A different kind of CARAT…

In the next month or so, Dr. Szto and his team will be part of a multi-centre clinical trial (CARAT) assessing the feasibility of injecting a recombinant human apolipoprotein A-1 (CER-001) in reversing cholesterol plaque buildup in coronary arteries.

This clinical trial is aimed at patients who present to Peninsula Private Hospital with acute coronary syndrome (either unstable angina or mild heart attack).

During the initial angiogram, an intravascular ultrasound (IVUS) device is pulled back to view the inside of the coronary artery. This device will build a 3-D image of the artery and plaques that are present. The patient will then receive 10 weekly injections of the medication (or placebo).

At the end of 12 weeks, the patient will then undergo a repeat IVUS procedure to measure the amount of plaque that is present. This result will be compared to the initial IVUS study at baseline, to determine if the active medication can shrink plaques.

Patients will be recruited when they present to their doctor or hospital with symptoms suggestive of unstable angina.

On the road with the paramedics in Frankston

Here is an article about Paramedics and how they bring people to hospital with suspected heart attacks…

The link is here.


From the Mornington Peninsula LEADER, 10 AUG 2011

MICA Paramedics Yvette and Cam (seated) treat patient Spencer at his Langwarrin house. Picture: JASON SAMMON

MICA Paramedics Yvette and Cam (seated) treat patient Spencer at his Langwarrin house. Picture: JASON SAMMON

IN A cosy house next to Frankston Hospital, coffee is being made. It’s 6.40am and a new shift on MICA 6 (Mobile Intensive Care Ambulance) is about to start.

MICA paramedics Yvette and Cam are making sure the dual-car ambulance “truck” is ready. They have worked together for years. Today Yvette will treat patients while Cam will drive and act as support.

The first call comes through on the portable radio at 7.56am.

A 43-year-old man in Langwarrin has chest pains. It could be a heart attack.

The siren is switched on and they’re on their way, followed by a support MICA single responder driven by team manager Doug Quilliam.

As Cam guides the truck through heavy morning traffic, Yvette checks the message on the computer screen. “He’s conscious and breathing,” she said.

The siren is turned off and on several times on the journey.

“Big trucks can’t instantly stop for us,” Cam said.

“And it can cause drivers to panic. I don’t want them to pull over on the other side of the road. I refuse to overtake on the left-hand side. It’s very dangerous.”

In no time, we arrive at a suburban home. Spencer began to experience chest pains at 7.30pm the night before. “It’s like a hot, sharp knitting needle through my chest,” Spencer said as he rated the pain 7 out of 10.

Spencer’s father suffered a heart attack – and Spencer is a smoker.

His wife, Leanne, said Spencer didn’t want her to trouble anyone.

“But all I could think of was the TV ad where the man says ‘if only I’d called an ambulance’,” she said.

Spencer is given an aspirin and tells the paramedics the pain is radiating into his throat.

It feels like he’s got a lump in his chest. Cam applies electrocardiogram (ECG) patches. Yvette checks the ECG results.

“OK, we’ll call Peninsula Private Hospital. You could possibly be having a heart attack,” she said.

More paramedics arrive as Spencer is given pain relief and an anti-nausea injection and is loaded on to a trolley for the short trip to hospital.

Out of sight of her small children, Leanne breaks down. Doug Quilliam comforts her.

The ECG results are sent by Bluetooth to the hospital and a smooth ride into a special entrance created for ambulances sees Spencer being wheeled straight into surgery.

It’s 8.55am, an hour since the call. It’s been a quick procession of events: it needs to be, with heart attacks.

Head cardiologist Dr Greg Szto orders an emergency coronary angiogram to see if there is a blockage requiring a coronary angioplasty or stent.

But then it’s good news: it appears there isn’t a blockage. The map of Spencer’s heart on the computer screen shows all is normal.

“It’s a great outcome,” Yvette said.

Then the next call comes through.

A 78-year-old woman in Seaford is suffering chest pain and is in severe respiratory distress.

MICA 6 is on its way.

How Steve Jobs and Apple enhance my professional life

Today i Sad…

Steve Jobs has passed on, and I will mourn the incredible life of a wonderful creative human being. One who has no notion of popular opinion, one who didn't care about what others think, one who only cared about how we will create and enrich our lives and activities – with the gadgets that he and his company created.

I have been the recipient of many of his devices over the last 8 or so years. These devices have had a significant impact on my life in general, but I want to share with you the incredible impact it has had on my professional life.

First was the iMac, which became our home PC… Hang on, even before that were the iPods, but these were mainly the domain of my kids, especially daughter.

In late 2007, I manage to convince my sister visiting from Denver to purchase 3 of the first generation iPhones and bring it with her. But it took another 3 months before I could jail-break and use it !! There has been many other generations of iPhones in the Szto household since…

Our first Apple laptop was a Macbook, for my daughter at her school. Before that it was an IBM laptop, which she could turn the screen around to write on, and the teachers were thrilled. But the Macbook created some problems for Han, because it was not supported by the IT department. Never mind, because of Han's persistence, the IT changed to accomodate her, and the rest is history. Now you see Macs at Toorak College everywhere…

I bought a Macbook Pro, for work. My office has a server based on Microsoft Windows, and so is the Electronic Medical Records software. My IT support manager was not sure if the Mac would be able to access the Windows-based software. No problems, it connected via a VPN tunnel the very first time we tried, and I have not have any problems ever since connecting remotely to my office computer, even when I am attending a conference in New Orleans, Paris or Beijing. I can connect to my desktop computer in my office and report echos, type letters, and send them out, all from the other side of the world. When I am consulting in Rosebud or Mornington, I use the Macbook Pro to access the patient's electronic records and letters and results. When I travel to conferences overseas, I usually bring along the Macbook Air, since it is lighter and easier to carry, and I can use it to access my office as well.

When I have seen my patient, I pick up my latest iPhone, and using the Dictate app, start dictating my letter, which will be formatted and sent to the office computer for my transcriptionist to pick up and start transcribing… No more dictaphone in my pocket.

I also have my iPad 2 with me when I consult. It has the Skype app in there, and periodically it will be used to connect to my medical colleagues, who use the Skype app to discuss a live case with me (videoconferencing). This way, using Telehealth, I can see the patient remotely in the GP's office, and advise on treatment all without me touching the patient. Telehealth is a fully funded program by the Australian government to encourage doctors to communicate with each other when the tyranny of distance prevents the patient from getting access to a specialist easily. Imagine if you are somewhere in remote Australia and you got sick, no worries, ask the local doctor there to fire up a webcam and Skype and lo, I will be in your face in no time…

After performing a coronary stent or pacemaker procedure, I use the Macbook Pro or even the iPad to access my office clinical records software via wi-fi, and type my report, before sending them out to referring doctors instantly via the internet, and generate faxes and electronic records instantly.

In all these activities, Apple and its products have helped me perform my tasks in the most seamless fashion, everything works and so intuitively. I don't have to hunt for the latest printer driver, the mindless wi-fi settings, and never has a virus been sighted or even thought of….

I can also download a PDF document, edit or write on it using the TextEdit software that comes with the Mac, and print it our or send it off, without a hitch. Needless to say all my talks and presentations are done on the Mac again without any hitches when connecting to projectors etc. I once sat and watched in embarrassment for a top-rank world-renowned cardiologist, who was on his first visit to Australia, and giving a presentation where NONE of his videos would play (using Windows of course), and I thought that if only he had used a Macbook….

So there, you can see how I don't read the Green Guide anymore, because I don't need to find the latest solution to a technical problem, or buy another gadget to make my Windows laptop work etc… I also don't need to visit Sim Lim Square or Hunan IT mall in S'pore for the same reasons.

Once you own an Apple product, there is no need to find other solutions, everything is there, and works perfectly, right out of the box.

This is my small tribute to Steve Jobs.

Recent results from the European Society of Cardiology meeting

Brief clinical trial results from the recent ESC meeting in Paris:

ARISTOTLE: Apixaban (factor Xa inhibitor) bests warfarin in preventing stroke in patients with non-valvular atrial fibrillation.

PRODIGY: Increased bleeding complications in patients taking 24 vs. 6 months of dual anti platelet therapy (aspirin + clopidogrel).

CORP: Colchicine prevents recurrent pericarditis.

ISAR-CABG: DES drug-eluting stents) beat BMS (bare metal stents) in SVG's at one year.

dal-VESSEL: Dalcetrapib raises HDL cholesterol but not blood pressure.

RUBY-1: No benefit of using factor Xa inhibitor in ACS

Read all about it here: http://www.escardio.org/congresses/esc-2011/congress-news/Pages/welcome.aspx

Pacing the Heart with Light

In future, you may be able to pace a heart by switching on the light!!! Read on….



Pacing the Heart with Light

A new study uses optogenetics to control beating heart cells, pointing the way toward a better pacemaker.

  • TUESDAY, AUGUST 16, 2011

In the past few years optogenetics, using a combination of genetic manipulation and simple pulses of light, has made it possible to control cells in the brain with astonishing precision—altering brain activity and even behavior in animals.

Now scientists are starting to look beyond the brain as they explore the technology's potential applications. A recent study in Circulation: Arrhythmia & Electrophysiology showed how modified cells that respond to low-energy blue light can be used to stimulate heart tissue to beat. The researchers say this represents a first step toward a new, more efficient and precise kind of pacemaker. Light-sensitive cells could serve as a conductor of the heart's rhythm, creating a biological pacemaker generated from the patient's own cells.

Optogenetics involves genetically engineering cells with light-sensitive proteins, so that scientists can activate them with light. One of the obstacles in using optogenetics as a clinical tool is the need to introduce genes into cells. To get around the problem, the researchers in the current study, led by Emilia Entcheva, a bioengineer at SUNY Stony Brook, decided to take advantages of the tight communication between heart-muscle cells. These cells beat synchronously because they are coupled to one another through cell junctions.

Rather than having to modify every cell in the heart to respond to light, Entcheva says, it's possible to inject a small population of light-sensitive donor cells, and allow those cells to couple with, and orchestrate, the beating of the normal tissue.

To test the approach, the researchers created a line of light-sensitive cells and paired them with heart cells. When stimulated by light, this hybrid cell population contracted in waves that matched the electrical pulses.

Entcheva says she envisions harvesting cells from a patient and genetically altering them to respond to light. By injecting enough modified cells—she estimates that half a million, or a couple of millimeters of tissue, should be enough—it could possible to pace the entire heart. She says that light would use less power than electricity, while offering "unprecedented spatial and temporal resolution"—an advantage in targeting specific parts of the heart. The most likely way to deliver light, she says, would be through thin fiber-optic cables.

The technique has more immediate applications as a research tool, for probing the workings of heart cells or helping test for possible cardiac side effects in drugs. Light, Enthcheva says, would enable more high-throughput screening than current methods, which rely on stimulating cells with electrodes.

Miguel Valderrábano, a cardiologist at the Methodist Hospital in Houston, says that for the past decade scientists have been working on new kinds of biological pacemakers, which usually incorporate cells that are genetically engineered to beat spontaneously in a specific way. The idea of creating cells that instead respond to light is an intriguing new strategy, he says: "It is definitely a conceptual breakthrough in the field of biological pacemaking."

Like other approaches, the technique faces significant hurdles—for instance, making sure the pacemaker cells integrate properly with normal cells. Although biological pacemakers are attractive in theory, they must demonstrate significant advantages over the tried-and-tested electrical devices. "Biological pacemakers have a hard road ahead to outperform regular pacemakers," says Valderrábano.

Electronic tattoo ‘could revolutionise patient monitoring’

Fancy a tattoo? In hospital, it could be your next type of monitor of your vital signs… Read on…


11 August 2011

By James Gallagher, BBC News Health


An "electronic tattoo" could herald a revolution in the way patients are monitored and provide a breakthrough in computer gaming, say US scientists.

They used the device, which is thinner than a human hair, to monitor the heart and brain,according to a study in the journal Science.

The sensor attaches to human skin just like a temporary tattoo and can move, wrinkle and stretch without breaking.

Researchers hope it could replace bulky equipment currently used in hospitals.

A mass of cables, wires, gel-coated sticky pads and monitors are currently needed to keep track of a patient's vital signs.

Scientists say this can be "distressing", such as when a patient with heart problems has to wear a bulky monitor for a month "in order to capture abnormal but rare cardiac events".

Solar cells

With the tattoo, all the electronic parts are built out of wavy, snake-like components, which mean they can cope with being stretched and squeezed.

There are also tiny solar cells which can generate power or get energy from electromagnetic radiation.

The device is small, less than 50 micrometres thick – less than the diameter of a human hair.

The sensor is mounted on to a water-soluble sheet of plastic, so is attached to the body by brushing with water, just like a temporary tattoo.

It sticks on due to weak forces of attraction between the skin and a polyester layer at the base of the sensor, which is the same force which sticks geckos to walls.

In the study, the tattoo was used to measure electrical activity in the leg, heart and brain. It found that the "measurements agree remarkably well" with those taken by traditional methods.

Skin electronicsThe sensor moves with the skin

Researchers believe the technology could be used to replace traditional wires and cables.

Smaller, less invasive, sensors could be especially useful for monitoring premature babies or for studying patients with sleep apnoea without them wearing wires through the night, researchers say.

Prof Todd Coleman, from the University of Illinois, said: "If we want to understand brain function in a natural environment, that's completely incompatible with studies in a laboratory.

"The best way to do this is to record neural signals in natural settings, with devices that are invisible to the user."

The device was worn for up to 24 hours without loss of function or skin irritation.

However, there are problems with longer-term use, as the skin constantly produces new cells, while those at the surface die and are brushed off, meaning a new sensor would need to be attached at least every fortnight.

'Electronic skin'

When the tattoo was attached to the throat, it was able to detect differences in words such as up, down, left, right, go and stop.

The researchers managed to use this to control a simple computer game.

John Rogers, professor in material science and engineering at the University of Illinois, said: "Our goal was to develop an electronic technology that could integrate with the skin in a way that is invisible to the user.

"It's a technology that blurs the distinction between electronics and biology."

Prof Zhenqiang Ma, an electrical and computer engineer at the University of Wisconsin, argued that the technology could overcome issues with bulky sensors.

"An electronic skin will help solve these problems and allow monitoring to be simpler, more reliable and uninterrupted.

"It has proved to be viable and low-cost in this demonstration which will greatly facilitate the practical clinical use of the electronic skin."

New Approach to Treating Heart Failure – Omecamtiv Mecarbil

This is referenced from: Drug Discovery and Development, 19 August, 2011



A novel drug that activates a protein that increases the contraction of heart muscle could lead to a new approach to treating systolic heart failure (SHF), a condition characterised by the inability of the heart to contract strongly enough. The results of the first two clinical studies involving the drug omecamtiv mecarbil, published in a special European Society of Cardiology issue of The Lancet, suggest that it could be a promising treatment for SHF, which currently affects about 20 million people in the USA and Europe and leads to at least 4 million admissions to hospital each year.

Omecamtiv mecarbil was designed by a team lead by Fady Malik from Cytokinetics Inc, South San Francisco, USA, to activate cardiac myosin, a motor protein in heart muscle cells that generates the force required for heart muscle to contract. In preclinical studies, omecamtiv mecarbil improved the strength of each heart muscle contraction, increasing the duration of the contraction and the volume of blood moved, without increasing oxygen consumption. But until now, whether this unique mechanism could be translated into humans was not known.

Currently used inotropic drugs (that alter the force of muscular contractions) improve contractility by increasing the concentration of calcium inside cells, which accelerates the speed of contraction but shortens systolic ejection time and can cause potentially life-threatening side effects such as abnormal heart rhythms and myocardial ischemia (restricted oxygen-rich blood flow to the heart muscle).

John Teerlink from San Francisco Veterans Affairs Medical Center, San Francisco, USA and colleagues report the first trial of omecamtiv mecarbil in humans which was designed to establish the maximum tolerated dose and demonstrate an effect in people. Omecamtiv mecarbil or placebo was given once a week as a 6-hour intravenous infusion to 34 healthy men for 4 weeks. Each sequence consisted of three ascending omecamtiv mecarbil doses (ranging from 0.005 to 1.0 mg/kg per hour) and a placebo infusion.

The maximum tolerated dose was 0.5 mg/kg per hour. Omecamtiv mecarbil increased stroke volume (the volume of blood pumped by the heart with each beat), ejection fraction (measurement of the strength the heart has on contraction) and fractional shortening (measurement of the left ventricle's overall effectiveness during contractions) compared with placebo. Increases in systolic ejection time and systolic function were directly proportional to escalating doses in omecamtiv mecarbil, with no significant adverse effects reported in doses up to 0.625 mg/kg per hour.

The authors say: "This study provides the first clinical evidence for the translation into human beings of a novel mechanism to directly improve cardiac function, namely cardiac myosin activation…and supports potential clinical use of the drug in patients with heart failure."

In the first study of omecamtiv mecarbil in heart failure patients, a team led by John Cleland from University of Hull, East Yorkshire, UK conducted a phase 2 trial to investigate the effects of omecamtiv mecarbil given intravenously over 2, 24, or 72 hours to 45 patients with stable heart failure who were already receiving standard treatment.

Omecamtiv mecarbil gave a significant dose-dependent increase in several measures of the heart's pumping function including increasing the duration of systole, stroke volume, and ejection fraction. A significant association between improving systolic function and increasing plasma concentration was also noted.

The authors say: "Omecamtiv mecarbil has dose-dependent and concentration-dependent effects on cardiac function that appear in plasma concentrations that are well tolerated by patients with stable chronic heart failure."

They conclude: "Further studies are needed to establish whether the observed effects on cardiac function translate into benefits on symptoms, quality of life, exercise capacity, morbidity, or mortality."

In a Comment, Kenneth Dickstein from the University of Bergen, Stavanger University Hospital, Stavanger, Norway says: "The data presented in these two papers supports further investigation of omecamtiv mecarbil's therapeutic role in appropriate patients." But, he adds: "Very few new agents have survived the most rigorous test, the randomised clinical trial assessing clinical outcomes…Let's find out how this theory performs in practice."

How to have a low-carb snack

This article from about.com (http://lowcarbdiets.about.com/od/whattoeat/a/snacks.htm) is very helpful for people who want to snack but don’t want the high-carb content of most snacks… Enjoy…

It’s important to have access to nutritious low-carb snack food so that if you get hungry between meals you won’t reach for crackers and chips.

Ideally, a low-carb snack should have protein, healthy fat, and some fiber (so the best thing would be to have some raw veggies with your eggs or jerky). Here are some easy snack ideas. I will be adding to the list as time goes on. If you have easy ideas for snacks, come share in our Forum.

  • Celery with peanut butter
  • Celery with tuna salad
  • Hard boiled eggs
  • Deviled eggs
  • Dill pickles and cheddar cheese (no kidding, it’s a great combo)
  • 1/4 cup berries with 1/3 cup cottage cheese
  • Nuts (keep raw ones in the freezer if you think you’ll overeat them)
  • Sunflower seeds (get them in the shell so it will take longer to eat them)
  • Other seeds (How to Toast Pumpkin or Squash Seeds)
  • Low-Carb Trail Mix
  • Jerky (beef or turkey — try to find low-sugar varieties)
  • Low-carb shakes
  • Cheese sticks, such as string cheese
  • Sugar-free Jello, alone or with cottage cheese and a sprinkling of nuts
  • Make sugar-free lime Jello with part coconut milk — For a large package, dissolve the powder in a cup of boiling water, add a can of coconut milk, and then add the rest of the water. Stir well.
  • Pepperoni “chips” — Zap the slices in the microwave
  • Cheese with a few apple slices
  • 4-ounce plain or sugar-free yogurt with berries and flax seed meal
  • Smoked salmon and cream cheese on cucumber slices
  • Lettuce Roll-ups –- Roll luncheon meat, egg salad, tuna or other filling and veggies in lettuce leaves
  • Lunch Meat Roll-ups –- Roll cheese or veggies in lunch meat (read the labels for carbs on the lunch meat)
  • Spread bean dip, spinach dip, or other low-carb dip or spread on the lunch meat or lettuce and then roll it up
  • Raw veggies and spinach dip, or other low-carb dip
  • Pork rinds, with or without dip
  • Ricotta cheese with fruit and/or nuts and/or flax seed meal
  • Mushrooms with cheese spread inside (or other spreads or dips)
  • Low-carb snack bars (watch out for sugar alcohols, especially maltitol)
  • Product Review: Atkins Advantage Bars
  • Pepperoni Chips — Microwave pepperoni slices until crisp. Great with cheeses and dips
  • Garlic Parmesan Flax Seed Crackers
  • Parmesan Crisps — Good when you want a crunchy snack.
  • Peanut Butter Protein Balls
  • More Snack Recipes


What Are Carbohydrates?

Carbohydrates, along with fats and proteins, are one of the three main classes of food. Carbohydrates are organic compounds consisting mainly of sugars, starches and fiber.Plants make carbohydrates during photosynthesis and store them as any of the saccharides (sugars) described below. They are used primarily for energy in the body. If carbohydrate isn’t used in short order, it is stored. A certain amount can be stored in the liver and muscles asglycogen, and the rest is stored as fat. Unlike protein and essential fats, our bodies can get along without dietary carbohydrate if needed.

Unlike fat and glucose, our body has little capacity to store protein. If we were to stop eating protein, our body would start to break down muscle for its needs within a day or so. Extra protein can be broken down into glucose in a process called gluconeogenesis. On low carb diets, this happens continually. One benefit of obtaining glucose from protein is that it is absorbed into the bloodstream very slowly, so it doesn’t cause a rapid blood sugar increase.