Sundeep Mishra

Are western guidelines good enough for Indians? My name is Borat.

Physicians in an attempt to give their patients the best possible care need to be updated on the evolving body of scientific research, trials, case reports, and combine this evidence with their own clinical experience keeping in mind each individual patients circumstances and preferences. To address this felt need, guidelines are systematically developed statements designed to help clinicians make management decisions. While a multitude of guidelines are available from developed world they might not exactly fit into developing world context. Thus a host of fresh guidelines might be required to fill this void or the existing guidelines modified (supplemented, altered or deleted) to be relevant to this part of the world.

Does modern medicine increase life-expectancy: Quest for the Moon Rabbit?

The search for elixir of immortality has yielded mixed results. While some of the interventions like percutaneous coronary interventions and coronary artery bypass grafting have been a huge disappointment at least as far as prolongation of life is concerned, their absolute benefit is meager and that too in very sick patients. Cardiac specific drugs like statins and aspirin have fared slightly better, being useful in patients with manifest coronary artery disease, particularly in sicker populations although even their usefulness in primary prevention is rather low. The only strategies of proven benefit in primary/primordial prevention are pursuing a healthy life-style and its modification when appropriate, like cessation of smoking, weight reduction, increasing physical activity, eating a healthy diet and bringing blood pressure, serum cholesterol, and blood glucose under control.

Diuretics in primary hypertension - Reloaded.

Diuretics have long been cherished as drugs of choice for uncomplicated primary hypertension. Robust mortality and morbidity data is available for diuretics to back this strategy. Off-late the interest for diuretics has waned off perhaps due to availability of more effective drugs but more likely due to perceived lack of tolerance and side-effect profile of high-dose of diuretics required for mortality benefit. Low-dose diuretics particularly thiazide diuretics are safer but lack the mortality benefit shown by high-dose. However, indapamide and low dose chlorthalidone have fewer side-effects but continue to provide mortality benefit.

What ails the practice of medicine: The Atlas has shrugged

Health-care providers are currently facing a huge challenge. At one end they are expending a huge amount of time and energies on health-care delivery including time spent on upgradation of their knowledge and skills (to remain abreast with the field and be able to provide state-of-art patient care), sometimes even at the expense of themselves and their families. On the other hand they are not receiving adequate re-imbursement for their efforts. To compound the problem several traders have entered the profession who are well adept in the materialistic approach abandoning the ethics (which currently happens to be the flavor of society in general), giving a bad name to the whole profession and causing severe grief, embarrassment and even dis-illusion to an average physician. The solution to the problem may lie in weeding out these black sheep as also realization by the society that the whole profession should not be wrongly labeled, rather a hard toiling and a morally driven practitioner should be given his/her due worth.

Is smog innocuous? Air pollution and cardiovascular disease

Air pollution is a significant environmental and health hazard. Earlier studies had examined the adverse health effects associated with short- and long-term exposure to particulate matter on respiratory disease. However, later studies demonstrated that was actually cardiovascular disease that accounted for majority of mortality. Furthermore, it was not gaseous pollutants like oxides of nitrate, sulfur, carbon mono-oxide or ozone but the particulate matter or PM, of fine or coarse size (PM2.5 and PM10) which was linearly associated with mortality; PM2.5 with long term and PM10 with short term. Several cardiovascular diseases are associated with pollution; acute myocardial infarction, heart failure, cardiac arrhythmias, atherosclerosis and cardiac arrest. The ideal way to address this problem is by adhering to stringent environmental standards of pollutants but some individual steps like choosing to stay indoors (on high pollution days), reducing outdoor air permeation to inside, purifying indoor air using air filters, and also limiting outdoor physical activity near source of air pollution can help. Nutritional anti-oxidants like statins or Mediterranean diet, and aspirin have not been associated with reduced risk but specific nutritional agents like broccoli, cabbage, cauliflower or brussels sprouts, fish oil supplement may help. Use of face-mask has been controversial but may be useful if particulate matter load is higher.

Do we need to change the medical curriculum: regarding the pain of others.

The current curriculum is behind its time and urgently requires to be reformed. The changes required are not only in the amount and type of desired information but also in the way this knowledge is acquired. Further, literature, art and philosophy require to be integrated in the curriculum so that a medical student can find his/her bearings in the society. Finally, but most importantly focus must be on developing empathy so that a prospective physician can correlate with the pain of patients and act towards relieving it rather than intellectualizing it.

Guidance on reuse of cardio-vascular catheters and devices in India: A consensus document

Reuse of medical device is accepted worldwide. Benefits of reuse include not only cost saving but a favorable impact on environment. However, certain requirements should be met for reuse to be safe and effective. The devices, which can be reused, should be clearly defined, a meticulous process for dis-infection and sterilization followed and its functionality ascertained before use. Further, an appropriate consent should be obtained where necessary and the cost saving entailed should be directly passed on to the patient.

A fresh look at bioresorbable scaffold technology: Intuition pumps

Bioresorbable scaffolds (BRS) are a new enticing treatment option in coronary interventions. Absorb BVS™ Is the most widely used and researched polymer based BRS, eluting everolimus. However currently it has several technical limitations; low radial support, larger strut size, poor visualization, poor deliverability and complex implantation technique. Magnesium based BRS are an alternate but they are also limited not only by lower radial support and poor visualization but also earlier bio-absorption. Material processing: blow-molding, annealing, polymer orientation, change in composition and use of higher molecular weight polymer, as well new polymers like tyrosine or salicyclate analogs and even hybrid (polymer and metallic) combined with intelligent cell design has led to evolution of BRS technology. Newer BRS has higher radial strength, lower strut thickness, improved visualization, ease of scaffold implantation as also optimal bio-resorption time.

Management algorithms for acute ST elevation myocardial infarction in less industrialized world

AIIMS, New Delhi, India Department of Physiotherapy, School of Allied Health Sciences, Manipal University, Manipal 576104, Karnataka, India Department of Cardiology, AIIMS, New Delhi, India d PES-IMSR Superspeciality Hospital, Kuppam, District Chittoor, Andhra Pradesh, India e Interventional Cardiology & HOD Cardiology, The Mission Hospital, Durgapur, India f Sengupta Hospital and Research Institute, Nagpur, Maharashtra, India Clinical Research, Fortis Health Care, Fortis Escorts Heart Institute, Okhla Road, New Delhi 110025, India Apollo Speciality Hospitals, Vanagram, Chennai, India Medical College Vadodara, Vadodara, India Department of Cardiology, MGM New Bombay Hospital, New Mumbai 400702, India k Christian Medical College Hospital Vellore, Vellore 632004, India Dept of Medicine, Kishori Ram Hospital & Diabetes Care Centre, Kishori Ram Road, Basant Vihar, Bhatinda, India Moolchand Medicity, New Delhi, India Cardiology Department, LTMGH Sion, Mumbai, India CARE Hospitals, Hyderabad, India Dept of Cardiology, BHU, Varanasi, India

Are all stents equal - Need for scoring system to evaluate stents?

Currently drug eluting stents (DES) have reached a high degree of sophistication where there seems very little scope of improvement. Even so every year or so there is some advancement in technology and a new version is released, which is claimed to be a new generation (rather than pipeline innovation). It is really important to define what pipeline extension is and what is new innovation (generation)? This classification would not only be useful from regulatory perspective but also determining the true value of a product allowing for a correct pricing, which should ideally be able to mark-up for a real innovation.