March 11  2015, Wednesday
editorial
Diagnosis of hypertension in childhood requires repeated BP measurements
Dr KK AggarwalOne needs to confirm presence of hypertension based on three blood pressure measurements at separate clinical visits.

Normative BP percentiles are based upon data on gender, age, height, and blood pressure measurements from the National Health and Nutrition Examination Survey and other population–based studies.

In a study published in the journal Pediatrics, initial BP measurement was normal (below the 90th percentile), pre–hypertensive (systolic or diastolic BP between the 90th or 95th percentile) and hypertensive (systolic or diastolic BP =95th percentile) in 82, 13, and 5 percent of children.

At follow–up, subsequent hypertensive measurements were observed in only 4 percent of the 10,848 children who had initial hypertensive values. In the cohort, the overall prevalence of hypertension was 0.3 percent.
eMedipics IMA,IJCP,HCFI
CPR-10 Training Camp at Press Club-8th March 2014
News
  • Vegetarians appear to be at lower risk for colorectal cancer than nonvegetarians, suggests new research. Investigators noted that those who consumed a vegetarian diet had a 22% lower risk for all colorectal cancers than those who ate meat. The study was published online March 9 in JAMA Internal Medicine.
  • A study revealed that an intranasal formulation of oxytocin cut food consumption by an average of 122 kcal in a single-meal test involving 25 healthy men of varying body mass indexes. The results were presented March 8 at the annual meeting of the Endocrine Society, ENDO 2015.
  • The anti-interleukin-5 monoclonal antibody, reslizumab, reduces asthma exacerbations in patients with inadequately controlled asthma with elevated blood eosinophil counts, suggest results from two duplicate phase 3 trials published online in The Lancet Respiratory Medicine.
  • New research suggests that the lower a woman's vitamin D levels are as she transitions to menopause, the greater is her risk of sustaining a non-traumatic fracture. The findings are published online in the Journal of Clinical Endocrinology and Metabolism.
  • Patients who continue to take proton pump inhibitors (PPIs) after a first episode of Clostridium difficile infection may be at increased risk of recurrence, suggest new findings published online in JAMA Internal Medicine.
Dr KK Spiritual Blog
Why do we place our hands over the flame?

Flame is the "flame" of true knowledge. At the end of any aarti, we place our hands over the flame and then touch our eyes and the top of the head. It means "May the light that illuminated the Lord light up my vision; May my vision be divine and my thoughts noble and beautiful."

The metaphysical implication of aarti extends further. The sun, moon, stars, lightning and fire are the natural sources of light. The Lord is the source of these wondrous phenomena of the universe. It is due to Him alone that everything exists.

As we light up the Lord with the flame of the aarti, we turn our attention to the very source of all light which symbolizes knowledge and life. Also, the Sun is the presiding deity of the intellect, the moon, that of the mind, and fire, that of speech. The Lord is the supreme consciousness that illuminates all of them. Without Him, the intellect cannot think, the mind cannot feel and the tongue cannot speak. The Lord is beyond the mind, intellect and speech.

How can these finite entities illuminate the Lord? Therefore, as we perform the aarti we chant:

Na tatra suryo bhaati na chandra taarakam, Nemaa vidyuto bhaanti kutoyamagnib

Tameva bhaantam anubhaati sarvam, Tasya bhasa sarvam idam vibhaati


"He is there where the sun does not shine, nor the moon, stars and lightning. Then what to talk of this small flame (in my hand), everything (in the universe) shines only after the Lord, and by His light alone are we all illumined"

In our spiritual journey, even as we serve the guru and society, we should willingly sacrifice ourselves and all we have, to spread the "perfume" of love to all.

We often wait a long while to see the illuminated Lord. But, when the aarti is actually performed, our eyes close automatically as if to look within. This is to signify that each of us is a temple of the Lord.
IMA,IJCP,HCFI
Cardiology eMedinewS
  • A new study has suggested that among nondepressed or mildly depressed primary-practice patients, statin use is associated with a lower risk of major adverse cardiac events (MACE) at 3 years; however, in outpatients with newly diagnosed moderate to severe depression, antidepressant therapy is linked with a lower risk of this outcome. The study will be presented at the American College of Cardiology (ACC) 2015 Scientific Sessions.
  • Two new studies have suggested that testosterone therapy might not cause cardiovascular harm. Both the studies are scheduled for presentation at the American College of Cardiology (ACC) 2015 Scientific Sessions.
CPR Devices Approved for Paramedics
The FDA approved the ResQCPR System of two devices for use by first responders doing cardiopulmonary resuscitation (CPR) on people in cardiac arrest.

"When used together, the two devices may increase the amount of oxygenated blood circulated through a patient's body during CPR" versus the standard technique, the agency noted in announcing the approval.

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One portion of the system -- the ResQPump Active Compression Decompression CPR Device -- features a handle with two hand grips that attaches to the patient's chest with a toilet plunger-style suction cup so that paramedics can both push to deliver compressions and pull to actively decompress the chest with 10 to 20 lbs. of lift.

The device also has a pressure gauge and a timing mechanism to help maintain the recommended compression depth and rate.

The second device -- the ResQPod 16.0 Impedance Threshold Device -- fits onto the rescue face mask or breathing tube and impedes airflow into the chest during chest decompression for "preloading."

By reducing the pressure inside the patient's chest, it draws more blood back to the heart, the FDA explained, which can yield a greater volume of blood flowing out of the heart during the next compression to improve overall blood circulation compared with standard CPR.

The device was invented by a physician after caring for a patient whose family used a toilet plunger to resuscitate him, the Journal of Emergency Medical Services reported. (MedPage Today)
Pediatrics eMedinewS
  • Children born to women with untreated depression during pregnancy have increased risk for asthma, but prenatal exposure to most antidepressants does not further increase the risk, suggests a new study published online March 9 in Pediatrics.
  • Serious bacterial infection in children is increasingly healthcare-associated and resistant to empirical antibiotics, and the healthcare-associated bacteremia is associated with increased length of stay, suggests a new study published online March 9 in Pediatrics.
Event
IMA,IJCP,HCFI
Make Sure
Situation: Doctor, this patient has developed acute renal failure.

Reaction: Oh my God, I forgot that he was on furosemide. I gave him full dose of amikacin.

Lesson: Make sure, before calculating the dose of aminoglycoside (amikacin) that furosemide and other loop diuretics, which enhance its nephrotoxicity are not being administered to the patient.
Medicolegal
Dr Sudhir Gupta, Prof & Head, Forensic Medicine & Toxicology, AIIMS

What is the concept of Brain stem death?

Medullary neurons are most resistant to anoxia; if they are dead, then higher centers are also dead

There are three distinct schools of thought to diagnose death: (i) French school that is similar to Harvard (ii) English school that is similar to Harvard (iii) Austor–German school that includes Harvard criteria and bilateral serial angiography of internal carotid and vertebral artery criteria. A negative angiogram for more than 15 minutes proves death.
  • No spontaneous movement
  • Apnea when tested for a period of 4 min at a time
  • Absence of brainstem reflexes: (a) dilated and fixed pupil (b) absent corneal reflexes (c) absent Doll’s head phenomenon (d) absent cilospinal reflexes (e) absent gag reflex (f) absent vestibular response to caloric stimulation (g) absent tonic neck reflex
  • EEG not mandatory
  • Spinal reflex not important
  • All the findings above remain unchanged for at least 12 hours.
Brainstem death can be pronounced only if the pathological processes responsible for above are deemed irreparable with presently available means.

The basic teaching of the American school was not the brain, but brainstem death, after which there is the point of no return that should be equated as death. There were several reasons for this equation:
  • Medullary neurons are most resistant to anoxia, if they are dead then higher centers are also dead
  • Brainstem is responsible for the vital functions because it is the seat of respiratory and circulatory center
  • Brainstem is necessary for proper functioning of the cortex as all sensory and motor nerves pass through this gateway.
  • Immediately after an individual is put on respirator and other life support systems, a systemic examination is done to exclude the possibility of brainstem death. If Minnesota criteria are fulfilled, life support systems should be withdrawn and the person is to be declared dead.
Dr Good Dr Bad
Situation: A patient with skin diseases needed circumcision and wanted to know whether mediclaim covers it or not.

Dr. Bad: It will not be covered.

Dr. Good: It will be covered.

Lesson: Circumcision is excluded unless it is necessary for treatment of a disease.

(Copyright IJCP)
IJCP Book of Medical Records
IJCP’s ejournals
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eMedi Quiz
The exaggerated lepromin test seen in cases of Lucio phenomenon is called as:

a. Mitsuda's reaction
b. Medina-Ramirez reaction
c. Fischer's test
d. Fernandez reaction

Yesterday’s Mind Teaser: IRIS commonly occurs after how many weeks of ART initiation

a.1-4 week
b.2-12 weeks
c.12-24 weeks
d. After 6 months

Answer for yesterday’s Mind Teaser: b.2-12 weeks

Correct Answers received from: Raju Kuppusamy, Dr Gopal Shinde, Daivadheenam Jella, Dr Jainendra Upadhyay.

Answer for 9th March Mind Teaser: a. hemiplegia

Correct Answers receives: Dr Avtar Krishan, Daivadheenam Jella, Dr Shangarpawar, Dr Gopal Shinde, Dr Shangarpawar, Bouvi Ram.
Rabies News (Dr A K Gupta)
What is the role of monoclonal antibodies in rabies?

Monoclonal antibodies against rabies virus have been widely used in the diagnosis and immunological analysis of rabies. Human monoclonal antibodies to rabies virus G protein are also expected to be used as a replacement for rabies immunoglobulin (RIG) in the post–exposure treatment of rabies. In 1978, Wiktor reported the preparation of rabies virus monoclonal antibodies. Since then, rabies virus monoclonal antibody (mAb) technology has been more and more widely used in basic research and diagnosis of rabies.
CPR 10
Total CPR since 1st November 2012 – 101090 trained
Video of the Day
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

Kishan, SM Heart Care Foundation Fund, Post CHD Repair

Deepak, SM Heart Care Foundation Fund, CHD TOF
IMA NEWS
Dear Sir, This to inform you that Sri B Narayana Reddy, Advocate filed CRP No:3920/2014 on behalf of IMA (Hq).The said CRP was disposed of on 6/3/2015 by Hon'ble justice Dilip B Bhosale by directing the lower court to dispose the IA filed by three suspended members. Along with the CRP, justice Dilip B Bhosale also closed the contempt petition No:2151/2014 filed by members. Order copies will come in due course. With regards, Anil Kumar, Advocate.
Sonal Namaste
The SAVE LIVES: Clean Your Hands annual initiative is part of a major global effort led by the World Health Organization (WHO). It includes the "My Five Moments for Hand Hygiene", which define the key moments when healthcare workers should perform hand hygiene.

This evidence-based, field-tested approach is applicable in a wide range of settings. The WHO approach recommends HCWs clean their hands:
  • Before touching a patient
  • Before clean/aseptic procedures
  • After body fluid exposure/risk
  • After touching a patient
  • After touching patient surroundings
Media
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Inspirational Story
The Greatest Gift is Love

A woman came out of her house and saw three old men with long white beards sitting in her front yard. She did not recognize them.

She said, "I don’t think I know you, but you must be hungry. Please come in and have something to eat." "Is the man of the house home?" they asked. "No", she said. "He’s out." "Then we cannot come in", they replied. In the evening when her husband came home, she told him what had happened. "Go tell them I am home and invite them in!" The woman went out and invited the men in. "We do not go into a House together," they replied.

"Why is that?" she wanted to know. One of the old men explained: "His name is Wealth," he said pointing to one of his friends, and said pointing to another one, "He is Success, and I am Love." Then he added, "Now go in and discuss with your husband which one of us you want in your home."

The woman went in and told her husband what was said. Her husband was overjoyed. "How nice!!" he said. "Since that is the case, let us invite Wealth. Let him come and fill our home with wealth!" His wife disagreed. "My dear, why don’t we invite Success?"

Their daughter–in–law was listening from the other corner of the house. She jumped in with her own suggestion: "Would it not be better to invite Love? Our home will then be filled with love!" "Let us heed our daughter–in–law’s advice," said the husband to his wife. "Go out and invite Love to be our guest."

The woman went out and asked the 3 old men, "Which one of you is Love? Please come in and be our guest." Love got up and started walking toward the house. The other two also got up and followed him. Surprised, the lady asked Wealth and Success: "I only invited Love, Why are you coming in?"

The old men replied together: "If you had invited Wealth or Success, the other two of us would’ve stayed out, but since you invited Love, wherever He goes, we go with him. Wherever there is Love, there is also Wealth and Success!"
Wellness Blog
Add fiber to the diet only slowly

Fiber is a plant substance that is required for a healthy diet. Lots of fiber is needed each day to help reduce the risk of heart disease, improve digestion, prevent constipation and maintain a healthy body weight.

Fiber can be found in fruits, whole grains and vegetables. Most adults should eat at least 20 to 35 grams of fiber every day; though the doctors say most people only eat about half as much. It’s best to slowly increase the fiber in your diet instead of piling it on all at once. A sudden increase in fiber intake can cause abdominal discomfort.

Fiber intake should be at least 14 grams per 1000 calories daily; higher fiber intake may improve glycemic control. Saturated fat should be less than 7 percent of calories and there should be minimal trans fat. Total cholesterol should be less than 200 mg daily.

There is an average fall of 1.2/1.3 mmHg blood pressure with average 10 gram intake of fiber.

Certain soluble fibers (psyllium, pectin, wheat dextrin and oat products) reduce bad LDL cholesterol. Every gram increase in soluble fiber reduces LDL cholesterol by an average of 2.2 mg/dL. The message is incorporation of greater amounts of fiber, in which carbohydrate is derived from unprocessed whole foods.
Child Sexual Abuse: UNICEF, IMA join hands to help doctors identify, treat cases
By: Express News Service | Pune | Published on: March 10, 2015 2:48 am

UNICEF and the Indian Medical Association (IMA) have joined hands to help medical practitioners identify, report and treat cases of child sexual abuse.

Child sexual abuse is a widespread phenomenon and can cause life-long consequences on the physical and mental health of a child. In India, 4.5 per cent of girls aged between 15-19 have been subjected to sexual abuse. Boys are also exposed to sexual violence but to a less extent.

In 2012, India adopted the Protection of Children from Sexual Offences (POCSO) Act, a comprehensive law which defines a child as any person below the age of 18. The Act applies to all cases of sexual assault on a child and defines sexual offences as penetrative sexual assault (Section 3), (non-penetrative) sexual assault (Section 7), sexual harassment (Section 11) and use of a child for pornography (Section 13).

Announcing the special partnership, UNICEF India and IMA said they will equip medical practitioners with a detailed understanding of diverse facets of child sexual abuse (CSA), along with relevant legal provisions. Medical practitioners are often the first point of contact in a child sexual abuse case and are required to take prompt action to ensure immediate and effective treatment of the child.

The programme aims to build a nation-wide cadre of doctor-trainers who can later disseminate the knowledge at different levels. Under the supervision of IMA state branches, these doctor-trainers will take the training forward to state and district levels. To assist these trainers, UNICEF has provided technical support to IMA for the preparation of a teaching manual and key messages for doctors. The focus will be to inform and implement 10-key action points about child sexual abuse that every doctor should know while handling such cases.

“Medical professionals have a critical role to play in the prevention, detection and response to sexual offences against children,” said A Marthanda Pillai president, and Dr KK Aggarwal, secretary general, IMA.

“In a case of sexual assault on a child, it is the legal duty of a doctor to give medical care, collect forensic evidence, report the offence to the police and give testimony in court if required. Under Section 166B of the Indian Penal Code (IPC), a doctor who refuses to perform a medical examination in a case of sexual assault can be punished with imprisonment up to one year and/or fine,” added Dr Aggarwal.

Releasing the set of 10-key action points about child sexual abuse for medical practitioners, Dr Aggarwal said, “These messages will be distributed to more than 2.5 lakh doctors through 30 state level branches and 1,700 district branches of IMA.”

Launched by UNICEF as a global initiative, the ‘End Violence against Children’ campaign builds on the growing consensus that violence against children can no longer be tolerated and that serious attention and collective action are required to reduce violence against children.

Make DMC functional, demands IMC

Bindu Shajan Perappadan | The Hindu | New Delhi, March 9, 2015

The Indian Medical Association has complained that Delhi Medical Council (DMC) in spite of having completed formalities for elected and nominated members, the Gazette Notification still has not taken place.

Dr. K. K. Aggarwal, IMA honorary secretary general, said: “DMC office-bearers (2009-2014) whose term expired on 20th December, 2014, by default, is still carrying out functions.”

Delhi Medical Association (DMA) president Dr. Anil Goyal said DMC is without democratically elected body.

Giving details of the Council’s set-up Dr. Aggarwal said: “There are 23 members in DMC; of these eight were elected on 16th November, 2014 and another was elected on 22nd November, 2014.’

The Lt. Governor nominated 4 members on 22nd December, 2014; eight members from various medical colleges were elected before 20th December, 2014. Two are Director Health Services and Dean Universities as ex-officio members.

“Since 22nd January, 2015, the file cleared by Lt. Governor for Gazette Notification is still pending with the new AAP Government. IMA has written to the Chief Minister with no action so far. DMA representative also met the Chief Minister and the Health Minister with no result. IMA is seeking legal options also so that the democracy of DMC is maintained,’’’ noted Dr. Aggarwal.

DMC performs both regulatory as well as educational functions for the medical profession in Delhi.
IMA to frame guidelines for swine flu, dengue
Kavita Kishore | The Hindu | Chennai, March 9, 2015

With diseases like swine flu and dengue affecting the population across the country every year, the Indian Medical Association (IMA) is formulating a set of guidelines that will help the government prepare for disease outbreaks.

The guidelines will stress the need to standardise testing, vaccinations (if available), treatment and cost of medication for various disease outbreaks. According to K.K. Aggarwal, Secretary General, IMA, there is currently no government policy to deal with outbreaks and epidemics.

“Dengue, swine flu and other outbreaks should also be treated as a national calamity and the government should have a policy on how to deal with them,” he said, adding that the IMA would present its recommendations to the government soon. The IMA’s guidelines would insist that news and information about any outbreak should come only from a single source. “Different doctors are giving out varied information, which is adding to the panic about swine flu. When there is only one source for information, it will be more regulated,” Dr. Aggarwal added.

In terms of the pricing, the cost of vaccines, medication, and hospitalisation for all outbreaks should be covered by the Central Government Health Scheme, the guidelines state.

Speaking of the swine flu vaccine, Dr. Aggarwal said the government should have been prepared and apprised pharmaceutical companies of the potential demand several months earlier. “There are over 25 lakh healthcare workers in the country, but only several thousands of units of vaccine available,” he said.

Need for standardised testing, vaccinations, treatment and cost of medication for various disease outbreaks will be covered.
MEDICAL COUNCIL OF INDIA
No.MCI-211(2)(Gen.)/2014-Ethics/158215
Date: 11.02.2015

To

All the Principals/Deans of Medical Colleges,

Director Medical Education /Director General (Health) Services of All States

Principal-Secretary (Health/Medical Education of Al States)

Vice-Chancellors of all Universities

Registrar of all State Medical Councils

Sir,

It has been come to the notice of Medical Council of India that a number of doctors have presented themselves before the assessments conducted by MCI in various medical colleges and instances have been reported where the doctors were not actually working on permanent basis on the medical colleges but have only presented themselves for the purpose of inspection. Wherein a large number of such cases, MCI has taken action against the doctors, it is necessary for the State Medical Councils, Universities/Colleges and other medical institutions to issue necessary circulars in this regard.

This is a matter of serious nature and such practice undermine the quality of medical education in the country and MCI has taken serious nature and such practice as permissible under the Indian Medical Council (Professional Conduct, Etiquettes and Ethics) Regulations, 2002.

It is necessary that wide publicity be given under your jurisdiction informing and advising doctors to refrain from such practices and presenting themselves before inspection in various institutions at the time of inspection while not being on the permanent rolls of the medical colleges. It may also be clarified that as per MCI Regulations there is no system of part time/honorary teachers.

Action taken may be intimated to this office on priority basis.

24.02.2015
Yours faithfully
(Dr. Reena Nayyar)
Secretary I/C
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Quote of the Day
Start by doing what's necessary; then do what's possible; and suddenly you are doing the impossible. Francis of Assisi
Reader Response
Sir, 'The rule of 80' for a healthy living is marvelous. All the risk factors are taken care of in a simple methodology. Thanks & regards: Dr BV Sai Chandran
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IMA Humor
One day Paddy, an Irishman, goes into a pharmacy, reaches into his pocket and takes out a small Irish whiskey bottle and a teaspoon.

He pours some liquid onto the teaspoon and offers it to the pharmacist and says, "Could you taste this for me, please?"

The pharmacist takes the teaspoon, puts it in his mouth, swills the liquid around and swallows it.

"Does that taste sweet to you?" says Paddy.

"No, not at all," says the pharmacist.

"Oh that's a relief," says Paddy.
"The doctor told me to come here and get my urine tested for sugar."
March 12 is World Kidney Day: Kidney Health for All!
The prevalence of chronic kidney disease or CKD has increased in the past few years in India. Early diagnosis and management delays progression and improves outcomes.

Patients who have diabetes, high blood pressure, atherosclerotic heart disease, peripheral vascular disease and a family history of kidney failure are especially at high risk of developing CKD, said Padma Shri Awardee Dr A Marthanda Pillai National President IMA and Padma Shri, Dr B C Roy National Awardee & DST National Science Communication Awardee, Dr K K Aggarwal, President Heart Care Foundation of India and Honorary Secretary General IMA.

In its early stage, CKD has no symptoms – it is silent. This is also the stage when it is most treatable; hence, early diagnosis and intervention is very important. If left untreated, it can lead to kidney failure, they further added.

World Kidney Day is a joint initiative of the International Society of Nephrology (ISN) and the International Federation of Kidney Foundations (IFKF) to create awareness about the health of our kidneys. The theme this year is ‘Kidney Health for All’. In line with this theme, IMA released guidelines to reduce the risk of developing kidney disease.
  • If you have diabetes, keep your blood sugar level under control
  • Monitor and control your blood pressure with a goal of 140/90 mm Hg or less, if you are older than 60 years and have diabetes or CKD. In patients aged 60 years or above, who do not have diabetes or CKD, the goal blood pressure level is less than 150/90 mm Hg
  • Eat a healthy diet
  • Maintain a healthy body weight.
  • Reduce intake of salt.
  • Maintain a healthy fluid intake; if you have diarrhea, vomiting, or fever, drink adequate fluids to avoid dehydration
  • Exercise regularly
  • Quit smoking and use of other tobacco products; smoking reduces blood flow to the kidneys and may worsen kidney disease, which may already exist.
  • Avoid regular intake of over-the-counter pills such as painkillers as they can damage the kidneys
  • Get your kidney function checked if you are in the high risk group.