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The choice between rail and road:perspectives from Delhi

Ami Banerjee
Last edited 5th December 2011

This week I started a 3-week research trip to India, based at the Centre for Chronic Disease Control in New Delhi. Yesterday I rediscovered the joy of train travel. My morning began with a ride on the efficient Delhi metro at 6.15am. The service is state-of-the-art in South Asia, and in my view, compares very well with similar services in many high-income countries. Alongside the option of driving, sitting on the train from Delhi to Chandigarh was not only much more relaxing, but I actually had the time to take in the views as we travelled through colourful North Indian villages.

Contrast this with the situation on India’s roads. Even in urban centres such as Delhi, the chaos of road traffic makes you wonder at how survival statistics are not worse. India has a higher rate of road traffic accidents (RTAs) than anywhere in the world, according to the World Health Organisation’s report last year, with 14 people dying every hour on the road. Globally, RTAs make up a third of unintentional injury deaths, with double the death rate and three times the burden of disability in low-middle income countries compared with high-income countries, which are less able to cover the huge economic and social costs. Children are more likely to be victims, and RTAs are projected to be fourth leading cause of death in 2030.

One recent post-mortem study from Kolkata found that a staggering 63.1% of deaths were due to accidents, mostly on the roads. The dire circumstances which can result from RTAs are shown by a case report from Jaipur, India, simply titled, “An unusual presentation of head injury: teeth in brain”.

Interestingly, an analysis from the UK estimated that walking to and from stations accounted for 65% of the overall door-to-door risk of being killed on rail journeys; with the rail system itself accounting for only 21% of the risk. In other words, it is the risk of the road which causes deaths on trains in England as well. There are calls for better data globally, since only 20 countries have the high-quality data needed to accurately estimate mortality from RTAs but I think I have read enough. I will use the train whenever possible. The urgent message for Indian policymakers is that a comprehensive policy for road safety is required and fast.

Self-monitoring of blood thinners halves your risk of clots

Carl Heneghan
Last edited 1st December 2011

Here are some links to news stories of cebmblog and colleagues work published in the Lancet today

Self-monitoring of oral anticoagulation: systematic review and meta-analysis of individual patient data Lancet

Self-Monitoring of Blood Thinner May Halve Clot Risk
MSN Health
People taking the blood-thinning drug warfarin who monitor their own blood and adjust their dosage can reduce the risk of blood clots by half, British researchers report. Warfarin is taken to prevent potentially deadly clots in patients with conditions such as atrial fibrillation – an abnormal heart rhythm – or a mechanical heart valve. But if the blood is thinned too much, serious bleeding can occur. Keeping the drug in check requires monthly monitoring and frequent doctors visits. ‘The concept of self-care and self-monitoring is a growing part of health care. It is used widely in diabetes, asthma and hypertension management,’ said lead researcher

Dr Carl Heneghan, director of the Centre for Evidence-Based Medicine at the University of Oxford. ‘The evidence shows that self-monitoring is an effective strategy to reduce thromboembolic events in patients taking oral anticoagulants such as warfarin,’ he added.

Home monitoring of ‘blood thinners’ is effective
Web MD

Patients Can Safely Manage Blood Thinners Themselves
MedPage Today

There is also a neat peice by Jonathan Wood from the University of Oxford press office Blood clot risk halved for patients checking own warfarin dose

Patients who monitor their own treatment with warfarin or other blood-thinning drugs reduce their risk of developing blood clots by half, an Oxford University study has found.......

Beyond trials and looking to prevention. Notes from AHA 2011

Ami Banerjee
Last edited 15th November 2011

Since the early trials of beta-blockers and thrombolysis, or “clot-busting” drugs, in cardiovascular disease, the American Heart Association Scientific Sessions and other international cardiology meetings have been dominated by highly-anticipated “late-breaking” or “hot trials” sessions. During these talks, thousands of conference attendees would clamour to hear the results of trials of new drugs reported for the first time. As well as being highly talked about, they greatly influence projections of how the drug will perform in the real market: akin to a stockmarket floor for pharma. Today new drug trials are still by the dozen, but difficult economic times, increased regulation of pharma and wider and quicker dissemination of results may be changing the role of these sessions.

Aside from the trials, three messages are coming through loud and clear from this year’s meeting in Orlando. First, although the best-attended sessions are still the trials of new interventions and drugs for the range of cardiovascular disease, the number of talks devoted to primary prevention and primordial prevention is growing. In other words, prevention of the development of disease and prevention of the development of risk factors of disease, respectively

Second, there is a shifting focus on risk factors as continuous exposures over the whole lifespan. For example, we have talked about “pack-years” of smoking for a long time, i.e. an individual’s lifetime exposure to cigarette smoke. Rather than looking at arbitrary cut-offs for risk factors such as hypertension or high cholesterol, it may make more sense to look at the burden of that risk factor over their lifespan, and in combination with other risk factors.

Third, in the aftermath of the September UN high-level meeting, there is an increasing recognition of the global health aspects of heart disease and stroke. In a session chaired by Professor Sir Magdi Yacoub, eminent cardiac surgeon and long-term activist for improved health services for heart disease in low-income countries, a researcher from Mozambique showed the huge disease burden how feasible screening for common heart diseases can be, even in rural settings.

All three of these changes are welcome and signal gradual, encouraging paradigm shifts among both researchers and health professionals to look at the bigger picture of prevention and population approaches to cardiovascular disease.

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