Author: admin

 

I wonder if you noticed that at least 3 cricketers in the last 2-3 years developed a sore throat, requiring a cough syrup. Sore throats are pretty common , last 5- 7 days, with a virus being usually the cause. It really needs no treatment as the course is self limiting. Drinking warm beverages or warm saline gargling brings considerable relief. A pain killer can be taken in case of excessive discomfort, but never give aspirin to a child ( as this may trigger Reye’s syndrome). But our cricketers were found to have taken terbutaline by the BCCI ( the exalted Indian cricket board), which then slapped bans effective from a back date. So an 8 month ban actually became effective for as little as 4 months. No wonder the Sports Ministry of the government of India has tried its best to make the BCCI realise that it cannot be jury and executioner, not cannot and should not check for banned performance enhancing drugs on its own and then slap strange back dated bans on the culprits. There is obviously a conflict of interest apart from the fact that the testing may neither be robust enough or worse the burden not large enough. Apparently a little ore than 200 samples were sent by the BCCI to a national doping laboratory that detected 5 positive samples; there is no record of how these 5 cricketers were dealt with; or whether they were dealt with at all. The sports ministry is therefore keen to bring the process of checking for doping under the National Anti-Doping Agency or NADA, which operates under the regulatory authority of WADA or the World Anti-Doping Agency. Every Indian sport federation is subject to NADA’s testing; the BCCI insists for some strange reason to be outside NADA’s ambit. It believes that its own system for checking doping is robust enough.

 

A sore throat may be because of streptococcal bacteria , in which case an antibiotic is administered to resolve the infection. This too rarely lasts a more than a week. There is neither science nor logic in administration of terbutaline to an athlete for a sore throat. Remarkably Mr Yusuf Pathan when nabbed with terbutaline in his urine sample , in all wisdom confessed that he had to take terbutaline for a sore throat; the BCCI as customary handed him a back dated ban. Mr Pathan made a statement of how proud he was to play for his state and his Motherland. One can only hope that he does not use terbutaline again while playing for the next edition of the IPL. Or at least does not get caught.

 

 

Continue reading “TERBUTALINE TURBOCHARGED CRICKET”

 

 

 

 

Recently many cardiovascular  professional bodies pulled down the high blood pressure threshold, needing treatment , from 140 mm Hg systolic and 90m mm Hg diastolic to 130 mm Hg systolic and 80 mm Hg diastolic. The impetus for lowering blood pressure threshold from 140/90 to 130/ 80 was largely based upon a single trial, albeit a large randomised one that showed slight improvement in clinical outcomes but accompanied with the offshoot of serious adverse effects, when blood pressure was lowered below 130 mm Hg systolic. I have never been a great admirer of the “SPRINT” study and have stuck out my neck by expressing my views in the past. I am more comfortable keeping the threshold at 140/90 because I am not convinced that there is incremental advantage in lowering it below 130/80 as many of my colleagues would recommend on the basis of international guidelines. By lowering the threshold millions more people get branded as hypertensives, and hence obviously many millions of tablets get prescribed, with little advantage. Someone somewhere is raking in a lot of moolah. However it is well known that almost 600,000 people die of heart attack or stroke in the US alone in a year.

 

An interesting study, published last week( N Engl J med 2019;381: 243-51) has received little attention. In fact it has gone completely under the radar. Maybe because it has not shown any difference in the composite of myocardial infarction (heart attack), ischemic or hemorrhagic stroke in more than 1 million middle aged people followed for almost 8 years. The researchers pored through data on more than 36 blood pressure readings of 1.3 million or 13 lakh participants. There were almost 19% participants who could be labeled as hypertensive when the 140/90 threshold was employed, but this jumped to 43.5% with 130/80. The prevalence of people with high blood pressure thus more than doubles with the lower threshold label. Results demonstrated that both systolic and diastolic blood pressure measurements influenced clinical outcomes. There was an increase of 18% in clinical outcomes when the systolic threshold was breached, and an increase of 6% with raised diastolic blood pressure. Crucially, researchers found similar increase in risks with both thresholds of 140/90 or 130/80.I must dilate on this, there was no increase in death or stroke with the 140/90 cohort versus the 130/80 group.

 

Continue reading “SHOULD BLOOD PRESSURE THRESHOLD BE LOWERED FROM 140/90 TO 130/80 ??”

 

 

 

 

I was a part of the delegation of the Indian president in the mid nineties that was travelling to Brazil. We had a stopover in New York city. The entire Indian delegation was put up at the Waldorf hotel with the president. Mr Narayanan  was a terrific human being; erudite, sophisticated yet spectacularly down to earth. It was therefore a pleasure and privilege to accompany the president in his foreign travels. I am let me confess a poor traveller. But during the Waldorf stay I desperately wanted to trace a  school mate, Satindar Sood had played for the Indian school boys cricket team. We had been terrific friends in school. He tried his best to make me take up cricket but my heart form the beginning was always into long distance running, but I did not mind playing for the school cricket team. I therefore make sure I have my eyes on the ball, be it a doosra or a googly, that are thrown at you by the dozens each day in current India. I knew Satindar’s address by heart, which I provided the secret service personnel guarding us.  One big guy got back to me in less than 15 minutes with confirmation that my mate was residing  in New Jersey and also provided me  his telephone number, and I could actually talk to my friend.I was most impressed by  the  American secret service .  I mention this small story because I witnessed that evening the efficiency of American protocol.

 

Even as I write there are thousands of hospital emergencies in this country being managed mostly  by  most junior doctors, who right now must be saving thousands of lives by treating patients with a compound fracture, a heart attack, a heart failure, an epileptic fit, a traffic accident victim and so on. Remember saving lives comes as naturally to the frontline doctor as breathing.

Do read Mr Kulkarni’s piece on Gandhiji’s sacrifice for muslims and Pakistan in todays Dawn; he also dilates on Mr Jinnah’s love for the city of Bombay and the house he built there. He records the 14 meetings of Gandhiji and Mr Jinnah to prevent  the great partition; all to no avail as matters turned out. The thrust of the article is that we should pay heed to these 2 titans of the subcontinent.  For how long should two countries with 2500 miles of common border, be at each others throat? For how much longer will we mistrust one another and hurl abuses at each other. Maybe the status quo suits many parties, which includes politicians, bureaucrats and the military. It is imperative that we stop looking for guidance and light from people, however noble and exalted, of the past. If we have the brains to launch a rocket to the moon we should be able to tackle the monstrous animosity against out neighbour.

 

 

The United States looked the other way for decades whilst Pakistan accumulated hundreds of nuclear weapons, directed mostly at Delhi. No major western newspaper has expressed concern at formidable nuclear arsenal of Pakistan. The book ‘Deception’ is a must read for those interested in the nuclear weaponisation of Pakistan by a couple of investigative reporters from the London Times.

 

 

 

The United States is indeed an incredible country but American scientists have been for decades weaponising any insect they could get their hands on. They would inject mosquitoes, fleas and even ticks with every imaginable bacteria or virus to deliberately spread disease in what was considered enemy population. Kennedy did not flinch from dropping thousands and thousands of insects carrying incapacitating bacteria over Cuba. Plum Island in New York was one such centre where a corkscrew shaped bacteria was probably injected into ticks, the ticks would bite a human and introduce the corkscrew shaped bacteria in a person’s blood system. Initially there would be flu like symptoms accompanied by a rash on the body that in many cases appeared like a bulls eye target. There would be joint pains for months that could be crippling ,and in 10 to 15% cases there could even be heart disease such as heart blocks or neurological disease such a nerve paralysis and meningitis. The chronic form may be due to lingering molecule in the bacterial cel wall eliciting an immune response ( Proc of National Academy sciences USA jury 2, 2019).The disease was called “Lyme’ because it was recognised first in the township of Lyme, and the first scientist to discover the bacteria was Willy Burgdorfer ( Swiss American) in the early nineteen eighties. Burgdorfer became a celebrated and much applauded scientist who gathered numerous International awards. But towards the end of his life he revealed that he along with other scientists had worked for years in developing the technique of infecting ticks with the Borrelia burgdorfer bacteria ( this is on video record). That the bacteria was not a natural occurring one, nor an off shoot of environmental change, but specifically engineered in a secret military bioweapons lab for the specific aim of incapacitating humans. Today almost 400,000 suffer from Lyme disease in the US alone accounting for huge burden of morbidity. Antibiotics are effective but treatment for the chronic version is yet to be established. This bioweapon programme and Burgdorfer’s role is described in riveting detail in Kris Newby’s book “Bitten; The Secret History of Lyme disease and Biological Weapons.” The book has been taken seriously by the American House of Representatives to call for an investigation by the department of defence whether such a sector program existed in the fifties to the seventies and whether the disease was sparked by accident release of weaponised ticks or deliberately. Interestingly a series of cases of Lyme diesel were reported from Haryana in the “Indian journal of dermatology, venereology and leprology in 2014; 80:320-323.” The authors wondered as to how and where did the disease suddenly appear in Haryana.

 

 

I cannot emphasise enough that winning the ODI World Cup should be considered a stunning achievement, but one life saved by a junior doctor in the Emergency is still far far better.It is time to end 70 years of toxic and needless hostilities; this may not be possible by merely quoting Gandhiji or Mr Jinnah . The responsibility lies with us, not with jingoistic superpatriotism but by applying a calibrated and sensible approach.

 

Coronary stenting has revolutionised the treatment of heart disease. Lakhs of patients destined for CABG surgery are now tackled with a percutaneous technique that does not need general anaesthesia, almost completely does the job of rectifying ischemia, with the patient being discharged next day or even the same day in selected cases. No amount of praise for the pioneer researchers can be enough. We have a device that cuts mortality apart from providing excellent symptomatic relief. Chest pain and breathlessness become complaints of the past as if by magic, by the insertion of a thin catheter from the wrist or the groin. The stent is a metallic mesh tube that is lined by a plastic polymer laced by a medicine that prevents restenosis of the coronary artery.We now have second generation stents that are markedly thin in size. The procedure is reasonably simple for the experienced operator. Experts in the field do not hesitate to treat complex lesions that would surely have been managed by bypass surgery in the past.

 

The job however is not complete with insertion of the stent. Stenting procedure has to be followed by months of anti platelet therapy, which consists of pills. The pills are invariably tablet aspirin accompanied with a P2Y12 inhibitor. The P2Y12 receptors on the surface of platelets are the glue that binds them to form a clot. There are 3 P2Y12 inhibitors in the market; clopidogrel, prasugrel and ticagrelor, all available in the Indian market.

 

In cricketing analogy ,once the base has been set in a one day game, someone has to consolidate the score by launching himself in the death overs. Bairstow and Roy have been laying down superb foundations for the English, while Stokes and Buttler do the demolition job towards the end. Dhoni has been a stunning finisher all these years, in fact he has been regarded as the best in the business. But it is becoming obvious that he no longer possesses that prowess. The ongoing World Cup has exposed his inability to ratchet up the strike rate , a strike rate of 100% or less in a World Cup semifinal would just not good enough. Good work done by Sharma and Kohli at the top has to be bolstered by a strike rate around 140-150% later on, the strike rate of course should fetch some handsome runs too.

Continue reading “REDUCE DAPT DURATION AFTER STENTING BUT NEVER REDUCE THE STRIKE RATE AT DEATH OVERS.”

 

 

 

I distinctly remember Mr Imran Khan stating more than once that the solution to the Kashmir problem should be a cricket match. If India were to win ,Kashmir would be hers, but in case Pakistan were the victors then ‘paradise on earth’ would be rightfully their territory. Those were the days when the Pakistani cricket team more or less had an edge on India. Pakistani batting then was not only rock solid but buttressed by arguably the finest pace attack on the planet. Mr Imran Khan, no minnow with the bat , was a terrific fast bowler. Somewhere down the line he mastered the reverse swing too. It would be interesting to know of his personal opinion in current times, bearing in mind that now its the Indian cricket team that bats deep with one of the most potent pace attack. Mr Imran Khan understandably refrains from attaching any form of cricket to Kashmir. Not test, not one day cricket nor the T20 form. To his credit Mr Imran Khan was right up there as one of the best all rounders in the world. So it comes as some surprise that such a fine cricketing brain is now batting in the murky world of Pakistani politics. I personally preferred him when he made those frank promulgations that smacked of simplicity in a man who played with a straight bat.

 

I am compelled to recollect those artless days; we also believed that saturated fat was a killer. The equation was simple, eat meat particularly red meat and you would kick up your cholesterol level. The spike in cholesterol in turn would clog your arteries, resulting in heart attacks and stroke. There was the famous “seven countries” data that set up the high cholesterol diet equals heart attack hypothesis. It was only much later we all found that that the “seven countries” data was full of holes. I have elaborated on the flaws in the past. Every randomised study on saturated fats has failed to show reduction in heart attacks by having a diet with reduced saturated fats. The Women’s Health Initiative followed 49,000m postmenopausal women for 8 years who had been on a low fat diet, but could not record reduction in the risk of death, heart attack or diabetes. The conclusion was no different when saturated fat was replaced by a vegetable oil (polyunsaturated fat). There were more heart attack and death in the intervention group. There have been 2 such randomised trials, both concluded that replacement with a vegetable oil somehow did not lower clinical events.

Continue reading “IT’S NOT THE CHOLESTEROL STUPID, IT’S TMAO WHICH IS THE CULPRIT”

 

 

An interesting article recently published dilates on the fact that a drug backed by solid evidence in the past may be found ineffective some years later. Beta blockers considered indispensable subsequent to an acute myocardial infarction are now not recommended in post MI patients with normal left ventricle function. A beta blocker does not improve clinical outcomes in a post MI patient who does not have an impaired left ventricle. Another drug seems to be fizzling out as a prophylaxis against cardiovascular events. Three randomised trials have shown little or no benefit in clinical outcomes with prophylactic aspirin. In fact prophylactic aspirin is almost always associated with increased bleeds, which can be a serious advert effect. Some years ago however aspirin had consistently demonstrated good efficacy as a prophylactic in middle aged people. Prophylactic aspirin was backed by reasonably good evidence of better clinical outcomes. Why does the same medicine at the same dosage not work any longer? The explanation is simple; over the years population has altered, people are more health conscious now with much better lifestyle application. Also there is much greater emphasis on control of high blood pressure and management of lipids with statins. The net result is that the marginal albeit clinically significant prophylactic advantage has evaporated. Evidence based medicine is not forever, there can be an expiry date.

Continue reading “INTRA-AORTIC BALLOON TRUMPS INOTROPES IN DECOMPENSATED HEART FAILURE”