Laser-activated tissue repair: No Scars No Stitches

Wow !

Stuffs of science fiction and Bollywood movies are rapidly coming to pass.  Photochemical tissue bonding, or laser-assisted nanosuturing is a novel technique that allows the surgeon to close the epidermal defect with laser following the application of a light-sensitive dye to the wound edges eliminating the need for epidermal suture placement.

As this article extols it as a new cutting-edge technology that may rewrite the surgical books in terms of standard surgical closure procedures. After the clinical trials the results are described thus:

Results showed that a vast majority of the patients preferred the laser-assisted approach. In all cases, the tensile strength was comparable if not better than the traditional closure technique, and the scar appearance of the laser-treated side in many of the patients was near imperceptible.

Though in a few cases, the scar was not clinically and aesthetically attractive, Dr. Tsao says, the laser-treated side was always the better appearing side. There were no complications, infections or dehiscence associated with either the traditional or the laser-assisted treated wound edges.

Patients were evaluated at two weeks, three months and at six months. Study endpoints included efficacy of wound closure, vascularity, pigmentation, elevation, atrophy and scar appearance. The surgical sites were evaluated by two blinded physicians and patients were also asked to make an evaluation based on the same attributes.

You can read the complete article here at Modern Medicine.


Informed Consent and Surgery

Pen and PaperHave you ever undergone any operation like gall bladder removal or appendectomy or for hydrocele? I am sure you gave your consent for the surgery. Did you understand the understand the procedure and the possible complications? The common sense approach is that before conducting any procedure the physician discusses the natural history of disease and the available treatments both surgical and otherwise. In case of surgery the procedure should be explained in layman terms including the preoperative preparations, the anaesthesia and surgery itself and the expected recovery and the untoward events that can happen. The common sense approach is that all possible complications having a greater chance than 1% are discussed with the patient and subsequently a written and signed form included in the notes. In the present day scenario with increasing medical bureaucracy and distrust a signed consent form in the medical records has become the end all. An example is the change required from the Mayo’s clinic following their legal entanglement. I quote-

Mayo”s long-standing practice had been for doctors to give patients detailed oral explanations of the risks, benefits and alternatives to a procedure and to get verbal consent and document it in patients” charts, spokesman Brian Anderson said. Patients weren”t asked to sign specific consent forms, he said. “We”ve always had an informed consent process,” Anderson said. “That is certainly critical, ethically paramount.”

Similarly one of my former institution required a hand written consent of few lines basically stating that the patient was aware of the possible complications including death (which is true though rare) and consented for the procedure. I would be surprised if the patients who indeed developed complications did feel informed later in retrospect. The sad thing is; there is no escape from law- the form is the only thing that matters 6 months hence. Image courtesy:

Kindle 2.0 and MyBebook reader

Amazon has released all new Kindle 2.0 just a week back ; it looks like a great machine and they will start shipping later in the month. What I was hoping for was a larger size-something like A4- and better contrast and detailing- something I still await.

I am already using an ebook reader – my bebook a variant of Hanlin v3 which is marketed by from Netherlands. I have been using it for the last 3 months and  it has been great. I need not carry a handful of books each time I travel and  what is even better; I carry this around with me and can read while waiting- in  clinics, on road basically whenever i wish. It supports most ebook formats from pdf, mobi, lit, epub, doc, html, txt, prc, fb2, jpg files besides playing mp3. I have a preference for reading in lit or rtf formats with a tiny clock running at the top of the page.

I have downloaded a great number of books for free from Project Gutenberg with no DRMs  and few new ones from mobipocket directly onto ereader using USB.And one thing is for sure- reading on eink or viziplex (as both the BeBook and Kindle use) is waaaay easier on the eyes rather than reading on the computer or cellphone reader and you do need a nightlamp/ light for reading in bed at night.

The great features of Kindle 2.0 is wireless connectivity with basic browsing and storage of library on their network. They have also removed SD card storage present in the first Kindle and is present in the Bebook. A lot of features of Kindle is available only in the US and for me that is a minus. The downside is that the complex pdf files do not display so well and that is true for mybebook as well.

If you love reading and do not yet have a ereader I would suggest you get one as early as possible and enjoy the pleasure of reading!


Heart Diseases and Genetics.

As advances in genetics are made the influence of genes on individual’s health is all the more apparent. It is quite well known that people of South Asian origin are inordinately susceptible to heart diseases besides diabetes and associated metabolic syndromes.

Today’s Genetics Nature carries a paper delineating the high incidence of genetic mutation among Indians which is associated with Cardiomyopathy and heart failure.Heart failure is a leading cause of mortality in South Asians. However, its genetic etiology remains largely unknown1. Cardiomyopathies due to sarcomeric mutations are a major monogenic cause for heart failure (MIM600958). Here, we describe a deletion of 25 bp in the gene encoding cardiac myosin binding protein C (MYBPC3) that is associated with heritable cardiomyopathies and an increased risk of heart failure in Indian populations (initial study OR = 5.3 (95% CI = 2.3–13), P = 2 times 10-6; replication study OR = 8.59 (3.19–25.05), P = 3 times 10-8; combined OR = 6.99 (3.68–13.57), P = 4 times-11) and that disrupts cardiomyocyte structure in vitro. Its prevalence was found to be high (approx4%) in populations of Indian subcontinental ancestry. The finding of a common risk factor implicated in South Asian subjects with cardiomyopathy will help in identifying and counseling individuals predisposed to cardiac diseases in this region.

This article was further reported in Medical News Today

The Worst Luck In The World? The Heart Disease Mutation Carried By 60 Million

Heart disease is the number one killer in the world and India carries more than its share of this burden. Moreover, the problem is set to rise: it is predicted that by 2010 India’s population will suffer approximately 60% of the world’s heart disease. Today, an international team of 25 scientists from four countries provides a clue to why this is so: 1% of the world’s population carries a mutation almost guaranteed to lead to heart problems and most of these come from the Indian subcontinent, where the mutation reaches a frequency of 4%.

Considering that the mutation is so dangerous; how come it is so common? Well-

The combination of such a large risk with such a high frequency is, fortunately, unique. “How can such a harmful mutation be so common?” asks Chris Tyler-Smith from The Wellcome Trust Sanger Institute, Hinxton, UK. “We might expect such a deleterious change to have ‘died out’.

“We think that the mutation arose around 30,000 years ago in India, and has been able to spread because its effects usually develop only after people have had their children. A case of chance genetic drift: simply terribly bad luck for the carriers.”

The original advanced online paper is here( in pdf)

Image: topher76

Doctors influenced by Rest and Fluids Industry

This physician enjoyed an all-expenses-paid trip to Aspen, just for telling his patients to “relax.”

I have noticed that medical satire from is awfully good. Hats off to the writers(?writer). In keeping with the current flaying of pharma-physican backslapping ties; The Onion investigates and finds ulterior motive in prescription of just fluids and rest for common cold rather than antibiotics ;-0

The investigation—the full details of which will be disclosed in this newspaper over the coming months—documented thousands of instances in which sick patients were repeatedly instructed, often verbatim, to “lie down and drink plenty of liquids.” This treatment, recommended a staggering 4 out of 5 times on average, was in each case prescribed by a physician known to have recently enjoyed a golf vacation courtesy of Big Rest and Fluids.

“You have no idea how deep this goes,” said Dr. X, a physician who wished to remain anonymous. “They’ve got everyone, from the pediatricians and family doctors, right on down to the school nurses. We’ve had the cure for the common cold for nearly 40 years, but it’s still ‘rest and fluids, rest and fluids.’ Why? Because these guys are getting paid through the nose, that’s why.”

The ending of the article is pretty good too…


The complete article from The Onion

Spot the helmet

In news from Nigeria is something quite familiar to Indians. People are refusing to wear helmets while riding two wheelers which was made compulsory from the first of January this year.

Police in Nigeria have arrested scores of motorcycle taxi riders with dried fruit shells, paint pots or pieces of rubber tire tied to their heads with string to avoid a new law requiring them to wear helmets.

The regulations have caused chaos around Africa’s most populous nation, with motorcyclists complaining helmets are too expensive and some passengers refusing to wear them fearing they will catch skin disease or be put under a black magic spell.

Reuters reports . Nothing new there excepts for the outlandish explanations. I don’t wear helmets as it musses my hair!

End (Edge) of life issues –

Sometime back, when I was a trainee, we used to get patients at the end of their life. They would come to us tired and dejected (and angry) after  treatment from premier hospitals all over the country; having tried various form of alternative therapies and charlatans. And we would evaluate them and send them back to their homes. Some saw the futility and accepted while some fought to be admitted and die in the ICU. Overall there was (is) singular lack of knowledge and guidelines for the patients, their relatives and also among the physicians and health care workers.

I looked around and found there were no institute or place for such people and their families for guidance. The few places that existed were religion affiliated and their outlook was not what was needed. After so many years; even today no such places exist.

In recent time this area of end of life issues and hospice care has seen advancement especially in United States. A great series of articles was published in the Dallas News which I would recommend to everybody. Excerpts

Nobody wants to die a slow, lingering death. But many Texans do. Half die in hospitals. One in five passes away in intensive care. Often, their last months of life are expensive, painful exercises in medical futility.

Health care reformers in Dallas and around the nation are pushing for a better way to help people at the edge of life.

Practitioners of “palliative care” combine traditional medicine with pain relief, spiritual counseling, and practical advice for patients and families.

These articles derive from the experiences of palliative care team at the Baylor University Medical Center in Texas.

Unlike hospice, palliative care can continue alongside aggressive, life-sustaining treatments. Palliative doctors, nurses and other clinicians guide patients and families through searingly painful choices, including decisions to avoid overly invasive care. They aim to help patients live as well as possible for as long as possible, and to help grieving families prepare for the inevitable.

Research indicates that such “comfort care” sometimes can prolong life more effectively than aggressive surgical, chemical or radiation therapies. It also can reduce medical expenses; Medicare spends 28 percent of its annual budget on care given in the last year of life.

She describes the families and their emotions so well, highly recommended reading includes video clips.

Mr. Bourque tried telling Michelle that her mom might not make it. The little girl set stuffed animals and a purple-and-orange squirt gun on her mother’s emergency-room gurney like talismans.

The Bourques were medical people. Mr. Bourque, 44, was a pediatric ICU technician starting nursing school; Mrs. Bourque, 45, was a pediatric respiratory therapist. They couldn’t kid themselves, but it wasn’t clear how much their daughter understood.

They’d tried to spare her, and sensed that Michelle was trying to protect them, too. They all needed help to get through what was coming. But nothing else could happen as long as Mrs. Bourque was trapped in agonizing pain.

In this era when nothing is ever enough and the machines can breathe for you; pump your heart; feed you forever; but cannot think for you: read here the series by Lee Hancock.

Drug marketing and dichotomy

When I began my practice following residency I became aware of the cesspool that medical and associated profession have become. Each day was (is) a learning experience. Not that one is completely unaware of the ground realities- but first hand experience is humbling.

I was reading a blog post by Jim Sabin wherein he comments on an article on “Drug promotional practices in Mumbai: a qualitative study” in the Indian Journal of Medical Ethics (April-June 2007 issue) and surmises

All of the issues described in Mumbai are present in the U.S., but in India the pharmaceutical practices are more brazen. Federal and state regulatory capacity is significantly less in India than in the U.S. Perhaps more important, organizations – medical schools, hospitals, medical societies, and more – currently have less capacity to push back against commercial forces than comparable institutions in the U.S.

But the Indian media is sinking its teeth into the issue of commercial corruption of medical decision making (see, for example, “Are your drugs boosting your doctor’s lifestyle?” in yesterday’s Times of India here). The same ethical drama is playing out globally, just with different timing.

the ground reality and the extent is so so much worse that it is mind boggling. and to be frank the medics/doctors are ending up being bit players.

Pic from

Patients Overcrowding in ER? Lets hangout in Hallways!! few are in cafeteria-

(Image from dailylife .com)

I came across this article while surfing which made me read it again carefully. The health blog in the wall street journal describes a novel way of managing Emergency overcrowding

Here’s one way to ease overcrowding in the emergency room: Move patients to the hallway.

Some hospitals are giving it a try, putting patients in hallways when they’re ready to be admitted, the Associated Press reports

The bizarre ideas germinating in managerial cubicles would put Dilbert’s Pointy headed Boss in throes of delight. The practice was justified by

Peter Viccellio, clinical director of the emergency department at Stony Brook University Medical Center in Stony Brook, N.Y., was involved with a study that found that the practice didn’t do any harm. And before the hospital went this route, on busy days “things would grind to a halt and people would wait to be seen,” he told the AP. Worse, infectious patients would wait in the ER hallways for isolation rooms to open up elsewhere.

I wonder if the said observations were deduced from the hopelessness of the situation. The statement which struck me the most came from one of the proponents of the idea

Nurses, meanwhile, tend not to like the practice. But Carolyn Santora, who heads patient safety efforts at Stony Brook, told the AP that’s fine with her. “I want them to hate it,” she said. “I want them to do everything to expedite flow to get the patient out of the hallway.”

This attitude is typical of the adversarial roles the clinicians (including doctors, nurses, paramedics,cleaners etc as a team) have to face as a team from the managers and the public in general as ‘the problem‘. It is like shooting the messenger-

The reason the nurses are uncomfortable is because they know how dangerous the practice is; they know the enormous stupidity of the move and because they care about the patients despite perceptions otherwise.

Just give them time to accept and acclimatize to the new rules and they will no longer be so uncomfortable!! After all they are powerless and the strings are in someone else’s hands.

The rules and circumstances are so different in India but the end result is all the same. I used to send people with minor lacerations for tea just to have space to deal with the real sick.

Photocredit: taken out of context here.