’m not against vaccinations in general. Only against Hep A vaccination for children in endemic areas

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.

 

 

 

Last night I saw PGI in my dreams. Not my ex-girlfriend. PGI stands for Post Graduate Institute for Medical Education & Research. Located in Chandigarh – The City Beautiful – this place is a tertiary referral center for five states: Punjab, Haryana, J&K, Rajasthan & parts of UP. I think now one should also add Uttaranchal to this list.
What I dreamt was not my life in PGI, rather my exit from it. I was driving out in my brand new Santro with myCity Beautiful wife with a 14” television and the monitor of my Celeron 256 PC in the back seat. This is exactly what had happened in Dec 2001. But the importance of that is best understood in perspective. 

 

 

 

The year 1994, Sridhar & I ( I did pick up ‘Hi, myself Venkatesh’ from punjabi friends at chandigarh, but I’m normal now!) went to PGI to give the entrance exam. Sridhar got into Radiodiagnosis in Jan & I got into Internal Medicine in July of the fateful year. We had entered PGI with an old suitcase each – not branded, just bought off Sadar bazar in Delhi. Once allotted rooms in the hostel (good old Kairon block!), both of us had bought mattresses costing 150 bucks apiece (Indian rupees!). Those were all the assets we had apart from the shirts on our backs.

 

Eight years later, Sridhar was already in Boston and he missed this scene: I had joined a corporate hospital in Mohali and was shifting out of PGI campus a week ahead of my last working day there. There was a small one ton truck in front full of my effects: furniture, books, refrigerator and clothes. I had just bought the car I was driving and was the proud owner of my small TV & the desktop in the back.

 

I commented to my wife that everything in the truck and the car – every single thing except her – was earned & not bequeathed: including the two medical degrees which would later be my passports to better jobs. At that precise point we were passing the main gate of my Alma Mater. Impulsively I pulled over outside. We both got off the car and watched the main entrance. We silently paid homage to great institute that made our life and got into the car & drove off.

 

What I am today is what you have made out of me: Thanks PGI…