August 10  2015, Monday
eMedinewS
editorial
Stroke prevention guidelines
• Risk calculators, such as that endorsed by the American Heart Association (AHA) and the American College of Cardiology (ACC), can be useful in assessing patients’ risk for stroke in a holistic context. However, these tools should not absolutely dictate treatment decisions for each individual patient.

• Not all strokes are ischemic. Clinicians should consider noninvasive screening of the cerebral vasculature for patients with at least two first-degree relatives with a history of subarachnoid hemorrhage or intracranial aneurysms.

• The minimal amount of exercise recommended to prevent stroke is 40 min/day at 3 to 4 days/week.

• Statins should be first-line agents for stroke prevention among patients who meet the 10-year risk criteria for use of these drugs.

• Niacin can raise high-density lipoprotein cholesterol levels, but it is unproven in preventing stroke. Similarly, fibric acid derivatives may not actually prevent stroke.

• Hypertension should be treated to a goal blood pressure (BP) of less than 140/90 mm Hg to prevent stroke. Achieving target blood pressure is, in itself, more important than the types of medications used to treat hypertension.

• However, evidence exists that reducing systolic BP to a target of less than 130 mm Hg may prevent more strokes.

• Self-measured BP monitoring helps to reduce overall BP values and is recommended.

• A graded positive relationship appears to exist between the degree of obesity and the risk for stroke, regardless of other cardiovascular risk factors. Weight loss reduces BP and blood glucose levels and has been demonstrated to reduce the risk for stroke in long-term research protocols.

• Comorbid diabetes should not alter BP targets to prevent stroke, but these patients should preferentially receive a statin. The 10-year overall cardiovascular risk profile should be used to decide on aspirin prophylaxis for these patients; the presence of diabetes alone is less appropriate as an indication for aspirin therapy.

• Dabigatran has been associated with lower risks for stroke and embolic events compared with warfarin, as well as a lower risk for intracranial hemorrhage, among patients with AF. However, dabigatran was associated with a higher risk of gastrointestinal bleeding vs warfarin. Dabigatran may also slightly increase the risk for myocardial infarction.

• Rivaroxaban is more similar to warfarin in risk reduction for stroke or embolism among patients with AF, with a lower risk of serious bleeding.

• Similarly, the benefit of apixaban vs warfarin in cases of AF is more marked for intracranial hemorrhage vs stroke prevention.

• Economic analyses of the three new oral anticoagulants have generally been favorable.

• The three new anticoagulants and warfarin can be considered for patients with AF and a CHA2DS2-VASc score of 2 or more. Treatment choice should be individualized based on patients' risks of bleeding, tolerability, cost, and patient preference.

• Patients with AF and a CHA2DS2-VASc score of 0 should not receive anticoagulant or aspirin therapy; treatment may also be withheld among patients with a score of 1.

• Patients with mitral stenosis and a previous embolic event should receive anticoagulant therapy. Even severe mitral stenosis with left atrial enlargement might serve as an indication for anticoagulants.

• For patients who receive an aortic or mitral bioprosthesis, aspirin is sufficient in stroke prevention.

• Patients with asymptomatic carotid stenosis should receive aspirin and a statin. Carotid endarterectomy may be considered if the level of stenosis exceeds 70% and the risk for serious perioperative morbidity and mortality is less than 3%, but the efficacy of endarterectomy vs modern medical therapy is not well established.

• Risk stratification using transcranial Doppler ultrasound screening should be initiated at age 2 years for patients with sickle cell disease, and these patients should receive annual screening through age 16 years.

• Migraine with aura has been associated with a higher risk for stroke among women. Women with migraine should be urged not to smoke and should consider other methods of contraception besides oral contraceptives.

• Chronic inflammatory diseases, such as rheumatoid arthritis, should be considered risk factors for stroke.

• Annual influenza vaccination may reduce the risk for stroke among high-risk adults.

• Aspirin at a dose of 81 mg per day or 100 mg every other day remains recommended for patients at high risk for stroke, including those with chronic kidney disease. Aspirin should not be used to prevent stroke among patients whose sole risk factor is diabetes or asymptomatic peripheral artery disease.

• According to the new guidelines on primary stroke prevention, aspirin at a dose of 81 mg per day or 100 mg every other day remains recommended for patients at high risk for stroke, including those with chronic kidney disease. Aspirin should not be used to prevent stroke among patients whose sole risk factor is diabetes or asymptomatic peripheral artery disease.

• Warfarin, dabigatran, rivaroxaban, and apixaban may be recommended to prevent stroke among high-risk patients with AF. The main benefit of newer agents compared with warfarin is a reduction in the risk for intracranial hemorrhage.
(Medscape Cardiology)
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News
Oncology
Gastroenterology
Methylated MDGA2 detection may be a new biomarker for gastric cancer prognosis, suggests new research published in the journal Gut. The biomarker has been shown to predict poor prognosis in patients with gastric cancer, especially in the early stages.

Rheumatology
The presence of synovitis on Doppler ultrasound (DUS) helps predict failure on tapering of biologic therapy in patients with rheumatoid arthritis (RA), suggests new research published in Rheumatology.

Obstetrics and Gynecology
A maternal-fetal medicine surgeon with Magee-Womens Hospital of UPMC, the North American Fetal Therapy Network has published evidence-based and consensus-driven recommendations for the management of identical twin pregnancies in the journal Obstetrics and Gynecology. The guidelines are intended to help general obstetric practitioners understand some of the complexities that can affect the development of identical twins sharing one placenta.

Nephrology
Neurology

Impaired kidney function may lead to decreased blood flow to the brain, resulting in the occurrence of stroke or dementia. The findings appear in an upcoming issue of the Journal of the American Society of Nephrology (JASN).

Diabetes
Infectious diseases

New research suggests that high blood sugar unleashes destructive molecules that interfere with the body's natural infection-control defenses. Researchers suggested that sugar-derived molecules can weaken infection-fighting antimicrobial beta-defensin peptides. The findings are published in PLos One.
Cardiology eMedinewS
  • The National Institute for Health and Care Excellence (NICE) has recommended a new treatment, edoxaban, to help prevent strokes and systemic embolism in patients suffering from non-valvular atrial fibrillation.
  • The Society of Thoracic Surgeons, the Society of Cardiovascular Anesthesiologists, and the American Society of ExtraCorporeal Technology have released a set of clinical practice guidelines to address management of a patient's temperature during open heart surgery. The guidelines are published in the August issue of The Annals of Thoracic Surgery.
Pediatrics eMedinewS
Pediatrics
A Norwegian study of kindergarten children reveals that girls are more interested in language activities than boys. Thus, boys may receive less linguistic stimulation and become less prepared for school than girls.

Pediatrics
Diabetes
A new study has found that physical activity provides the greatest benefits to adolescent insulin resistance - a risk factor for type 2 diabetes, when the condition peaks at age 13, but provides no benefit to it at age 16. The findings, published in Diabetologia, could help design more effective interventions for children by targeting the early-teens.
Make Sure
Situation: A patient with rheumatic arthritis was not given penicillin prophylaxis, and subsequently developed another attack.
Reaction: Oh my God! Why was the prophylaxis not started?
Lesson: Make sure that one administers secondary prophylaxis in the setting of suspected poststreptococcal reactive arthritis for up to one year after the onset of symptoms. Evidence of valvular disease after one year should prompt continued prophylaxis; otherwise, antibiotic prophylaxis may be discontinued.
Dr Good Dr Bad
Situation: A patient with Chikungunya was found to have high ESR.
Dr. Bad: It may not be Chikungunya.
Dr. Good: This is Chikungunya.
Lesson: ESR is high in Chikungunya.

(Copyright IJCP)
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Sameer Malik Heart Care Foundation Fund
The Sameer Malik Heart Care Foundation Fund is a one of its kind initiative by the Heart Care Foundation of India instituted in memory of Sameer Malik to ensure that no person dies of a heart disease because they cannot afford treatment. Any person can apply for the financial and technical assistance provided by the fund by calling on its helpline number or by filling the online form.
Madan Singh, SM Heart Care Foundation Fund, Post CAG
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eIMA News
Govt nod enough for intake hike in medical colleges: SC
NEW DELHI: August 9, 2015, DHNS

A medical college, recognised by the Medical Council of India (MCI) and the central government for running MBBS or post-graduate medical course, is not required to seek fresh recognition to increase the intake.

Only permission from the central government is sufficient for raising the intake, the Supreme Court has held.

In an important verdict, a bench of Justices Anil R Dave and Kurian Joseph explained provisions of the Indian Medical Council Act, 1956, which has been a matter of several legal battles between a particular medical college and the regulatory body, MCI.

“Once a medical college is recognised under Section 11 of the Act along with medical qualification, thereafter, for increase in the admission capacity in any course of study or training that is recognised under Section 11 of the Act, only permission from central government as per the scheme under Section 10A of the Act is required,” the bench said.

The court said that under the scheme of the Act, permission is for the admission capacity and recognition is for the course and the institution. So when a course and an institution is notified as a recognised course and a recognised institution, the admission capacity or its increase in any recognised course needs only the permission of the central government, it added.

The bench passed its verdict while allowing a writ petition filed by Chennai-based Sree Balaji Medical College and Hospital. It said the college should be allowed to increase the MBBS course intake from 150 to 250 for 2015-2016.
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Inspirational Story
The power of encouragement

A really nice story reminding us not to give up too early…

Dante Gabriel Rossetti, the famous 19th-century poet and artist, was once approached by an elderly man. The old fellow had some sketches and drawings that he wanted Rossetti to look at and tell him if they were any good, or if they at least showed potential talent.

Rossetti looked over them carefully. After the first few, he knew that they were worthless but Rossetti was a kind man, he told the elderly man as gently as possible that the pictures were without much value and showed little talent. He was sorry, but he could not lie to the man. The man was disappointed, but seemed to expect Rossetti’s judgment.

The old man then apologized for taking up Rossetti’s time, but asked him to look at a few more drawings. Rossetti looked over the second batch of sketches and immediately became enthusiastic over the talent they revealed. “These,” he said, “Oh, these are good.”

“This young student has a great talent. He should be given every help and encouragement. He has a great future.” Rossetti could see that the old fellow was deeply moved.

“Who is this fine young artist?” he asked. ”Your son?” “No,” said the old man sadly.

“It is me - 40 years ago. If only I had heard your praise then! For you see, I got discouraged and gave up – too soon.”
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Wellness Blog
All About Calcium Carbide

• Under PFA Section 44AA, the use of calcium carbide for artificial ripening of mangoes, apple, plum, banana is prohibited and can attract both imprisonment and fine.

• Calcium carbide powder is usually kept wrapped in paper between the fruits (unripe mangoes) in a basket or box.

• Once the basket of mango is closed from the top, calcium carbide absorbs moisture and produces acetylene gas, which accelerates the ripening process of fruits.

• The health hazards are related to the gastrointestinal tract, kidney, heart, liver and brain and in the long-run, cancer.

• Calcium carbide is cheap and 1 kg of calcium carbide 1kg is sufficient to ripe 10 tons of fruit.

• How do we know that the fruit has been artificially ripened with calcium carbide?
o It will be less tasty.
o The aroma will be different
o It is uniform in color.
o The color of the mango changes from green to dark yellow.
o It will have a shorter shelf life.
o It will be overtly soft.
o There may be black patches on the mango skin.
o There may be multi color patches on the skin of the mango (Red, yellow, green patches)

• How should artificially ripened fruits be handled?
o Never eat off–season fruits, especially before time
o Rinse all fruits in running tap water for few minutes before use.
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Rabies News (Dr A K Gupta)
What is the criterion for "protection" after immunization?

The rabies virus neutralizing antibody (RVNA) titer of 0.5 IU/ml of serum in the vaccinated person is considered protective.

The facility for this test is available at NCDC, Delhi, CRI, Kasauli, Pasteur institute, Coonnor, NIV, Pune and NIMHANS, Bangalore
eIMA Quiz
How often should you have a Pap smear?
A. Once a year after puberty.
B. Once a year after either turning 21 or having sexual intercourse for the first time.
C. Once a year after age 21 and every two years after 30.
D. Once a year if you’re not in a monogamous relationship.
E. Once a year unless you’ve been vaccinated against the human papillomavirus (HPV). Then the screening is not necessary.

Yesterday’s Mind Teaser: When should you have your first cholesterol screening?
A. At age 10.
B. At age 20.
C. At age 35.
D. At age 40.
E. It depends on your risk factors.

Answer for Yesterday’s Mind Teaser: B. At age 20.
Correct Answers received from: Jayshree sen, jainendra upadhyay, dr k raju, dr pravin h patel, dr b r bhatnagar, dr madhusudhan g,
Answer for 8th August Mind Teaser: a. Ineffective health maintenance
Correct Answers received from: Dr.K.V.Sarma, Dr Poonam Chablani, Dr Jainendra Upadhyay
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Traffic policeman: "Didn’t you hear my whistle, madam?"
Woman driver: "Yes, but I don’t like flirting while I'm driving."
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Panchamrit body wash
Panchamrit is taken as a Prasadam and is also used to wash the deity. In Vedic language, anything which is offered to God can also be done to the human body. Panchamrit bath, therefore, is the original and traditionally full bath prescribed in Vedic literature. It consists of the following:
• Washing the body with milk and water, where milk acts like a soothing agent.
• Next is washing the body with curd, which is a substitute for soap and washes away the dirt from the skin.
• The third step is washing the body with desi ghee, which is like an oil massage.
• Fourth is washing the body with honey, which works like a moisturizer.
• Last step is to rub the skin with sugar or khand.
Sugar works as a scrubber. Panchamrit bath is much more scientific, cheaper and health friendly.
Press Release
A second attack of dengue is more dangerous

If you have suffered from dengue last year, you need to be more careful as the second attack of dengue may be more dangerous than the first attack, said Padma Shri Dr. B C Roy National Awardee & DST National Science Communication Awardee, Dr K Aggarwal, President Heart Care Foundation of India and Honorary Secretary General IMA

Elaborating on this, Dr. Aggarwal said that there are four different types of dengue and one can, therefore, suffer with dengue four times in his or her lifetime. The second or subsequent dengue infections tend to be more serious.

Dr. Aggarwal said that a person with dengue can also simultaneously suffer from malaria. Malaria and dengue together can lower platelet counts to a dangerous level leading to complications.

In a dengue season, nobody should take aspirin for fever as it can precipitate bleeding, he added.

In dengue most complications occur within two days of the fever subsiding and most people are casual during this period. Any type of abdominal pain, giddiness or weakness after the fever has subsided should be attended to, by a doctor. Dengue complications during this period are due to shift of blood volume and patient requires rapid infusion of oral or intravenous fluids in large quantity.

Dr. Aggarwal said that platelet transfusion is not required even if the count is as low as 10000 unless there is an associated bleeding.