Key points from Dr. C. Venkata S Ram’s lecture at Safdarjung Hospital, New Delhi on 26.07.2013

Dr C. Venkata S. Ram, MD, MACP, FACC, FASH

Dr. C. Venkata S. Ram, a world renowned expert in hypertension delivered a guest lecture on “Appraisal and Reappraisal of Hypertension in 2013”. The lecture was attended by the medical staff and students of Safdarjung hospital and the medical college. He outlined the recommendations of the latest guidelines from the European Society of Cardiology/European Society of Hypertension. Dr. Ram synthesized the following major points from the latest European Hypertension Guidelines:

1. All patients with hypertension should be treated to keep the upper (systolic) blood pressure to 140 mm Hg.
2. In patients with diabetes the lower (diastolic) BP should be 85 mm Hg.
3. In older patients < 80 years, the systolic BP can be kept 140-150 mm Hg.
4. Blood pressure more than 140/90 increases the risk of cardiovascular disease.
5. Salt consumption recommendation is 5 to 6 gram per day.
6. Reducing the salt to 5 gram per day can reduce upper blood pressure by up to 2 mm Hg in normal persons and 4 to 5 mm Hg with patients with high blood pressure.
7. Loosing 5 kg of weight can reduce systolic blood pressure by 4 mm Hg.
8. Regular aerobic exercise training can reduce the mean blood pressure by 7 mm Hg.
9. Drug therapy should be started typically within a few weeks
10. The main aim of treatment is to lower blood pressure rather than how it is lowered.
11. ACE inhibitors and AR blockers should not be combined for uncomplicated hypertension.
12. Those people whose blood pressure is not getting controlled, renal denervation therapy should be considered.
13. Despite overwhelming evidence that hypertension is a major cardiovascular risk, studies show that many are still unaware of the condition, that target blood pressure levels are seldom achieved. They report that hypertension affects 30-45% of people in Europe.
14. Perhaps the biggest single change in the new document is the adoption of a single systolic blood pressure target for almost all patients: 140 mm Hg, this replaces the previous, more complicated target, which included both systolic and diastolic recommendations for different levels of risk.
15. The approach to drug therapy for hypertension has also been thoroughly revised. Drugs are no longer suggested for the treatment of high normal blood pressure. No single drug or class is given special preference, since the benefits of treatment are largely based on the blood pressure lowering effect of the drugs. The guidelines recommend an individualized approach to treatment, based on clinical and demographic considerations.
16. The guidelines provide perspective on the much-discussed new technology of renal denervation for resistant hypertension. The guidelines say that renal denervation is “promising” but that more trials are needed before it can be fully assessed.

Elderly new onset diabetes a new sub group of diabetes

Elderly patients with new-onset diabetes and poor sugar control (HbA1c of 7.5% or higher) are linked with increased mortality risk. There is no U-shaped risk pattern, unlike that reported for elderly patients with long-standing diabetes.

In a study published in July edition of Diabetes Care, patients with the highest levels of HbA1c also were least likely to undergo a coronary revascularization procedure.

The findings are totally different from the results in elderly with long-standing diabetes.

The researchers conducted a retrospective observational study of data from a cohort of 2994 individuals (48% males) living in the Sharon-Shomron District, Israel, who were insured by a large provider.

The study subjects were 65 years or older when they were newly diagnosed with diabetes in 2003 or 2004. The patients were assumed to have type 2 diabetes, since type 1 diabetes is very rare at this age, and only 0.1% to 3% of the patients were receiving insulin therapy.

The patients were followed for 7 years or until they reached a study outcome: coronary revascularization — PCI or CABG — or mortality.

At baseline, patients had a mean age of 75.6 years. They were stratified into 4 groups, based on their average HbA1c levels during follow-up: less than 6.5% (n=1580), 6.5% to 6.99% (n=611), 7% to 7.49% (n=367), and 7.5% or greater (n=436).

During a mean follow-up of 5.54 years, 1173 participants (39.17%) died. All-cause mortality rates were 41%, 32%, 36%, and 46%, in the 4 groups.

Compared with participants in the group at lowest risk of dying (those with an average HbA1c level of 6.5% to 6.99%), patients in the group with the highest HbA1c levels (>7.5%) had a significant increased mortality risk.

These findings differ from a previous large, retrospective cohort study of patients older than 50 who had long-standing diabetes and intensive hypoglycemic treatment, where researchers reported finding a U-shaped risk pattern, and an HbA1c level of about 7.5% was associated with the lowest all-cause mortality (Lancet. 2010;375:481-489).

The difference in mortality patterns between our finding and the aforementioned study underscores the need to differentially treat elderly patients with new-onset [diabetes] and elderly patients with long-standing disease.

During follow-up, 285 participants (9.51%) underwent PCI or CABG. The rate of coronary revascularization was highest in the patients with an average HbA1c level of 6.5% to 6.99% and lowest in the patients with an HbA1c level of 7.5% or higher.

This inverse relationship may be the result of a protective effect of revascularization against mortality, or the patients with the highest levels of HbA1c may have received suboptimal medical treatment for various reasons. (Source Medscape)

Osteoporosis is preventable and treatable

Osteoporosis is termed as "The Silent Thief," because it can progress for years without symptoms, robbing the strength from bones until a fracture occurs. Early diagnosis can check bone loss and reduce risk of fractures. 

Though osteoporosis can occur in any one, it is more common in older women after menopause. Risk of osteoporosis is so high in women that developing an osteoporosis–related hip fracture is equal to combined risk of developing breast, uterine, and ovarian cancer.

One out of every five persons who has a hip fracture will not survive more than 1 year. Men and younger women are also victims to osteoporosis.

The standard x–ray cannot diagnose osteoporosis until approximately 30% of bone is already lost. A Bone Mineral Density test is the best way to detect osteoporosis before a fracture occurs.

Four out of 10 women above 50 years of age experience a hip, spine, or wrist fracture during their lifetime.

Marked rise in under-30 heart patients

The age of heart patients has been falling over the years. Heart patients in their 20s are not unheard of, they are still uncommon.  However, we do see many with heart attacks in their early 30s, reports TOI.

As per Dr Prafulla Kerkar, head of cardiology at KEM Hospital, in a study of 350 heart attack patients, 9.5% of cases were below 40 years of age and 3% below 30. In almost all the young patients, smoking was invariably a common factor.

According to the November 2009 issue of Harvard Men's Health Watch, as many as 10% of all heart attacks in men occur before the age of 45. In older adults, around 80% of these attacks stem from coronary artery disease. 

The Coronary Artery Risk Development in Young Adults (CARDIA) study in the US evaluated more than 5,000 young adults ages 18 to 30 and then monitored them for up to 15 years to find out how their risk factors influenced their heart health. The overall incidence of heart attack is 13% for the 18-25 age group and 18% for those aged between 25 and 30. 

There is no pooled data or large-scale analysis in India. But hospital record surveys have revealed a variable percentage of 9% to 15% heart attacks below the age of 40 years across the country. The statistics are only increasing by the day.

Snoring how boring

When this irritating sound blasts through the quietness of the night it can drive the sanest of people insane – well almost! There are many couples who have divorced on this ground. It’s no joke to be accused of snoring – neither for the snorers nor for the sufferers who have to endure sleepless nights! Even the fair sex is not immune to this malady howsoever they might deny it.

The cause of snoring is air flowing through the open mouth and causing the soft palate (side area around the back of the tongue and the tonsils) to vibrate. This results in the production of sound – the snore!

Medically, snorers are found to be more prone to:

• Heart attacks
• Sudden death

Certain conditions can predispose to snoring. These are:

• Enlarged tonsils or adenoids
• Congestion in the nasal sinuses
• Deviated nasal septum
• Loose dentures
• Nasal polyps
• Sleeping on your back (causes the tongue to fall back and block the windpipe partially)
• Aging causes the throat muscles to become flabby. This is also caused by alcohol, and certain drugs – tranquilizers, pain killers, or sedatives, all of which depress the brain and cause the muscles to be loose.

Practical remedies for this malady

• Find the cause and treat it if snoring is due to any of the above conditions. Corrective measures should be undertaken ant it may stop snoring.
• Sleeping on the side: The tongue does not block the airway and hence helps to prevent snoring. For this purpose a ball is stitched on the back of the night suit shirt to remind the person to sleep on the side.
• A special anti snoring pillow can be made in which the portion under the neck is higher than the one under the head, hence extending the neck this prevents snoring.
• Lose weight if you are overweight, especially around the belly.
• Stop smoking as smoke irritates the nasal mucosa and the throat.
• Sleep without dentures if you use them.
• For the sufferers, one last line: Stuffing your ears with cotton wool (or your partner’s mouth) or sleeping in another room may be the best answer to the solution. If nothing helps – just pray to God for endurance.

Excerpts of a meeting on Artificial Fruit Ripening held at Department of Food Safety, Government of Delhi

The meeting was chaired by Sh. K J R Burman, Secretary cum Commissioner Food Safety, Delhi Government and was attended by Dr. KK Aggarwal, President Heart Care Foundation of India; Dr. Ram Asrey from IARI, Dr. R.K. Sarin from Forensic Dept Delhi Government, Dr. S.K. Manocha from FICCI, Dr. Sanjay Rajput and Dr. J.S. Chauhan from SIIR apart from officials from Department of Food Safety.

·        To meet demands, 90% of the fruits in the market today are using artificial ripening methods.

·        Ripening agents allow many fruits to be picked prior to full ripening, which is useful, since ripened fruits do not ship well. For example, bananas are picked when green and artificially ripened after shipment after being treated with ethylene. Catalytic generators are used to produce ethylene gas simply and safely. Ethylene sensors can be used to precisely control the amount of gas.

·        Climacteric fruits (papaya, banana and mango) are able to continue ripening after being picked, a process accelerated by ethylene gas. 

·        Non-climacteric fruits can ripen only on the plant and thus have a short shelf life if harvested when they are ripe. Examples are grapes, jamun, kinnu, lemon and citrus fruits.

·        Calcium carbide is also used for ripening fruits artificially.  Calcium carbide reacts with water to produce acetylene, which acts as an artificial ripening agent.  Industrial-grade calcium carbide may contain traces of arsenic and phosphorus, which makes it a human health concern. The use of this chemical for this purpose is illegal in India. Calcium carbide releases phosphine gas, arsine gas, acetylene gas and all of them are toxic to the body.

·        Natural ripening of fruits occurs from inner to outer layer, while artificial ripening starts from the surface to the inner areas. Therefore, naturally ripened mango will be sweeter in the center and the artificially ripened fruit will be sweeter on the surface.

·        Iodine can be used to determine whether fruit is ripening or rotting by demonstrating if the starch in the fruit has turned into sugar. For example, a drop of iodine on a slightly rotten part (not the skin) of an apple will turn a dark-blue or black color, since starch is present. If the iodine is applied and takes 2–3 seconds to turn blue/black, then the process has begun but is not yet complete. If the iodine stays yellow, then most of the starch has been converted to sugar.

·        Storage of potatoes at 10–12°C with CIPC treatment is helpful in providing the consumers potatoes, which are not sweet in taste, during the summer and rainy seasons.

·        Ethylene is also a gaseous plant hormone. Early examples of the human utilization of ethylene to enhance fruit ripening include the ancient Egyptian practice of gashing figs to enhance ripening responses. 

The ethylene produced by the injured fruit tissue triggers a broader ripening response.  Similarly, the ancient Chinese practice of burning incense in closed rooms with stored pears (ethylene is released as an incense combustion by-product) stimulates ripening of the fruit.  

The idiom ‘one bad apple spoils the barrel’ is based upon the effect of one apple ripening (or rotting) and emitting ethylene which accelerates the ripening and senescense of apples stored with it. Another idiom is ‘Kharbuje ko dekh kar kharbuja rang badalta hai’.

·        Strategies to minimize fruit exposure to external sources of ethylene and treatments for managing the internal ethylene concentration are the key to commercial optimization of storage life and eating quality of many fruits. 

·        Respiration is a process of oxidative breakdown (catabolism) of complex molecules into simpler molecules, yielding energy, water, carbon dioxide and simpler molecules needed for other cellular biochemical reactions required for ripening.  The respiration rate per unit of fruit weight is (as a general rule) highest in immature fruit, with the respiration rate declining with age.  Thus respiration rate of fruit is an indicator of overall metabolic activity level, progression of ripening and potential storage life of the fruit (i.e. a low respiration rate means that the energy reserves will take longer to be consumed and the fruit can be stored for longer). 

Some fruits show a significant variation to the pattern of declining respiration rate during their ripening. They exhibit a distinct increase in respiration rates (a respiratory climacteric) of varying intensity and duration, commensurate with ripening.  Fruit that exhibit this characteristic increase in respiration rate are classified as ‘climacteric’ whereas fruits that follow the pattern of steadily declining respiration rate through ripening are classified as ‘non-climacteric’.

   

To find out whether a fruit is respiring or not, one can either use a respirometer which can measure the carbon dioxide outcome or one can put a fruit in a polythene bag and tighten it and look for presence of vapors on the surface after one hour.

·        Low temperature modulates the ripening of kiwifruit or banana in an ethylene-independent manner, suggesting that fruit ripening is inducible by either ethylene or low temperature signals.

·        Ethylene gas ripening can be detected by phenolphthalein test.

·        Arsine and phosphine gas can be deposited on the surface of the fruit.

·        Other natural ripening methods are by putting them in rice, straw (bhusa), wheat etc.

·        Everyone should know that gases produced by ripening can worsen or cause asthma in children.

·        Gama radiation technology is used in fruits either for disinfection or delaying the ripening process so that they can be exported.

New India Assurance company has decided to stop charging additional premium for those with diabetes and hypertension under its revised health insurance policy.

1. The state-owned insurer has also withdrawn a clause from its policy that excluded cover for ailments caused by tobacco consumption. The new health insurance policy, however, continues to exclude cirrhosis of lever caused by alcoholism. The earlier practice of having a four-year cooling period for pre-existing conditions will continue. This means that if a diabetic buys a policy, the coverage for diabetes related hospitalization will begin only after four years.

2.      Several US and Canadian companies have stopped clinical trials in India following an amendment to the rules which makes it mandatory for companies and educational institutions to meet all medical expenses of those who volunteer for clinical trials.

The new Drugs and Cosmetics (First Amendment) Rules, 2013, states that for an injury/illness, occurring to a clinical trial subject, he or she shall be given free medical management as long as required. "This does not specify what type or cause of injury. Thus a trial participant may be involved in a traffic accident or assaulted by someone, but under the open-ended clause, the trial sponsor has to cover all costs.

Another clause calls for financial compensation to be paid over and above costs of medical management in the case in the event of any illness, considered trial-related. But there is no clarity on what constitutes trial-related injury. Again any medication cannot work all the time. A person whose cancer was not stopped from progressing may claim compensation under this clause even though the treatment was effective during the trial.

We must also make a distinction between death of a patient during a clinical trial and death due to clinical trial. Patients who participate in clinical trials already have a disease which could be mild or serious. The death of a patient in a clinical trial could be due to various reasons, including a natural progression of the disease, new diseases, age-related disorders, or an unrelated complication. Patients who participate in a clinical trial receive greater degree of medical care than they would have under regular treatment because of the high level of investigations and patient management that a clinical study protocol requires.

According to the ministry of health, 89 deaths were attributed to clinical trials between 2005 and 2012 of which compensation was paid in 82 cases. [TOI excerpts]
3.      Less than a fortnight after rejecting pleas for lowering the age of juveniles from 18 years to 16 years in heinous crimes, the Supreme Court on Wednesday agreed to hear a PIL arguing that a juvenile's culpability should be determined on his mental maturity rather than physical age. Additional solicitor general Siddhartha Lutheran opposed the PIL and informed a bench of Chief Justice P Sathasivam and Justices Rojana P Desai and Ranjan Gogoi that on July 17, the apex court had decided a bunch of petitions rejecting pleas to lower the age of juveniles to 16 years.