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FIRST NATIONAL DAILY eMEDICAL NEWSPAPER OF INDIA
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  From the Desk of Editor–in–Chief
Dr KK Aggarwal

Padma Shri and Dr B C Roy National Awardee
Dr KK Aggarwal
President, Heart Care Foundation of India; Sr Consultant Physician, Cardiologist and Dean Medical Education Moolchand Medcity; Chairman Ethical Committee Delhi Medical Council; Chairman (Delhi Chapter) International Medical Sciences Academy; Hony Director IMA AKN Sinha Institute (08–09); Hony Finance Secretary National IMA (07–08); Chairman IMA Academy of Medical Specialties (06–07); President Delhi Medical Association (05–06), President IMA New Delhi Branch (94–95, 02–04); Editor-in-Chief IJCP Group of Publications & Hony. Visiting Professor (Clinical Research) DIPSAR

 
  Editorial …

8th March, 2011, Tuesday                                eMedinewS Presents Audio News of the Day

View Photos and Videos of 2nd eMedinewS – Revisiting 2010

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Supreme Court Judgment in Aruna Shanbaug case

WITHDRAWAL OF LIFE SUPPORT OF A PATIENT IN PERMANENT VEGETATIVE STATE (PVS)

126.There is no statutory provision in our country as to the legal procedure for withdrawing life support to a person in PVS or who is otherwise incompetent to take a decision in this connection. We agree with Mr. Andhyarujina that passive euthanasia should be permitted in our country in certain situations, and we disagree with the learned Attorney General that it should never be permitted. Hence, following the technique used in Vishakha’s case (supra), we are laying down the law in this connection which will continue to be the law until Parliament makes a law on the subject.

(i) A decision has to be taken to discontinue life support either by the parents or the spouse or other close relatives, or in the absence of any of them, such a decision can be taken even by a person or a body of persons acting as a next friend. It can also be taken by the doctors attending the patient. However, the decision should be taken bona fide in the best interest of the patient.

In the present case, we have already noted that Aruna Shanbaug’s parents are dead and other close relatives are not interested in her ever since she had the unfortunate assault on her. As already noted above, it is the KEM hospital staff, who have been amazingly caring for her day and night for so many long years, who really are her next friends, and not Ms. Pinky Virani who has only visited her on few occasions and written a book on her. Hence it is for the KEM hospital staff to take that decision. The KEM hospital staff have clearly expressed their wish that Aruna Shanbaug should be allowed to live. Mr. Pallav Shisodia, learned senior counsel, appearing for the Dean, KEM Hospital, Mumbai, submitted that Ms. Pinky Virani has no locus standi in this case. In our opinion it is not necessary for us to go into this question since we are of the opinion that it is the KEM Hospital staff who is really the next friend of Aruna Shanbaug. We do not mean to decry or disparage what Ms. Pinky Virani has done. Rather, we wish to express our appreciation of the splendid social spirit she has shown. We have seen on the internet that she has been espousing many social causes, and we hold her in high esteem. All that we wish to say is that however much her interest in Aruna Shanbaug may be it cannot match the involvement of the KEM hospital staff who have been taking care of Aruna day and night for 38 years.

However, assuming that the KEM hospital staff at some future time changes its mind, in our opinion in such a situation the KEM hospital would have to apply to the Bombay High Court for approval of the decision to withdraw life support.

(ii) Hence, even if a decision is taken by the near relatives or doctors or next friend to withdraw life support, such a decision requires approval from the High Court concerned as laid down in Airedale’s case (supra).

In our opinion, this is even more necessary in our country as we cannot rule out the possibility of mischief being done by relatives or others for inheriting the property of the patient.

127. In our opinion, if we leave it solely to the patient’s relatives or to the doctors or next friend to decide whether to withdraw the life support of an incompetent person there is always a risk in our country that this may be misused by some unscrupulous persons who wish to inherit or otherwise grab the property of the patient. Considering the low ethical levels prevailing in our society today and the rampant commercialization and corruption, we cannot rule out the possibility that unscrupulous persons with the help of some unscrupulous doctors may fabricate material to show that it is a terminal case with no chance of recovery. There are doctors and doctors. While many doctors are upright, there are others who can do anything for money (see George Bernard Shaw’s play ‘The Doctors Dilemma’). The commercialization of our society has crossed all limits. Hence we have to guard against the potential of misuse (see Robin Cook’s novel ‘Coma’). In our opinion, while giving great weight to the wishes of the parents, spouse, or other close relatives or next friend of the incompetent patient and also giving due weight to the opinion of the attending doctors, we cannot leave it entirely to their discretion whether to discontinue the life support or not. We agree with the decision of the Lord Keith in Airedale’s case (supra) that the approval of the High Court should be taken in this connection. This is in the interest of the protection of the patient, protection of the doctors, relative and next friend, and for reassurance of the patient’s family as well as the public. This is also in consonance with the doctrine of parens patriae which is a well known principle of law.

DOCTRINE OF PARENS PATRIAE

128. The doctrine of Parens Patriae (father of the country) had originated in British law as early as the 13th century. It implies that the King is the father of the country and is under obligation to look after the interest of those who are unable to look after themselves. The idea behind Parens Patriae is that if a citizen is in need of someone who can act as a parent who can make decisions and take some other action, sometimes the State is best qualified to take on this role.

129. In the Constitution Bench decision of this Court in Charan Lal Sahu vs. Union of India (1990)
1 SCC 613 (vide paras 35 and 36), the doctrine has been explained in some details as follows:

"In the "Words and Phrases" Permanent Edition, Vol. 33 at page 99, it is stated that parens patriae is the inherent power and authority of a legislature to provide protection to the person and property of persons non sui juris, such as minor, insane, and incompetent persons, but the words parens patriae meaning thereby ‘the father of the country’, were applied originally to the King and are used to designate the State referring to its sovereign power of guardianship over persons under disability. Parens patriae jurisdiction, it has been explained, is the right of the sovereign and imposes a duty on the sovereign, in public interest, to protect persons under disability who have no rightful protector. The connotation of the term parens patriae differs from country to country, for instance, in England it is the King, in 13 America it is the people, etc. The government is within its duty to protect and to control persons under disability".

The duty of the King in feudal times to act as parens patriae (father of the country) has been taken over in modern times by the State.

130. In Heller vs. DOE (509) US 312 Mr. Justice Kennedy speaking for the U.S. Supreme Court observed:

"the State has a legitimate interest under its parens patriae powers in providing care to its citizens who are unable to care for themselves".

131. In State of Kerala vs. N.M. Thomas, 1976(1) SCR 906 (at page 951) Mr. Justice Mathew observed:

"The Court also is ‘state’ within the meaning of Article 12 (of the Constitution)."

132. In our opinion, in the case of an incompetent person who is unable to take a decision whether to withdraw life support or not, it is the Court alone, as parens patriae, which ultimately must take this decision, though, no doubt, the views of the near relatives, next friend and doctors must be given due weight.

UNDER WHICH PROVISION OF THE LAW CAN THE COURT GRANT APPROVAL FOR WITHDRAWING LIFE SUPPORT TO AN INCOMPETENT PERSON

133. In our opinion, it is the High Court under Article 226 of the Constitution which can grant approval for withdrawal of life support to such an incompetent person. Article 226(1) of the Constitution states:

"Notwithstanding anything in article 32, every High Court shall have power, throughout the territories in relation to which it exercises jurisdiction, to issue to any person or authority, including in appropriate cases, any Government, within those territories directions, orders or writs, including writs in the nature of habeas corpus, mandamus, prohibition, quo warranto and certiorari, or any of them, for the enforcement of any of the rights conferred by Part III and for any other purpose".

134. A bare perusal of the above provisions shows that the High Court under Article 226 of the Constitution is not only entitled to issue writs, but is also entitled to issue directions or orders.

135. In Dwarka Nath vs. ITO AIR 1966 SC 81 (vide paragraph 4) this Court observed:

"This article is couched in comprehensive phraseology and it ex facie confers a wide power on the High Courts to reach injustice wherever it is found. The Constitution designedly used a wide language in describing the nature of the power, the purpose for which and the person or authority against whom it can be exercised. It can issue writs in the nature of prerogative writs as understood in England; but the scope of those writs also is widened by the use of the expression "nature", for the said expression does not equate the writs that can be issued in India with those in England, but only draws an analogy from them. That apart, High Courts can also issue directions, orders or writs other than the prerogative writs. It enables the High Courts to mould the reliefs to meet the peculiar and complicated requirements of this country. Any attempt to equate the scope of the power of the High Court under Art. 226 of the Constitution with that of the English Courts to issue prerogative writs is to introduce the unnecessary procedural restrictions grown over the years in a comparatively small country like England with a unitary form of Government to a vast country like India functioning under a federal structure."

136.The above decision has been followed by this Court in Shri Anadi Mukta Sadguru vs. V. R. Rudani AIR 1989 SC 1607 (vide para 18).

137. No doubt, the ordinary practice in our High Courts since the time of framing of the Constitution in 1950 is that petitions filed under Article 226 of the Constitution pray for a writ of the kind referred to in the provision. However, from the very language of the Article 226, and as explained by the above decisions, a petition can also be made to the High Court under Article 226 of the Constitution praying for an order or direction, and not for any writ. Hence, in our opinion, Article 226 gives abundant power to the High Court to pass suitable orders on the application filed by the near relatives or next friend or the doctors/hospital staff praying for permission to withdraw the life support to an incompetent person of the kind above mentioned.

PROCEDURE TO BE ADOPTED BY THE HIGH COURT WHEN SUCH AN APPLICATION IS FILED

138. When such an application is filed the Chief Justice of the High Court should forthwith constitute a Bench of at least two Judges who should decide to grant approval or not. Before doing so the Bench should seek the opinion of a committee of three reputed doctors to be nominated by the Bench after consulting such medical authorities/medical practitioners as it may deem fit. Preferably one of the three doctors should be a neurologist, one should be a psychiatrist, and the third a physician. For this purpose a panel of doctors in every city may be prepared by the High Court in consultation with the State Government/Union Territory and their fees for this purpose may be fixed.

139. The committee of three doctors nominated by the Bench should carefully examine the patient and also consult the record of the patient as well as taking the views of the hospital staff and submit its report to the High Court Bench.

140. Simultaneously with appointing the committee of doctors, the High Court Bench shall also issue notice to the State and close relatives e.g. parents, spouse, brothers/sisters etc. of the patient, and in their absence his/her next friend, and supply a copy of the report of the doctor’s committee to them as soon as it is available. After hearing them, the High Court bench should give its verdict. The above procedure should be followed all over India until Parliament makes legislation on this subject.

141. The High Court should give its decision speedily at the earliest, since delay in the matter may result in causing great mental agony to the relatives and persons close to the patient.

142. The High Court should give its decision assigning specific reasons in accordance with the principle of ‘best interest of the patient’ laid down by the House of Lords in Airedale’s case (supra). The views of the near relatives and committee of doctors should be given due weight by the High Court before pronouncing a final verdict which shall not be summary in nature.

143. With these observations, this petition is dismissed.

144. Before parting with the case, we would like to express our gratitude to Mr. Shekhar Naphade, learned senior counsel for the petitioner, assisted by Ms. Shubhangi Tuli, Ms. Divya Jain and Mr. Vimal Chandra S. Dave, advocates, the learned Attorney General for India Mr. G. E. Vahanvati, assisted by Mr. Chinmoy P. Sharma, advocate, Mr. T. R. Andhyarujina, learned Senior Counsel, whom we had appointed as amicus curiae assisted by Mr. Soumik Ghoshal, advocate, Mr. Pallav Shishodia, learned senior counsel, assisted by Ms. Sunaina Dutta and Mrs. Suchitra Atul Chitale, advocates for the KEM 13 Hospital, Mumbai and Mr. Chinmoy Khaldkar, counsel for the State of Maharashtra, assisted by Mr. Sanjay V. Kharde and Ms. Asha Gopalan Nair, advocates, who were of great assistance to us. We wish to express our appreciation of Mr. Manav Kapur, Advocate, who is Law–Clerk–cum–Research Assistant of one of us (Katju, J.) as well as Ms. Neha Purohit, Advocate, who is Law–Clerk–cum–Research Assistant of Hon’ble Justice Gyan Sudha Mishra. We also wish to mention the names of Mr. Nithyaesh Nataraj and Mr. Vaibhav Rangarajan, final year law students in the School of Excellence, Dr. B.R. Ambedkar Law University, Chennai, who were the interns of one of us (Katju, J.) and who were of great help in doing research in this case.

145. We wish to commend the team of doctors of Mumbai who helped us viz. Dr. J. V. Divatia, Professor and Head, Department of Anesthesia, Critical Care and Pain at Tata Memorial Hospital, Mumbai; Dr. Roop Gursahani, Consultant Neurologist at P.D. Hinduja, Mumbai; and Dr. Nilesh Shah, Professor and Head, 13 Department of Psychiatry at Lokmanya Tilak Municipal Corporation Medical College and General Hospital. They did an excellent job.

146. We also wish to express our appreciation of Ms. Pinki Virani who filed this petition. Although we have dismissed the petition for the reasons given above, we regard her as a public spirited person who filed the petition for a cause she bona fide regarded as correct and ethical. We hold her in high esteem.

147. We also commend the entire staff of KEM Hospital, Mumbai (including the retired staff) for their noble spirit and outstanding, exemplary and unprecedented dedication in taking care of Aruna for so many long years. Every Indian is proud of them.

To read the complete judgment, click here.

Dr KK Aggarwal
Editor–in–Chief
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  eMedinewS Audio PostCard

  Treating Diabetes Post 2010

Dr Ambrish Mithal speaks on
Role of gut hormones in type 2 diabetes

Audio PostCard
 
  SMS of the Day

(Dr GM Singh)

A great man shows his greatness by the way he treats little men. Thomas Carlyle

 
    Photo Feature from the HCFI

Dr. Sadhna Women Empowerment Awards Distributed

Dr. Sadhna Women Empowerment Awards were presented to women of eminence. Mrs. Trishla Jain, Social Worker was felicitated with the award on 27th February 2011.

 
Dr K K Aggarwal
 
    National News

Certificate courses in 2D and 3D Echocardiography/Fellowship Diploma in non invasive cardiology: Contact Dr KK Aggarwal, Moolchand Medcity, email: emedinews@gmail.com

Vector–borne diseases more fatal by the year

Dengue and other viral diseases are fast becoming a serious health hazard in the country. The number of Indians inflicted with dengue fever alone rose sharply by more than 50 per cent in 2010 over the previous year across the nation. What’s worse, the vector–borne disease is becoming more fatal every year. According to the Government data tabled in the Lok Sabha recently, the country reported 28,076 dengue cases in 2010, up from 15,535 in the previous year. The figures showed as many as 110 Indians succumbed to the disease against 96 during the period. The cases may be higher given ]that many States like Himachal Pradesh, Sikkim and Uttarakhand have not reported the incidents to the Central Health Ministry.

Dengue is caused by the bite of the female aedes aegypti mosquito that breeds in stagnant water, is marked by high fever, skin rashes and a sharp drop in blood platelet count that can prove fatal. Rise in infections can be blamed on a number of factors, including higher temperatures and increased flooding, both of which provide better breeding grounds for mosquitoes. Moreover, dengue no longer remained the rainy season related disease due to the growing threats owing to the climate change. Delhi, Punjab, Kerala, Gujarat, Rajasthan, Uttar Pradesh and Karnataka reported a significant increase in the dengue cases. In Delhi, vector–borne disease shot up from 1,153 in 2009 to significant 6,259 in the following year. The number of death also rose from 3 to 8.

"Though the cases of dengue in 2010 were reported more, the case fertility rate (mortality per 100 cases of dengue) has reduced to .04 per cent as compared to 1.3 per cent in 2005," a senior health official said. The Government has set up a network of 276 sentienl surveillance hospitals for diagnosis and treatment of the disease. A total 47,999 Chiunguniya cases were reported in 2010 with Uttar Pradesh topping the list at 20,503 followed by Karnataka (8740) and Maharashtra. In 2009, total number of cases stood at 73,288.

As per Government data, no death was occurred in 2009 and 2010 in the country due to Chikunguniya. Encephalitis syndrome including Japanese Encephalitis claimed 677 deaths in the country in 2010, maximum occurred in Uttar Pradesh (494) and Assam (117). In 2009 a total number of 4,482 cases were registered with 774 deaths. According to the World Health Organisation, about one in 300 infections results in symptomatic illness, which can be fatal in 30 per cent of cases as it affects brain. Patients who survive may be disabled for life. As per statistics, malaria cases have slightly decreased from 15,63574 in 2009 to 14,95817 in the following year. Similarly, death due to malaria has come down from 1,144 to 767. (Source: The Pioneer, March 07, 2011)

 
    International News

(Contributed by Rajat Bhatnagar, International Sports & Fitness Distribution, LLC http://www.isfdistribution.com)

Exercise is actually good for the knees, study shows

For years, studies have offered conflicting opinions on whether exercise is good for knees. A new report released today by the American College of Sports Medicine (ACSM) provides strong evidence that exercise is, in fact, good for the knees. The report, titled "What is the Effect of Physical Activity on the Knee Joint? A Systematic Review," was published this month in Medicine & Science in Sports & Exercise®, ACSM’s official scientific journal. A research study led by Donna Urquhart, Ph.D., and Flavia Cicuttini, Ph.D., examined the effects of physical activity on individual parts of the knee. "Several studies have already examined the impact of physical activity on the knee as a whole, but none have looked at the effect of physical activity on individual parts of the knee," said Dr. Cicuttini, head of the musculoskeletal unit in the School of Public Health and Preventive Medicine at Monash University in Australia. "As it turns out, exercise affects each part of the knee differently, which helps explain why there have been conflicting reports for so long."

According to the team’s findings, while exercise was linked to osteophytes, or bony spurs, there were no detrimental changes to joint space, the place where cartilage is housed. There were beneficial effects on cartilage integrity, with evidence of greater volumes and fewer defects. "These findings are significant, as they suggest that osteophytes, in the absence of cartilage damage, may just be a functional adaptation to mechanical stimuli," said Dr. Urquhart. The report comprised data from 28 studies, representing 9,737 participants from all parts of the world. All included studies examined the relationship between physical activity and knee osteoarthritis and also included MRI evidence of osteoarthritic knees when investigating disease progression or healthy knees when investigating disease incidence. Osteoarthritis – a degenerative joint disease that attacks cartilage and underlying bone and often preys on knees, hips and hands – affects nearly 27 million Americans and is the leading cause of disability in non–institutionalized adults.

(Dr Monica and Brahm Vasudev)

Glucose target for ICU patients should not exceed 180 mg/dL

According to the Endocrine Society, new glucose management guidelines released last week by the American College of Physicians may not go far enough to adequately protect patients in the intensive–care unit. In fact, the glucose target for ICU patients should be no more than 180 mg/dL, the group argued in response to the 200 mg/dL upper limit recommended by the ACP. In a statement, the Endocrine Society noted that exceeding the 180 mg/dL target has been linked to a great risk for infection, hospital stays that last longer, and higher rates of mortality.

Supreme Court ruling protects vaccine makers from lawsuits

The Supreme Court on Tuesday shielded the nation's vaccine makers from being sued by parents who say their children suffered severe side effects from the drugs. In a 6–2 vote, the court ruled against the parents of a child who sued the drug maker Wyeth for the health problems they say their daughter, now 19, suffered from a vaccine she received in infancy.

Medicinal leeches may transmit resistant Aeromonas infection

A resistant Aeromonas infection transmitted by a medicinal leech developed in a man undergoing reconstructive surgery of the jaw, leading to total failure of the graft, according to a case study in the Archives of Otolaryngology–Head and Neck Surgery. The researchers said leech therapy is the most effective nonsurgical management of soft–tissue venous congestion. But because Aeromonas hydrophila reside in the gut of Hirudo medicinalis, infections can occur in some 7% to 20% of cases. Prophylaxis with ciprofloxacin or trimethoprim–sulfamethoxazole is usually recommended prior to leech therapy. However, the investigators cautioned, ciprofloxacin–resistant strains of Aeromonas have been identified from environmental sources such as drinking water in Turkey, a lake in Switzerland, and the Seine River. (AMA News)

More vitamin D intake may be needed to cut cancer risk

It takes far more vitamin D than initially thought to dramatically cut the risk of several major diseases, including breast cancer, according to a study in the in the journal Anticancer Research.

 
    Infertility Update

(Dr. Kaberi Banerjee, Director Precious Baby Foundation, banerjee.kaberi@gmail.com)

What are some less common treatments for infertility?

Immunotherapy with Intravenous ImmunoGlobulin (IvIg) is a less common treatment that is becoming more recognized and utilized.

 
    Hepatology Update

(Dr. Neelam Mohan, Director Pediatric Gastroenterology, Hepatology and Liver Transplantation, Medanta – The Medicity, drneelam@yahoo.com)

Consider the following causes in a patient of hepatomegaly

  • With normal bilirubin: Consider hepatoblastoma, metabolic diseases.
  • With splenomegaly: TORCH infections, sepsis and disorders of carbohydrate metabolism, e.g. galactosemia.
  • Without splenomegaly: Liver tumor, choledochal cyst, biliary atresia, neonatal hepatitis.
  • With raised unconjugated bilirubin: CCF, toxins, hemolytic anemias.
 
    Medicolegal Update

(Dr Sudhir Gupta, Asso Professor, Forensic Medicine & Toxicology, AIIMS)

What is hallucination?

Hallucination is false sense perception without any external object or stimulus. A criminal act committed by a sane person, due to hallucination will make him responsible for his act and he will be liable to be punished. But if the act is committed by an insane person, due to hallucination, then he may not be held responsible or may be held partially responsible for commission of the act.

Apart from insanity, hallucination may also occur in conditions like high fever, delirium of any origin, delirium tremens, and drug intoxications. Hallucinogenic drugs, like cannabis, LSD, mescaline etc. and as withdrawal symptom of some drugs of addiction. It may affect one or more than one of the special nerves or nervous system. Accordingly, hallucinations are of the following types:

  • Visual hallucination: In this condition the sufferer experiences (visualizes) non–existent sights. He observes something without anything being present in front of him.
  • Auditory hallucination: The sufferer in this condition hears voices or sounds without any source or any such thing.
  • Olfactory hallucination: There is a false perception of smell or odor without any source.
  • Gustatory hallucination: The sufferer experiences different tastes without any food or drink.
  • Tactile hallucination: The sufferer experiences a sensation of crawling of insects over his body without any such a phenomenon actually happening.
  • Psychomotor hallucination: There is a feeling of movement of a part of the body, say a limb, though in reality there is no such movement.
 
    Legal Question of the Day

(Dr M C Gupta, Advocate)

Q. Can an MLC be prepared without the consent of the injured?

Ans.

  • An MLC may be prepared under the following circumstances:
    • When the injured presents himself and the condition is not serious and foul play is not suspected.
    • When police has been informed. This would be so in a case of suspected accident, poisoning, burns, coma or brought dead or where foul play is suspected.
    • When the case has been brought by the police.
  • In ‘a’ above, the patient has come on his own and consent should not be an issue.
  • In ‘c’ above, the person has been brought by the police and the request, under law, has been made by the police. Hence there is no question of consent.
  • In ‘b’ above, consent should not be an issue since it is, in any case, supposed to be a police case and, indirectly, equivalent to a case brought by or in the know of the police. However, it is always advisable to take consent of the injured person along with his thumb impression and signature. If he refuses consent, such fact should be recorded.
  • The above is in accordance with the guidelines laid down in the "Hospital Manual" published in 2002 by the Directorate General of Health Services, MOHFW, GOI, in Annexure V titled "The guidelines for medico–legal work—Pages 192–193".
 
    Obesity Update

Dr. Parveen Bhatia and Dr Rama Lakshmi

Childhood Obesity: Non pharmacological management

Non–pharmacological approaches should be the foundation of all obesity treatments, especially in children, and should always be considered as first–line therapy.

Treatment for children under age 7 and have no other health concerns, the goal of treatment should be weight maintenance rather than weight loss. This strategy allows the child to add inches in height but not pounds, causing BMI–for–age to drop over time into a healthier range.

Treatment for children 7 years of age and older: Weight loss is typically recommended for children over age 7 and for those having related health concerns. Weight loss should be slow and steady — anywhere from 1 pound (about 0.5 kilograms) a week to 1 pound a month, depending on child's condition.

Advice

Healthy eating

√ When buying groceries, choose fruits and vegetables.
√ Limit sweetened beverages
√ Limit the number of times you eat out, especially at fast–food restaurants.    Many of the menu options are high in fat and calories.
√ Discourage eating in front of a screen, such as a television, computer or    video game.

Physical activity

√ Limit recreational computer and TV time to no more than 2 hours a day.
√ Emphasize activity, not exercise: the objective is just to get him or her    moving. Free–play activities, such as playing hide–and–seek, tag or jump–    rope, can be great for burning calories and improving fitness.
√ Find activities your child likes to do.
√ If you want an active child, be active yourself. Find fun activities that the    whole family can do together. Never make exercise seem a punishment or a    chore.

 
    Useful Website

(Dr Surendernikhil Gupta)

KidSurvival

HIV Decline in Zimbabwe

http://www.childsurvival.net/?content=com_articles&artid=330

 
    Lab Update

(Dr Arpan Gandhi and Dr Navin Dang)

Allergy tests

The allergen–specific IgE antibody test is used to screen for an allergy to a specific allergen. It measures the amount of that suspected IgE antibody in the blood. Immunoglobulin E (IgE) is a protein associated with allergic reactions; it is normally found in very small amounts in the blood.

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    Medi Finance Update

BDO Budget Snapshot 2011–12
(Saurabh Aggarwal)

Proposed Direct Tax Amendments In Brief

Sunset Clauses for Section 80–IA/IB Provisions (Profit Linked)/Section 10

  • Terminal period for claiming deduction under section 80–IA, for any entity engaged in "generation and distribution of power, transmission or distribution of network lines", extended to 31 March 2012.
  • In case of commercial production of mineral oil – 7 years profit linked deduction to continue except for contracts awarded under a government of India scheme.
  • Section 10B – No extension has been granted for the existing STPI units
 
    Drug Update

LIST of approved drug from 01.01.2010 to 31.8.2010

Drug Name
Indication
DCI Approval Date
Imatinib Mesylate 100/400mg Tablets (Addl. Indication)
Adjuvant treatment of adult patients following resection of gastrointestinal stromal tumours (GIST)
05/04/2010
 
    IMSA Update

International Medical Science Academy (IMSA) Update

Glycemic control in type 2 diabetes

In Asian patients with type 2 diabetes, postprandial glucose 24 and 4 hour after meals was a predominant contributor to excess hyperglycemia in well–controlled patients and was equally important as fasting glucose or preprandial glucose in moderately to poorly controlled patients with mean HbA1c up to 10%.

 
    IJCP Special

Dr Good Dr Bad

Situation: A diabetic came with A1C 7.5%.
Dr Bad: Its ok.
Dr Good: You need better control.
Lesson: A1c goal is <7% for most patients.

Make Sure

Situation: A patient on 10 units of insulin developed hypoglycemia with 11 units of insulin.
Reaction: Oh my God! Why was additional insulin given?
Lesson: Make sure that insulin dose is correct. The formula is 1500/total daily dose. The value will be the amount of sugar fluctuation with one unit of insulin.

 
    Lighter Side of Reading

An Inspirational Story
(Contributed by Dr Muthumperumal Thirumalpillai)

Following is a letter a renowned Hong Kong TV broadcaster cum Child Psychologist wrote to his son. The words are actually applicable to all of us, young or old, children or parents.!

I am writing this to you because of 3 reasons

  1. Life, fortune and mishaps are unpredictable, nobody knows how long one will live. Some words are better said early.
  2. I am your father, and if I don’t tell you these, no one else will.
  3. What is written is my own personal bitter experiences that perhaps could save you a lot of unnecessary heartaches.

Remember the following as you go through life:

  • Do not bear grudge towards those who are not good to you. No one has the responsibility of treating you well, except your mother and I.
  • To those who are good to you, you have to treasure it and be thankful, and ALSO you have to be cautious, because, everyone has a motive for every move.
  • When a person is good to you, it does not mean he really likes you. You have to be careful, Don’t hastily regard him as a real friend. But once you find him so, give him your best shot.
  • No one is indispensable, there is nothing in the world that you must possess. Once you understand this idea, it would be easier for you to go through life when people around you don’t want you anymore, or when you lose what/who you love the most.
  • Life is short. When you waste your life today, tomorrow you would find that life is leaving you. The earlier you treasure your life, the better you enjoy life.
  • Love is but a transient feeling, and this feeling would fade with time and with one’s mood. If your so called loved one leaves you, be patient, time will wash away your aches and sadness. Don’t over exaggerate the beauty and sweetness of love, and don’t over exaggerate the sadness of falling out of love.
  • A lot of successful people did not receive a good education, but that does not mean that you can be successful by not studying hard! Remember that whatever knowledge you gain, is your weapon in life. One can go from rags to riches, but one has to start from some rags!
  • I do not expect you to financially support me when I am old, neither would I financially support your whole life. My responsibility as a supporter ends when you are grown up. After that, you decide whether you want to travel in a public transport or in your own sedan, to be rich or poor.
  • Always honour your words, but don’t expect others to be so.
  • You can be good to people, but don’t expect people to be good to you. If you don’t understand this, you would end up with unnecessary troubles.
  • I have bought lotteries for umpteen years, but I never struck any prize. It simply shows if you want to be rich, you have to work hard! There is no free lunch!
  • No matter how much time I have with you, let’s treasure the time we have together. We do not know if we would meet again in our next life.

Your Everloving Dad.

————————————

Mind Teaser

Read this…………………

Wood
John
Massachusetts

Yesterday’s eQuiz: A 75–year–old hypertensive male smoker is found to have a midline abdominal mass with a bruit on auscultation over the mass. Remainder of his examination is normal apart from a blood pressure of 165/100mmHg. LDL is 65 mg/dl and other labs are normal. What is the best next step?

1. Abdominal Ultrasound
2. Abdominal MR angiogram
3. Abdominal CT angiogram
4. Abdominal Arteriogram

Answer for yesterday’s eQuiz: Correct answer is 1.

This patient has several risk factors for abdominal aortic aneurysm (AAA) – male sex, advanced age, hypertension and smoking history. AAAs are usually asymptomatic as in this patient. The best initial investigation is an abdominal ultrasound as it gives the necessary information at a fraction of the cost, and time with no contrast exposure. It is useful for serial follow up of the aneurysm. Blood pressure control, lowering LDL below 100mg/dl and smoking cessation are other important measures in patients with AAAs.

Correct answers received from: Dr Manjesha, Dr Anil Bairaria, Dr U Gaur, Dr Neelam Nath, Dr Shubha Laxmi Margekar

Answer for 6th March Mind Teaser: Drop in the bucket
Correct answers received from: Dr Tara Natarajan, Dr Tara Natarajan, Dr B.N.Ganagdhar, Dr Rakesh Bhasin, Dr Anupam Sethi Malhotra, Dr Varsha Gupta, Dr Nandini Kapoor, Dr K.Raju  

Send your answer to ijcp12@gmail.com

————————————

Laugh a While
(Contributed by Dr G M Singh)

A retired consultant physician tells that when he sent a patient to the Royal Naval Hospital she reported that they had "put up a periscope and found an atomic bladder!"

………………………………

Continuing Ed for Doctors described in Bollywood songs……
(Dr Dolly Aggarwal)

Tujhme rab dikhta hai yaara main kya karoon: Visual Hallucination

 
    Readers Responses

1. Dear colleagues, the govt has proposed that a 5% service tax be applied on hospital bills and diagnostic tests. I do not oppose this proposal. A 5% tax does not and will not affect the vast majority of doctors who are practicing and offering consultation to patients. It will not mean raising our consultation fees as it will not apply to consultation charges. Any service tax on (centrally air–conditioned) hospital bills will be passed on to the patient and go straight to the govt. Why are we worried? The intensity with which IMA and Narayana Hrudaylaya have opposed this proposal is surprising. I was under the impression that the IMA stood for doctors. This 5% tax is not on doctors but on customers of centrally air–conditioned hospitals. Relax, stand back and re–evaluate the proposal. Service tax is on so many services, hospital bills and diagnostic tests are being added. Why not? Dr Maneesh Gupta

eMedinewS responds: I agree with your emotions but remember the following:

  1. The 5% service tax no doubt is only on centrally air–conditioned hospitals but is also for all diagnostic centres whether they are in that hospital or outside.
  2. The charges of diagnostics, therefore, will increase by 5%.
  3. It is likely that from next year it will become 10% as the 50% waiver will invariably be taken back. From the next year, routine consultations may also be included into the bracket.
  4. Also remember that once you are in that bracket of service tax, you will have to file monthly return for which just like income tax consultant you will have to hire a service tax consultant. For filing the returns, you will have to pay to your accountant as well as the CA. If your case comes under scrutiny, you will have the same problems that you face when your case comes under income tax scrutiny. These charges will invariably be passed on to the patient. You will have to increase your charges of consultation to come over that cost.
  5. I agree that doctors will not suffer, ultimately only patients will suffer.

    We, as medical professionals, have our primary duty to take care of the interests of the patients. If IMA is opposing this proposal, it is their duty. Regards, Dr. KK Aggarwal, Padma Shri & Dr. B. C. Roy National Awardee.

2. Dear Dr. Aggarwal, I don’t believe the following, published on 7 March 11, can be true–– "NABH accreditation (National Accreditation Board for Hospitals & Healthcare Providers) is mandatory for Hospitals, Dental centers, Blood banks, Eye banks and Healthcare providers. The Ministry of Health and Family Welfare made it mandatory for hospitals to have an NABH certification by December 2010." The above is likely to create unnecessary scare. Please reproduce in your newspaper the concerned rule/notification by which it has been made mandatory. M C Gupta, MD, LLM, Practicing advocate

eMedinewS responds: Thanks for pointing out the statement. The corrected language is as under: "The Ministry of Health and Family Welfare made it mandatory for hospitals to have an NABH certification by December 2010 if they want to treat the large pool of Central Government employees under the CGHS (Central Government Health Scheme)." Regards: Dr KK Aggarwal

 
    Public Forum

(Press Release for use by the newspapers)

International Women’s Day – 8th March: Focus on the heart of your beloved

All women are at risk of heart disease. Take all women older than 65 to a family doctor and ask for a prescription of 325 mg aspirin if not contraindicated. To reduce their risk, advise younger women to indulge in minimum of 60–90 minutes of moderate–intensity activity (e.g., brisk walking) on most, and preferably all days of the week.

These are a few of the updated guidelines for prevention of heart disease in the women released by Dr. KK Aggarwal, Padma Shri & Dr. B.C. Roy National Awardee and President, Heart Care Foundation of India, on the occasion of International Women’s day.

Women are at risk for heart disease and heart attacks, just like men. Heart disease is the leading cause of death among women over 65. Urban women are 4 to 6 times more likely to die of heart disease than of breast cancer.

Heart disease kills more women over 65 than all cancers combined. He said that a woman’s heart is different. Women get less attention when there is a heart attack and when they get one, the attack is more serious.

Facts and guidelines

  1. Women develop heart problems later in life than men –– typically 7 or 8 years later. However, by about age 65, a woman’s risk is almost the same as a man's.
  2. Women are less likely to survive heart attacks than men.
  3. Recommended lifestyle changes to help manage blood pressure include weight control, increased physical activity, alcohol moderation, sodium restriction, and an emphasis on eating fresh fruits, vegetables and low–fat dairy products.
  4. Advise women to quit smoking by counseling, nicotine replacement or other forms of smoking cessation therapy.
  5. Physical activity recommendations for women who need to lose weight or sustain weight loss includes minimum of 60–90 minutes of moderate–intensity activity (e.g., brisk walking) on most, and preferably all, days of the week.
  6. All women should reduce saturated fats intake to less than 7 percent of calories.
  7. Healthy women should eat oily fish at least twice a week for omega 3 fatty acids. Women with heart disease take a capsule supplement of 850–1000 mg of EPA (eicosapentaenoic acid) and DHA (docosahexaenoic acid), which to be increased to 2–4 grams if associated high triglycerides.
  8. Hormone replacement therapy and selective estrogen receptor modulators are not recommended to prevent heart disease in women.
  9. Antioxidant supplements (such as vitamin E, C and beta–carotene) should not be used for primary or secondary prevention of heart disease.
  10. Folic acid should not be used to prevent heart disease.
  11. Routine low dose aspirin therapy may be considered in women age 65 or older regardless of heart disease risk status, if benefits are likely to outweigh other risks in other means if not contraindicated.
  12. The upper dosage of aspirin for high–risk women is 325 mg per day rather than 162 mg.
  13. Reduce bad LDL cholesterol to less than 70 mg/dL in very high–risk women with heart disease.

Top 10 points: Preventing heart diseases in the women

  1. Increased emphasis on lifestyle changes
  2. Hormone replacement therapy does not help heart disease
  3. All women need adequate intake of omega–3 fatty acids
  4. All women should decrease intake of saturated fats
  5. All women need frequent exercise
  6. Nicotine replacement therapy may be used
  7. Antioxidants do not prevent heart disease
  8. Folic acid does not prevent heart disease
  9. All women older than 65 should consider daily aspirin
  10. High risk women need more aggressive cholesterol treatment
 
    eMedinewS Special

1. eMedinewS audio lectures (It may take a few minutes to open)

2. eMedinewS ebooks (It may take a few minutes to open)

 
    Forthcoming Events

ICC Cricket World Cup 2011

http://www.cricbuzz.com/cricket–schedule/series/228/icc–world–cup–2011

6th Annual Conference of Indian Academy of Nephrology (IANCON–2011)

March 12–13, 2011: Taj Deccan, Banjara Hills, Hyderabad–34
Faculty: Dr MS Amarsen, Dr KV Jhony, Dr SC Dash, Dr Kashivishweswaran, Dr V Sakhuja, Dr RK Sharma, Dr Girishnarayan, Dr Anuradha, Dr SK Agarwal, Dr P Sundarajan, Dr P Keshivya, Dr Ravi Raju, Dr Dilip Pahari, Dr LC Sharma, Dr Sanjeev Saxena, Dr Sanjay Gupta, Dr Abhijit Tarapdhar, Dr PP Verma, Dr Harun Rashid, Dr Sampath Kumar, Dr Sanjib Sharma, Dr S Padmanabhan.
Topics: CKD Symposium (From India, Nepal, Bangladesh), Newer concepts in the pathogenesis of hypertension, Fluid and Electrolyte & AKI, RAAS in treatment of Diabetic Nephropathy, Primary Prevention of CKD: Trials & tribulation in Indian condition, Vitamin–D andchronic kidney disease, Mycophenolate Vs Cyclyophosphamide in Lupus nephritis, Individual zinganemia therapy, How to monitor Immunosuppression minimization, Obesity Diabetes epidemic, Life Style changes & therapeutics, BKV and CMV Nephropathy, Leptospira and Acute Kidney Injury, HIV Nephropathy, Hypophosphatemia and Renal Disease, Immunosuppressant and risk of Malignancy, Pregnancy ARF, Expanding Dialysis services in Andhra Pradesh, Making kidney transplant easier for less privileged, Cardiovascular risk reduction in CKD
Organizing Secretary: Dr Sree Bhushan Raju, Associate Professor, Dept of Nephrology, NIMS, Hyderabad, Mob: 09848492951, sreebhushan@hotmail.com; www.ian2011.in
Note: "Prof SC Dash oration in Nephrology" from this year onwards. Three awards each in oral, poster and imaging in Nephrology sessions

Registration for Delegates Amount
Up to 15th February 2011
 
Rs. 1500/–
Up to 5th March 2011
Rs. 2000/–
Spot registration
Rs. 2500/–
Student
Rs. 500/–

DD/Cheque in favor of "IANCON–2011" payable at Hyderabad. Add Rs 100/– for outstation cheque.

CME on Pediatric Hepatology – 2011

In Association with Gastroenterology Chapter of IAP

Date: March 26–27, 2011; Venue: 2nd Floor, Auditorium, Medanta – The Medicity, Sector 38, Delhi NCR, Gurgaon – 122001, Haryana

Organizing Chairperson: Dr Neelam Mohan, Director, Department of Pediatric Gastroenterology, Hepatology and Liver Transplantation, Medanta – The Medicity

No registration fee. Prior registration is must

For More information please contact:
Dr Sakshi Karkra – 09971018789
Dr Avinal Kalra – 09717840850
Dr Mahinder S Dhaliwal – 09999669415
Ms Karuna – 09899996682

For detailed scientific program, click

eMedinewS Events: Register at emedinews@gmail.com

Medifinance Conference On Portfolio Management for Doctors and update on Budget 2011

Date: 13th March 2011, Time: 9 Am – 4 Pm
Venue: Auditorium, Delhi TB Association, 9 Institutional Area, Lodhi Road, New Delhi 110003
Speakers: Dr Subhash Lakhotia and other top of line from finance sector. Separate sessions for portfolio management, insurance, mediclaim, banking sector, investments primary market, secondary market, taxation, loans for setting up hospitals, nursing homes, labs, etc. all under one roof.

No entry fee, the number of participants will be limited to 100 on first cum first serve basis. advance registration by mail to hcfi.1986@gmail.com or by phone on 9899974439/9873716235.

World Fellowships of Religions and Perfect Health Parade

First ever Conference which will talk about science behind all Religions, Dharmas and Pathies under one roof
Subject: Global Warming, Ethnic Crises, How to be Healthy
Date: Sunday 3rd April, 2011;Venue: Maulana Azad Medical College Auditorium, New Delhi;Time: 8 AM – 4 PM

Parade through tableaus to be flagged off at 10 am from outside MAMC to move till 5 pm on different predefined routes in Delhi to create awareness about health matters.

Parade Route: Vikas Marg – Shahdara – Seemapuri – Guru Tegh Bhadur Hospital – Seelampur Pusta – Gandhinagar, to ISBT Kashmiri Gate – Civil Lines – Delhi University North Campus – Azadpur – Punjabi Bagh – Mayapuri – Raja Garden – Janakpuri – Tilak Nagar – Tihar Jail Road – Delhi Cantt. – R.K Puram – Munirka – IIT Gate – Panchsheel Park – Chirag Delhi Flyover – Nehru Place – Modi Mill Flyover – Ashram – Nizamuddin – Sunder Nagar – Pragati Maidan – ITO – finally culminate at Maulana Azad Medical College at 4pm.

Full day conference on ethnic crisis and global warming. Pre lunch session to be addressed by religious representatives who would talk on what each religion has to say. Post lunch to be addressed by doctors from all streams of medicinal practice (allopathy, ISM)
Register: rekhapapola@gmail.com

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