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    The everolimus eluting stent.

    The everolimus eluting stent.

     

    The presence of diabetes substantially alters prognosis and clinical outcomes after percutaneous coronary intervention (PCI). In recent years a number of studies comparing long- term efficacy and safety of various drug eluting stents (DES) have been published and the balance of evidence found to be substantially against the paclitaxel eluting stent (PES).

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    Towards the end of 2013 the Eight Joint National Committee (JNC) released the latest guidelines for treatment of adult hypertension. The 14-page document along with 300 pages of online supplement could be summarized into 2 simple messages; keep blood pressure below 150/90 in people over 60 years but below 140/90 in all other adults and that treatment could begin with any one of mainstream anti-hypertensive medication. One could initiate treatment with a thiazide type diuretic, ACE inhibitor, angiotensin receptor blocker (ARB) or a calcium blocker.

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    Alfred Nobel's will established the Nobel Prizes upon his death.He was worried about a destruction legacy because he had accrued his fortune from patenting dynamite in1867.

    Alfred Nobel’s will established the Nobel Prizes upon his death. He was worried about leaving a legacy of devastation because he had amassed his fortune from patenting dynamite in1867.

    IMG_1852

     

    There were an estimated 207 million cases of malaria in 2012 according to the official bulletin of the World Health Organization of which 627,000 died but no one is sure and a conservative estimate of the range is between 73000 and 789000 deaths. The problem is that it is impossible to gather accurate mortality data from some countries particularly African ones which suffer the most from the disease. Ninety percent of all malaria deaths occur in sub-Saharan Africa and 77% occur in children below 5 years; 1300 children die each day or one child every minute. Malaria remains a major scourge in the modern world despite recent advances in treatment, prevention and control.

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  4. Empagliflozin lowers mortality and hospitalisation for heart failure significantly in patients with diabetes already on optimal medication.

    Empagliflozin lowers mortality and hospitalisation for heart failure significantly in patients with diabetes already on optimal medication.

    Probably for the first time a glucose-lowering drug has shown significant 38% relative reduction in cardiovascular mortality and a 32% relative reduction all cause mortality. Empagliflozin, a sodium-glucose cotransporter 2 (SGLT2) inhibitor reduces serum glucose levels by cutting down renal reabsorption and increasing urinary excretion of glucose. A large industry sponsored randomized trial examined the effects of empagliflozin on cardiovascular outcomes in 7020 type 2 diabetes patients (mean age 63 years) with previous history of coronary artery disease, stroke, or peripheral arterial disease (EMPA-REG OUTCOME Trial).

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    A female Aedes Aegypti mosquito that can spread dengue,chickungunya and yellow fever.

    A female Aedes Aegypti mosquito that can spread dengue,chickungunya and yellow fever.

     

    Probably neither the prime minister nor the chief minister of Delhi including their mandarins in the health and urban ministries ever realized that the deadliest stalker on the planet is the mosquito. Mosquitoes kill more than 8 lakhs people in a year with man coming a distant second accounting for 5 lakh kills. The lion slaughters a mere 100 people, while snakes in a year send almost 50,000 to paradise. Astoundingly in all the din most anchors and panelists on television debates have been unable to pronounce Dengue correctly; the emphasis by the media has all along been (with some justification) on slinging as much mud as possible on Delhi hospitals; but not a whisper or murmur of the terrible ramifications of the horrendously dirty city we live in. There has not been the slightest hint suggesting removal of all those puddles of water or administering a vaccine.

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    THE RACE THAT SAVED THE REPUTATION OF ATHLETICS AND POSSIBLY ATHLETICS'S SOUL.

    THE RACE THAT SAVED THE REPUTATION OF ATHLETICS AND POSSIBLY ATHLETICS’S SOUL; USAIN BOLT DEFEATS JUSTIN GATLIN IN THE 100 m IN THE BEIJING WORLD ATHLETICS CHAMPIONSHIPS, 2015.

     

    A sensational leaked database form the archives of the International Association of Athletics Federations (IAAF) revealing rampant doping among elite medal winning athletes elicited little or no reaction from the Indian media. There was not one editorial, not one column and not a single blog on the biggest ever leak of 12000 blood reports done on 5000 international athletes from 2001 to 2012; of which 800 were considered suspicious by independent experts. A large chunk of these were from athletes in Russia, Ukraine, and Belarus while India contributed about 5% of suspect samples. Surprisingly the database suggested that Kenya too suffered from widespread blood doping including administration of synthetic erythropoietin (EPO) besides anabolic steroids. There have been no pre-competition blood tests of all athletes participating in the current Beijing world championships in which the Kenyans lead with 7 gold medals. Despite serious allegations by the London Times and German TV broadcaster ARD, the IAAF for all practical purposes appears to be disinclined to swoop down on drug cheats.

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    The new oral anticoagulants (NOAC’s) either directly inhibit thrombin (dabigatran) or factor Xa (rivaroxaban, apixaban and edoxaban). These direct oral anticoagulants have several advantages over vitamin K antagonists; they have a wider therapeutic window, quick onset of action, do not require regular blood coagulation monitoring, and have a shorter half lives. Warfarin (vitamin K antagonist) demands constant monitoring of the international normalized ratio (INR) that in turn compels dose adjustment. The new oral anticoagulants have proven to be viable alternatives to a vitamin K antagonist in industry sponsored randomized trials involving thousands of patients. The NOAC’s when compared to warfarin providing good anticoagulation (INR between 2and 3, 60% of the time) were found to be non-inferior and in some cases superior in patients with non-valvular atrial fibrillation. Intracranial and fatal bleeds were lowered by 50% with the NOAC’s and major bleeding by 28% as compared to warfarin.

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    JINNAH SAHIB WITH THE MOUNTBATTENS;APRIL 1947.

    JINNAH SAHIB WITH THE MOUNTBATTENS;APRIL 1947.

    JINNAH N MOUNTABTTENS

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    12 LEAD EKG SHOWING T-WAVE INVERSION IN LEAD1,AVL,V5-V6.

    FIGURE 1:  EKG SHOWING  T-WAVE  INVERSION  IN  LEADS  L1, AVL, V5-V6.

    FIGURE 2: TWO CHAMBER ECHO VIEW DEMONSTRATING LARGE MYXOMA IN LEFT ATRIUM (WHITE ARROW) WITH BREAKAWAY SATELLITE PIECE AT 6 O'CLOCK POSITION (RED ARROW) AND MILD PERICARDIAL EFFUSION (GREEN ARROW).

    FIGURE 2: TWO CHAMBER ECHO VIEW DEMONSTRATING LARGE MYXOMA IN LEFT ATRIUM (WHITE ARROW) WITH BREAKAWAY SATELLITE PIECE AT 6 O’CLOCK POSITION (RED ARROW) AND MILD PERICARDIAL EFFUSION (GREEN ARROW).

     

    FIGURE 3: TOTALLY OCCLUDED LEFT ANTERIOR DESCENDING CORONARY ARTERY AT MID-DISTAL REGION (WHITE ARROW).

    FIGURE 3: TOTALLY OCCLUDED LEFT ANTERIOR DESCENDING CORONARY ARTERY AT MID-DISTAL REGION (WHITE ARROW).

     

    FIGURE 4 : MRI SHOWING LARGE MULTIPLE EMBOLIC INFARCTS FROM LEFT ATRIAL MYXOMA IN BOTH CEREBRAL HEMISPHERES (WHITE ARROWS).

    FIGURE 4 : MRI SHOWING LARGE MULTIPLE EMBOLIC INFARCTS FROM LEFT ATRIAL MYXOMA IN BOTH CEREBRAL HEMISPHERES (WHITE ARROWS).

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    30 DAY RESULTS OF PCI WITH EVEROLIMUS ELUTING STENTS vs. CABG IN PATIENTS WITH DIABETES AMD MULTI-VESSEL DISEASE (PROPENSITY SCORE MATCHING).

    30 DAY RESULTS OF PCI WITH EVEROLIMUS ELUTING STENTS vs. CABG IN PATIENTS WITH DIABETES AMD MULTI-VESSEL DISEASE (PROPENSITY SCORE MATCHING; REFERENCE 3).

     

    The Future Revascularization Evaluation in Patients with Diabetes Mellitus :Optimal Management of Multivessel Disease (FREEDOM) was the largest randomized trial studying the impact of percutaneous intervention (PCI) with drug eluting stents (DES) versus CABG in patients of diabetes mellitus with multivessel disease. Nineteen hundred diabetic patients (mean age 63 years) were enrolled in 140 international centers; 83% had 3-vessel disease and 71% were men. The DES group received sirolimus or paclitaxel eluting stents, which are now considered first generation DES. Median follow up was 3.8 years. The primary outcome (death from any cause, nonfatal myocardial infarction (MI) or nonfatal stroke) was significantly more common in the PCI patients (27% vs. 19%; p=0.005); driven largely by rates of myocardial infarction (p<0.001) and death from any cause (p=0.049). The CABG group had both lower mortality (6% vs. 13%) and MI (11% vs.16%). Strokes were however more common with CABG (5.2% vs.2.4%; p=0.03). The authors concluded that CABG was superior to PCI in diabetic patients in that it significantly reduced death and MI (1).

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    Percutaneous intervention (PCI) has become standard care for treatment of patients suffering from acute coronary syndrome consisting of ST-elevation myocardial infarction (STEMI), non ST-segment elevation myocardial infarction (NSTEMI) and unstable angina. The procedure demands, for success, adjunctive therapy in the form of antiplatelet agents and anticoagulants. The Harmonizing Outcomes with Revascularization and Stents in Acute Myocardial Infarction (HORIZONS-AMI) trial established the role bivalirudin (a direct thrombin inhibitor); the trial compared bivalirudin with heparin plus a glycoprotein inhibitor (GPI) in patients with STEMI, with bivalirudin recording survival benefit extending to 3 years, albeit with a 5 fold increased incidence of stent thrombosis (ST) (1).

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    This week JAMA Internal Medicine published a massive retrospective study that included almost a million subjects. Almost half a million people taking statins were compared to an equivalent population not popping  any. They also added more than 26,000 patients on non-statin lipid lowering drugs. The authors observed, in their own words, a strong association between first exposure to statins and acute memory loss diagnosed within 30 days  following exposure. The increase in memory loss was 4.40 times compared with non-statin users; in other words statins hiked up loss of memory by 440%.

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    Traffic lights in Delhi are frequently non-functional;leading to noisy traffic snarls that significantly exacerbate air pollution; the sky at 10 am is not cloudy but full of dust.

    Traffic lights in Delhi are frequently non-functional;leading to noisy traffic snarls that significantly exacerbate air pollution; the sky at 10 am is not cloudy but full of dust (Jasola,New Delhi).

     

    Trucks cutting through Delhi insist that you honk be it day or night (this one is from the state of Haryana).

    Trucks that ply through Delhi insist that you honk , be it day or night (this one is from the state of Haryana).

     

    A recent New York Times article on the toxicity of Delhi’s air not only set the cat among the pigeons but compelled the Hindustan Times (a daily) to print a series of reports on it’s front page emphasizing the same. The Times quotes a remarkable study commissioned by Central Pollution Control Board; which then sat over the conclusions drawn by the investigators for more than half a decade. The study assessing lung functions in almost 6,000 Delhi school children from 36 schools (begun in 2002) found that 44% suffered from poor or restrictive lungs, and that 10-27% of them complained of headache, eye irritation, nausea, palpitation and fatigue. The Times correspondent decided enough was enough when he found that his little boy had developed full blown severe asthma necessitating hospitalization.

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    SIR WILLIAM WITHERING.

    SIR WILLIAM WITHERING

     

    GEORGE WASHINGTON AT THE BATTLE OF PRINCETON 1777.

    GEORGE WASHINGTON AT THE BATTLE OF PRINCETON 1777.

    ROBERT CLIVE MEETS MIR JAFAR AFTER THE BATTLE OF PLASSEY (PALASHI), 1757

    ROBERT CLIVE MEETS MIR JAFAR AFTER THE BATTLE OF PLASSEY (PALASHI), 1757.

     

    The last quarter of the eighteenth century substantially altered the complexion of the planet; the Yanks prevailed over the Brits under George Washington in the Battle of Princeton and the subsequent birth of the most powerful nation on Earth (January 1777). The Brits, however, 2 decades earlier had overcome Siraj-ud-Daulah in the Battle of Palashi (Plassey) to herald British imperialism over the Indian subcontinent,(courtesy the treachery of Mir JAfar).  It istill unclear whether Robert Clive bribed Mir Jafar to betray the Nawab of Bengal or Mir Jafar enticed Clive with a pay off to attack the Nawab with the assurance of deception in the heat of battle; anyway this classic non-military maneuver would be employed repeatedly by the English as they overran an ancient but corrupt civilization. The historic betrayal by Mir Jafar (not the first or last by an Indian) took place in June 1757.

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    Transcatheter aortic valve replacement (TAVR) has rapidly emerged as a viable alternative for the treatment of severe symptomatic valvular aortic stenosis (AS). Almost 100,000 patients of AS have benefited from this technique. Symptomatic severe AS is a killer that needs prompt surgical intervention. The PARTNER trials established the superiority of TAVR over medical management in inoperable cases, and equivalence with surgical valve replacement in high-risk patients of AS. The UK Registry of 870 patients with mean age of 82 years now provides long- term data on efficacy of TAVR from 25 centers spread out in England and Wales.

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