New rules to buy antibiotics

In the wake of the New Delhi metallo - beta - lactamase 1 (NDM 1) hoopla, the Drug Controller General of India has decided to introduce new rules to curb the sales of over-the-counter antibiotics.

Now patients will need to have two copies of prescription for buying a medicine, one copy to be kept with the chemist. What does it mean for the doctors? Do they have to write double prescriptions? These are grey areas and the details are sketchy. Nothing can be said with surety unless the DGCI issues clear guidelines.

The approach is new and hopefully it will reduce the abuse of antibiotics although I have my doubts if this will succeed in reducing the use of over-the-counter antibiotics. Law itself has never been a problem in India, the enforcement of the law is the problem. The failure of the present system is not because of it's inadequacy but due to the fact that no one is enforcing the present drug control laws. When the new regulation comes in effect who is going to enforce it? Unless it is enforced properly it will eventually be rendered useless as the present system.

The DGCI is also planning to introduce a new schedule of drugs called HX.

Do calcium supplements really cause heart attack: Controversy

In a recent study published in the British Medical Journal, researchers found a 30% increase in myocardial infarction (heart attack) with the intake of calcium supplements. Already several other researchers have questioned the validity of the conclusions of the study.

Let us see what the questions raised are.

Firstly, the study included 15 trials, that are 15 different studies, but the caveat is that patient level data was available for only 5 studies. What this means is that direct data was available for only 5 studies, in case of the other 10 studies no direct data was available. But the researchers have based their findings on these other 10 studies also.

The second question that has been raised and which is significant is that there is no linear correlation between the dose of calcium and the incidence of heart attack. This means that increased doses of calcium does not increase the risk of heart attack. Now if calcium really does cause heart attack, the findings should have been opposite, with increased doses of calcium there would have been increased risk of heart attack. This finding seriously contradicts the conclusion that calcium causes heart attack.

Thirdly, out of the 15 trials included cardiovascular outcomes were either incomplete or absent in 7 trials. This means that the data regarding heart attack was either incomplete or absent in 7 of the included studies. Now this is a serious methodological flaw.

Fourthly, the researchers have not mentioned whether there was adequate control for other confounders like smoking or hypertension (increased blood pressure). This is important because smoking or hypertension may them-selves cause heart attack, hence they are called confounders. To explain simply, let us suppose that a smoker is taking calcium supplements and has a heart attack. Now we cannot say that the heart attack was due to calcium supplements because smoking also causes heart attack. Thus the validity of the study can be questioned, as it did not address these issues.

The findings of the study are open to question. We should not adopt a knee-jerk reaction as calcium supplement is a cheap measure to prevent osteoporosis and most Indians are deficient in calcium. The findings need to be validated by further research. In the meanwhile, there is no cause for concern.

Links:

1. http://www.bmj.com/cgi/content/full/341/jul29_1/c3691

2. http://www.bmj.com/cgi/eletters/341/jul29_1/c3691

Problem of arthritis treatment in elderly

My father complained of pain in his right knee about one year ago. Initially he ignored it, thinking it to be due to overexertion but gradually the pain increased in intensity. There was restriction of movement in of the right knee joint. On examination, he was provisionally diagnosed as having osteoarthritis of the knee, confirmed with X-ray. He was prescribed Diacrein tablets and Aceclofenac 100 mg for pain control along with antacids. What happened next highlights the problem of treatment of arthritis in the elderly.

His arthritis was well controlled with medications. But after about 7 months on the treatment, he started feeling shortness of breath when he used the stairs. His blood pressure also spiked. When I examined him, I thought I have heard an ejection systolic murmur. Understandably I was worried. All the bad diagnoses came to my mind. He was examined by a cardiologist, my teacher actually, but he disagreed about the murmur. To establish a diagnosis, an ECG, chest X-ray and echocardiography was performed. Nothing was found. The cardiologist asked to discontinue the Aceclofenac and arranged for follow-up. A coronary angiogram was scheduled to be performed if the shortness of persisted on follow-up. On discontinuation of aceclofenac, my father did not complain of any shortness of breath. Presently, his arthritis is well controlled with acetaminophen (paracetamol).

This small anecdote demonstrates the problem in the control of pain in elderly arthritis patients besides the gastrointestinal problems caused by NSAIDs. Treatment of pain with Non steroidal anti inflammatory drugs (NSAIDs) causes significant cardiovascular problems. Several studies have shown NSAID use in elderly is an independent risk factor for hypertension (links given below). NSAIDs block the cyclooxygenase enzyme, nonselective NSAIDs block both COX-1 and COX-2 isoforms. COX-1 synthesize prostaglandins which are responsible for vasodilation and COX-2 produce prostaglandins which maintain diuresis and natriuresis. NSAIDs, thus may hypertension either by blocking the natriuresis causing sodium and water retention and by blocking vasodilation and production of vasoconstricting endothelins. A careful history taking is therefore of paramount importance while NSAIDs are prescribed to elderly as hypertension is a major risk factor for a variety of cardiovascular problems like myocardial infarction, stroke etc.

Currently there is interest in another novel group of drugs, which are CINODs (Cyclooxygenase inhibiting nitric oxide donators), which have much favourable gastrointestinal profile, and less chance of development of hypertension. As far as I know, at present CINODs are not marketed in India, but the introduction of CINODs will open up a new option arthritis treatment.

Links:

NSAID and hypertension

1.                  http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1381681/

2.                  http://www.ncbi.nlm.nih.gov/pubmed/9467684?ordinalpos=1&itool=PPMCLayout.PPMCAppController.PPMCArticlePage.PPMCPubmedRA&linkpos=1

CINODs

1.                  http://www.ingentaconnect.com/content/ben/chamc/2006/00000004/00000002/art00004

Naturopathy and Blasphemy

The guiding principles of naturopathy left me shocked. According to the Department of Ayush that promotes naturopathy, bacteria do not cause disease. Do they really believe it? Is Tuberculosis not caused by bacteria? May be they ought to look at the millions of TB bacilli multiplying within the lungs of TB patients, then the truth will dawn on them. I wonder if these practitioners of naturopathy have ever studied biology, leave alone medicine as even a student of class eight will tell you that bacteria causes disease. All their blasphemy can viewed here http://indianmedicine.nic.in/naturopathy.asp.  All diseases are same, as is their treatment is what they claim. May be when they have diarrhoea, they can treat themselves with drugs for constipation, all the treatment are same they say. I bet the result will be spectacular.

Another claim that they make is that acute diseases are our friends. Who in their right mind will make such claim? May be they can tell their philosophy to a patient dying of rabies, tetanus, pneumonia or hundreds of other deadly acute diseases. Makes me wonder what they do when they themselves are affected by so called friendly diseases.

There is a pathetic attempt at trying to impress the visitors by referring to Gandhiji. They don’t realize they are making a logical fallacy of Appeal to Authority, not that it is unexpected of them to make such a fallacy. Gandhiji may have been a virtuoso in many things but a doctor he was not. Only people who don’t have evidence to back up their claims make such attempts.

They also do a bang up job in listing their therapies. Space therapy, mud therapy, magneto therapy? Charged water? Stuff of fairy tales. Where is the evidence? Chromo therapy takes the cake in completely useless therapies. There is not an iota of biological plausibility in their claims.

If one considers that the government always says that there are not enough funds for meeting the basic health care needs of the people, the government expenditure on these completely useless therapies is totally unethical. The government fails to provide basic medicines and equipments to the hospitals because of lack of funds but it is prompt to sponsor these useless therapies. It is high time that the government stops promoting such useless therapies.

Anticancer vitamins busted!

Finally the proponents of vitamins can be put to rest. An article published in the American Journal of Epidemiology put a smile on my face and I kept smiling for the whole day. “Anticancer Vitamins du Jour—The ABCED's So Far”, this was the article by Tim Byers. This article was sweet music to my ears. The scores of nutritionists and their babbling… er may I say Quacking about how different vitamins can reduce the risk of varieties of cancer may also rest in peace now. They will probably not, but there is no harm in hoping. This further brings down the elevated position in which the T.V nutritionists put themselves. What will they say now when they face the evidence? Probably they will frown and say this is a conspiracy to drug the nation. Better still, they will say, “I know this works. I have given to many patients and they have improved.”

 

The article referred above summarizes the hype regarding different vitamins and their supposedly anticancer properties and how they failed to prove their efficacy in RCTs. In addition it also tells about the recent studies published in the journal refuting the claim of anticancer properties of Vitamin D.

If it were not for the nutritionists and their peddling of anticancer vitamin supplements to patients who are in need of treatment, this article would actually make me sad. If any vitamin does have anticancer properties, either therapeutic or preventive, it would have been great news for the patients.

It is rather interesting to note that the so-called “nutritionists” never peddle their offerings to those who really need them. There are thousands of children who are suffering from micronutrient deficiencies; I bet none of them can afford to consult a nutritionist. Nutritionists conveniently choose to forget them, instead choosing to counsel the wealthy. The reason is obvious.

 

Links: http://aje.oxfordjournals.org/cgi/content/full/172/1/1

Health Risk of Mobile Phones

In an article published in the CNN IBN on June 7, 2010, questions were raised about the effects of mobile phone base stations and mobile phone use in general and their effect on health. It was stated that ICMR would conduct a study to determine the effects of electromagnetic radiation emitted from mobile phones on health, whether it has any adverse effect on health and if so, what would be the recommended level of exposure. In true journalistic fashion, the report was skeptical about the use of mobile phones and almost seems to suggest that they were harmful, though probably the reporters themselves had a mobile phone in their pocket and were most likely using it.

Let ICMR take its own course but we can review the available scientific evidence on the use of cell phones and whether it has any adverse health effect. Firstly let us see what the WHO has to say. There are two WHO fact sheets titled Electromagnetic Radiation and Public Health: Mobile telephones and their base stations and Electromagnetic Radiation and Public health: base stations and wireless technologies. In these two fact sheets, WHO clearly states that there is no short-term health risk associated with the use of mobile phones and long term risk for 15 years usage also does not demonstrate any associated health risk.

It is worthwhile to note that FM radio signals and TV signals are absorbed by our body 5 times more than signals used in mobile telephones. Despite long continued exposure to FM radio waves and TV signals, no significant health risks have been demonstrated till date. Hence, in the same note, it would be unscientific to assume that use of mobile phones would be associated with a health risk.

In a recent study titled “Brain tumour Risk in Relation to Mobile telephone Use: Result of INTERPHONE International Case-Control Study” published in the International Journal of Epidemiology 2010, 39(3), 675-694, an interview based case-control study with 2708 glioma and 2409 meningioma cases and matched controls in 13 countries was conducted using a common protocol. Without going into the statistical details of the study, we can just state the conclusion that there is no increased risk of glioma or meningioma associated with mobile phone use.

In another study published in the British Medical Journal on June 22, 2010, titled "Mobile phone base stations and early childhood cancers: case-control study" that investigated the effect of exposure of mobile telephone signals on pregnant women and the risk of development of early childhood cancers, no association was found between the risk of early childhood cancers and mothers exposure to mobile phone signals.

Bottom line is that whoever is telling about the health hazards of mobile phone use, they are just trying to scare you because hard scientific evidence states otherwise.

Links:

1. http://ibnlive.in.com/news/cell-phone-towers-a-big-health-risk-in-cities/123060-17.html

2. http://ije.oxfordjournals.org/cgi/reprint/dyq079
3. http://www.bmj.com/cgi/content/full/340/jun22_1/c3077

What do patients want?

Some times I wonder what do patients want? Do they want to be treated by a compassionate but average doctor or an excellent but obnoxious doctor?


It’s a simple enough question but it does not seem to have a simple answer. To me it depends on my illness. Let us consider that I have a disease that is making me considerably miserable. I have visited, say three doctors. They have been considerate and empathic to my suffering but have been unable to diagnose my condition. Hence they have not been able to cure my disease. Now I go to visit a fourth doctor who is really obnoxious but he does diagnose me and eventually helps me out of my misery. Would I be grateful to that doctor? Most likely I would. Would I be offended by his obnoxiousness? Would I think him to be eccentric genius? Probably I would.



On the other hand, if I have a common condition and the doctor is inconsiderate? What would be my reaction? Would I be less tolerant of him than I would have been in the previous case? I would be, most likely. If the doctor is obnoxious when I am in severe pain but he eventually cures my pain, what will I think of him then?



Do the patient’s perception of the doctor’s behavior varies with the disease they are suffering from? What I mean to say is that if I have a condition that I believe only a particular doctor can diagnose and treat then do I become more tolerant of the doctor’s behavior?



Personally I believe that if a few doctors were not able to diagnose the patient’s disease and it is diagnosed a very obnoxious one then the patient would be tolerant of the obnoxious doctor. I cannot give any evidence in its support but this is my personal opinion. But for a common disorder, I believe the patients are not tolerant of the doctor’s obnoxiousness. When we are in some situation that is beyond our control and no body seems to be able to help then we would tolerate even the most inconsiderate one who is actually helping us, though what we would think of him is a matter of debate.



To what degree I would tolerate the obnoxiousness of a doctor? Being a medical student I don’t think I would be able to tolerate even one instance of obnoxiousness. But how much will a patient tolerate? Again I believe that depends on the patient himself. If he feels the doctor can help him though being obnoxious, the patient might tolerate him. But to do this the doctor would have to earn the trust of the patient. How much can a patient trust a doctor who is inconsiderate and obnoxious? How does a patient trust a doctor? What is trust based on? Is it based on the results that the doctor provides such as diagnosing the disease and providing actual treatment or how the doctor behaves with the patient? May be both are necessary for the patient to trust a doctor, but which is more important? Results or behavior?