June 11  2015, Thursday
eMedinewS
editorial
e–cigarettes should be regulated
Dr KK Aggarwal The Indian Government should regulate sale of e–cigarettes. Electronic cigarettes are a new fad in the society. Not only adults, children too are getting hooked to them. They are easily available through Internet and can be ordered and purchased in Indian rupees.

In its policy statement on e-cigarettes, published in the journal Circulation, the American Heart Association has asked the federal government to ban the sale of e-cigarettes to minors on the lines of the ban of cigarettes and smokeless tobacco products. The report has shown concern about the industries marketing and advertising e–cigarettes to children.

In the US alone, there are 466 brands and 7764 unique flavors of e–cigarette products available. These flavors have been specifically designed to attract the youth.

For the youth, an e-cigarette is high–tech, interesting and cool. In the US and in the west, an alarming number of middle and high school children are experimenting with e–cigarettes. It has also been seen that in experimental e–cigarette users, converting to regular smoking is very high.

The efficacy of e–cigarettes as a primary smoking cessation therapy has not been established.
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World Environment Day observed by IMA HQs at IMA House
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News
  • The American Geriatrics Society (AGS) is updating its Beers Criteria, which help prevent adverse drug events in older adults. The society is removing its recommendation to avoid nitrofurantoin in patients with a creatinine clearance level under 60 mL/min. The final version is scheduled to be published in July this year.
  • After one hospitalization for diabetic ketoacidosis (DKA), patients had a 10% greater risk of dying within 5 years; however, the risk of dying within 6 years increased by 30% after more than four hospitalizations for DKA, suggested a study presented at the American Diabetes Association (ADA) 2015 Scientific Sessions.
  • Women between 50 and 69 years of age who participate in screening mammography have about a 40% reduction in the risk for death from breast cancer, suggested an update from the International Agency for Research on Cancer (IARC) Working Group published online in the New England Journal of Medicine.
  • The addition of a long-acting intravenous calcimimetic, AMG416, to standard care improves the management of secondary hyperparathyroidism in hemodialysis patients, suggests new research presented at the European Renal Association–European Dialysis and Transplant Association 52nd Congress.
  • The heavy, long-term use of cannabis is associated with negative changes in parts of the brain not previously implicated, and is linked to deficits in learning and memory, suggested new research presented at the Society of Nuclear Medicine and Molecular Imaging 2015 Annual Meeting.
Dr KK Spiritual Blog
Spiritual prescriptions learnt from patients

In a hospital practice, we all are a witness to suffering all the time. When we were young, in medical college, we quite often were disturbed seeing the sufferings of the people. But, in our practice, we have learnt many spiritual prescriptions from our patients. These have not only helped us to heal our patients but also changed our perception to health and sickness.

I recall Swami Bodhanand, a disciple of Swami Chinmayananda, was once hospitalized under our care. When I asked him to give me a spiritual message, he told me only two words "Detached Attachment". He said, "As a doctor you should behave like a lotus leaf. It is wet as long as a drop of water is there, but once the drop is out, the leaf is as dry as if the water was never there." The message was that "we should be attached to our patients as long as they are with us. The day they die, we should be completely detached from them or else we will not be able to treat other patients".

I saw another spiritual guru through our Chief Anesthetist. The fee he paid to me was a spiritual message "Suno Samjho Jano Karo – Hear Understand Wisdom and Do”. He said that hearing is different from listening, listening is different from wisdom and wisdom is different from doing. Unless you hear, understand what you have heard and implement, the learning has no value.

One of my Buddhist patients gave me a spiritual learning, which has helped me a lot in my routine clinical practice. He taught me the basic Buddhist message that there is suffering all over; there is a reason for every suffering and it is possible to maintain sufferings. This message fits into the main message of Hinduism and also the main teaching from Garud Purana.

In Hinduism, we know that the very fact that we are born in this life means that in our last life, we could not get liberation as Hinduism believes that after liberation you are not reborn. Not getting liberated in the last birth means that some sufferings were left in our life. The basic purpose of this birth, therefore, is to face sufferings. When the basic purpose of our birth is to face sufferings, then why suffer from these sufferings. Every time we suffer, we should thank God that he has reduced one more. The period in between two sufferings is called a happy period (Sukh). In fact that period is nothing but a period of rest given by God to us to prepare the body for next suffering. This as a concept of counseling helps my patients in managing most of their mental disturbances.

Sometimes not telling a patient that he is suffering from terminal cancer works. One of my patient’s father aged 83 years was found to have extensive cancer of the prostate. Medically, we all gave him three months’ to live. My patient did not have the courage to tell his father or the family members that he (the father) had extensive cancer. He took me into confidence and played a game with the family. We gathered all the family members and told them that with the surgery this cancer had been cured. A party was organized in the evening to celebrate the cure. The magic happened; he lived almost a symptom–free life for the next 9 years. I have tried this on many of my patients thereafter and it works. The probable explanation was loss of fear of death, a confidence in his doctor and faith in himself.

The way to live up to the age of hundred is to go on working in life. My great grand–father–in–law was 75 years old, when I got married. That year, he gathered all family members across the world and said that his purpose of life was over and, he would like a collective family photograph and like to quit the world. Nothing happened for a year and on 20th July next year, he again played behaved the same way. Family from across the world gathered but he remained alive for another year. This went on for three years. Suddenly, we played a spiritual trick on him and told everyone to convince him that he is going to live for 100 years as he has many more work of the family to be done. Every year, we gave him law students from within the family to be taught (he was a lawyer himself), or gave him the responsibility of finding a boy for some eligible girl in the family. We made him teach and search for suitable bride/bridegrooms for years together and he actually died at the age of 100 years. This is the beauty of positive attitude in life.
Cardiology eMedinewS
  • Myocardial scintigraphy - molecular imaging of the heart - can be used to predict major adverse cardiac events (MACE) in patients with transthyretin-type amyloidosis, suggests a new study presented at the Society of Nuclear Medicine and Molecular Imaging 2015 Annual Meeting.
  • A study, presented at the American Diabetes Association (ADA) 2015 Scientific Sessions, revealed that patients with type 2 diabetes have nearly a twofold higher prevalence of heart failure when compared with matched controls.
Pediatrics eMedinewS
  • Prenatal maternal hemoglobin (Hb) levels appear to be related to early motor function in offspring, suggests new research published online June 8 in Pediatrics.
  • Delivering surfactant through a thin endotracheal catheter during continuous-positive airway pressure (CPAP) is a promising treatment for the extremely preterm infant in respiratory distress, reported a new trial published online June 8 in JAMA Pediatrics.
Make Sure
Situation: A patient on dialysis and on oral antacid developed aluminum toxicity.
Reaction: Oh my God! You should have put him on magaldrate preparations?
Lesson: Make sure to remember that magaldrate preparations do not cause aluminum toxicity in patients undergoing dialysis.
Dr Good Dr Bad
Situation:A man who was to be married was found to be HIV–positive. 
Dr Bad: Keep the report secret. 
Dr Good: I will inform the girl you are marrying. 
Lesson: Sections 269 and 270 of the Indian Penal Code provide as under: "269. Negligent act likely to spread infection of disease dangerous to life – whoever unlawfully or negligently does not act which is, and which he knows or has reason to believe to be, likely to spread the infection of any disease dangerous to life, shall be punished with imprisonment of either description for a term which may extend to six months, or with fine, or with both.

(Copyright IJCP)
Events
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eMedi Quiz
A 64-year-old old hypertensive obese female was undergoing surgery for fracture femur under general anesthesia. Intra operatively her end-tidal carbon-dioxide decreased to 20 from 40mm of Hg. followed by hypotension and oxygen saturation of 85%. What could be the most probable cause?

1. Fat embolism.
2. Hypovolemia.
3. Bronchospasm.
4. Myocardial infarction.

Yesterday’s Mind Teaser: At the end of a balanced anaesthesia technique with non-depolarizing muscle relaxant, a patient recovered spontaneously from the effect of muscle relaxant without any reversal. Which is the most probable relaxant the patient had received?

1. Pancuronium.
2. Gallamine.
3. Atracurium.
4. Vecuronium.

Answer for yesterday’s Mind Teaser: 3. Atracurium.

Correct Answers received from:: Dr Jainendra Upadhyay, Dr Jainendra Upadhyay, Daivadheenam Jella, Dr K Raju, Dr Poonam Chablani.

Answer for 9th June Mind Teaser: 4. Oxygen affinity of haemoglobin.

Correct Answers received: Dr K Raju, Dr Jainendra Upadhyay, Dr K V Sarma, Tukaram Pagad, Dr Poonam Chablani, Dr Amit Desai, Dr K C Sharma, Dr G Madhusudhan, Daivadheenam Jella.
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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
eIMA News
  • Chronic HBV infection, estimated to affect > 350 million people worldwide, is a substantial source of morbidity and mortality from cirrhosis and hepatocellular carcinoma. The ongoing cycle of transmission of HBV from an infected mother to her newborn during the perinatal period is an important source of infection.
  • Estimated glomerular filtration rate and albuminuria independently predict cardiovascular mortality and heart failure, according to a meta-analysis of individual data from more than 600,000 study participants published online  May 28 in the Lancet Diabetes and Endocrinology.
  • The overall prevalence of gout was 24.3%, and increased from 16.0% in those with eGFR ≥60 mL/min/1.73 m2 to 35.6% in those with eGFR <30 (Nephrol Dial Transplant. 2015;30(4):613-621).
  • A person is said to be prediabetic if he/she has a blood glucose abnormality indicating a risk of becoming diabetic: A fasting blood glucose level greater than 110 mg/dL (the cutoff is set at 100 mg/dL by the American Diabetes Association [ADA], up to 125 mg/dL); or a 2-hour blood glucose level greater than 140 mg/dL (up to 199 mg/dL) during an oral glucose tolerance test, in which case one speaks of glucose intolerance.
  • ADA Update: The addition of ranolazine (Ranexa, Gilead Science), an agent approved in the US for first-line use in angina or as an add-on therapy to other antianginal agents, significantly lowered HbA1c levels in type 2 diabetes patients when used as a monotherapy or when added to the sulfonylurea glimepiride.
  • Whole-brain radiotherapy (WBRT) should be avoided in patients with a limited number of brain metastases because it does not prolong survival, it reduces quality of life, and it causes cognitive decline (American Society of Clinical Oncology (ASCO) 2015 Annual Meeting).
  • The dipeptidyl peptidase 4 inhibitor (DPP-4) sitagliptin had a neutral impact on cardiovascular risk compared with placebo as part of usual care, an FDA-mandated outcomes trial has shown.
  • Biosimilars are large, complex drugs designed and proven to be very similar to existing biologic drug products. They are used in conditions where there are already biologic drugs being used. This includes the treatment of cancer and inflammatory diseases. The biggest advantage is that they may lower the cost of treatment. If they are good enough for the regulators, they are good enough for the patients.
  • The US FDA has released final regulations that, by the end of 2016, will end the practice of lacing feed for cows, hogs, poultry, and other animals with medically important antibiotics to promote animal growth. The use of antibiotics to treat bona fide health problems in livestock will come under the supervision of veterinarians.
Media
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Inspirational Story
Let the Light Shine

Bill was driving home one evening, on a two–lane country road. Work, in this small Midwestern community, was almost as slow as his beat–up Pontiac, but he never quit looking. Ever since the factory closed, he'd been unemployed, and with winter raging on, the chill had finally hit home.

It was a lonely road. Not very many people had a reason to be on it, unless they were leaving. Most of his friends had already left. They had families to feed and dreams to fulfill, but he stayed on.

After all, this was where he buried his mother and father. He was born here and knew the country. He could go down this road blind, and tell you what was on each side, and with his headlights not working, that came in handy.

It was starting to get dark and light snow flurries were coming down. He’d better get a move on. You know, he almost didn’t see the old lady, stranded on the side of the road. But even in the dim light of day, he could see she needed help.

So he pulled up in front of her Mercedes and got out. His Pontiac was still sputtering when he approached her. Even with the smile on his face, she was worried. No one had stopped to help for the last hour or so. Was he going to hurt her? He didn’t look safe, he looked poor and hungry.

He could see that she was frightened, standing out there in the cold. He knew how she felt. It was that chill that only fear can put in you. He said, "I’m here to help you ma’am. Why don’t you wait in the car where it’s warm? By the way, my name is Bill." Well, all she had was a flat tire, but for an old lady, that was bad enough. Bill crawled under the car looking for a place to put the jack, skinning his knuckles a time or two. Soon he was able to change the tire, but he had to get dirty and his hands hurt.

As he was tightening up the lug nuts, she rolled down her window and began to talk to him. She told him that she was from St. Louis and was only just passing through. She couldn't thank him enough for coming to her aid.

Bill just smiled as he closed her trunk. She asked him how much she owed him. Any amount would have been all right with her. She had already imagined all the awful things that could have happened had he not stopped.

Bill never thought twice about the money. This was not a job to him. This was helping someone in need, and God knows there were plenty who had given him a hand in the past. He had lived his whole life that way, and it never occurred to him to act any other way.

He told her that if she really wanted to pay him back, the next time she someone who needed help, she could give that person the assistance that they needed, and Bill added "…and think of me". He waited until she started her car and drove off. It had been a cold and depressing day, but he felt good as he headed for home, disappearing into the twilight.

A few miles down the road the lady saw a small cafe. She went in to grab a bite to eat, and take the chill off before she made the last leg of her trip home. It was a dingy looking restaurant. Outside were two old gas pumps. The whole scene was unfamiliar to her.

The cash register was like the telephone of an out of work actor-it didn't ring much. Her waitress came over and brought a clean towel to wipe her wet hair. She had a sweet smile, one that even being on her feet for the whole day couldn’t erase.

The lady noticed that the waitress was nearly eight months pregnant, but she never let the strain and aches change her attitude. The old lady wondered how someone who had so little could be so giving to a stranger. Then she remembered Bill.

After the lady finished her meal and the waitress went to get her change from a hundred dollar bill, the lady slipped right out the door. She was gone by the time the waitress came back. She wondered where the lady could be, and then she noticed something written on a napkin.

There were tears in her eyes, when she read what the lady wrote. It said, "You don’t owe me a thing, I’ve been there too. Someone once helped me out, the way I’m helping you. If you really want to pay me back, here’s what you do… "Don’t let the chain of love end with you." Well, there were tables to clear, sugar bowls to fill, and people to serve, but the waitress made it through another day.

That night when she got home from work and climbed into bed, she was thinking about the money and what the lady had written. How could she have known how much she and her husband needed it? With the baby due next month, it was going to be hard. She knew how worried her husband was, and as he lay sleeping next to her, she gave him a soft kiss and whispered in a soft, and low voice, "Everything’s going to be all right; I love you Bill."
Wellness Blog
Heart risks detected by age 7 in overweight kids

Children at risk of future obesity should be examined for body mass index rebound.

BMI rebound is the age at which body mass index (BMI) reaches its lowest point before increasing through later childhood, adolescence and adulthood.

An earlier BMI rebound age is associated with adverse risk factors for heart disease as measured at age 7: higher BMI, higher systolic and diastolic blood pressures, higher serum insulin and leptin levels, higher left ventricular mass and left atrial size.

Early BMI rebound age for children is lower than 4.4 years for boys and 4.2 years for girls. Normal values are 4.4 to 6.6 years for boys and 4.2 to 5.7 years for girls.

All children who start gaining weight between 3–4 years should be classified as a high risk for future diabetes and heart disease.
IMA Humor
Wonderful confession by a girl in church and amazing reply she got.

She: I am in love with a boy who is far away from me.

I’m in India and he lives in UK.

We met on marriage website.
Became friends on FaceBook.
Had long chats on WhatsApp.
Proposed each other on Skype.
And now 2 months of relationship through Viber.
I need your blessings and good wish, Oh God.

Guy besides her said: Now get married on Twitter.
Have fun on Tango.
Buy your kids from eBay.
Send them through Gmail.
And if you are fed up with your husband or kids then, unko OLX pe bech de…
Quote of the Day
You are never too old to set another goal or to dream a new dream. CS Lewis
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Reader Response
  • Dear Dr Aggarwal, Congratulations to you and IMA on inauguration of Generic drugs store at IMA HQs: Regards, Rahul Gupta.
  • Congratulations for this good initiative. Best wishes and regards, Chandrakant.
  • Respected Sir, Grand salute to you and IMA HQs for making good efforts in reducing financial burden of common man by launching the Jan Aushadhi store. This proves that IMA is not only concerned about health but also about social welfare of community. A real good effort to boost up the doctor patient relationship and uplift the image of doctors in the society. Long Live IMA. Dr Sofiya Ansari
  • Congratulations Dr KK Aggarwal and IMA team!  Very proud of your achievements. I agree with your branding by India and IMA on all relief efforts Best wishes: Rajeev
  • Dear Dr Aggarwal, I am a regular reader of all your articles being published here. The inspirational stories are very touching. Please publish a collection of it. All the best. Regards: Dr Himanshu
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Press Release
Exercise: a prescription

Stating why one should do exercises 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 laid down a few facts about exercise.
 
  • Exercise reduces the chances of getting heart disease. For those who already have heart disease, exercise reduces the chances of dying from it.
  • Exercise lowers the risk of developing hypertension and diabetes.
  • Exercise reduces the risk for colon cancer and some other forms of cancer.
  • Exercise improves mood and mental functioning.
  • Exercise keeps the bones strong and joints healthy.
  • Exercise helps you to maintain a healthy weight.
  • Exercise helps maintain independence into later years
  • Age is no bar; there is abundant evidence that exercise can enhance health and well-being. But today, TV watching, surfing the Internet, or playing computer and video games is replacing the helpful exercises for most people.
  • The minimum threshold for good health is to burn at least 700 to 1,000 calories a week through physical pursuits.
  • Exercise improves health and can extend life. Adding as little as 30 min of moderately intense daily physical activity can help one avoid a host of serious diseases, including heart disease, diabetes, depression, and several types of cancer, particularly breast and colon cancers.
  • Regular exercise can also help one sleep better, reduce stress, control weight, brighten mood, sharpen mental functioning, and improve sex life.
According to Harvard researchers, a well-rounded exercise program must have all the following four components:
  • Aerobic activity is the centrepiece of any fitness program. Most benefits of exercise revolve around aerobic cardiovascular activity, which includes walking, jogging, swimming, and cycling. One should work out at moderate intensity when performing aerobic exercise; brisk walking that quickens the breathing is one example. This level of activity is safe. 
  • Strength training protects bone. Strength or resistance training, such as elastic-band workouts and the use of weight machines or free weights, are important for building muscle and protecting bone. Bones lose calcium and weaken with age, but strength training can help slow or sometimes even reverse this trend.
  • Flexibility exercises ease back pains. Muscles tend to shorten and weaken with age. Shorter, stiffer muscle fibres make one vulnerable to injuries, back pain and stress. But regularly performing exercises that isolate and stretch the elastic fibres surrounding the muscles and tendons can counteract this process. Stretching improves posture and balance.
  • Balancing exercises prevents fall. Balance erode over time, and regularly performing balance exercises is one of the best ways to protect against falls that lead to temporary or permanent disability. Balance exercises take only a few minutes and often fit easily into the warm-up portion of a workout. Many strength-training exercises also serve as balance exercises. Or balance-enhancing movements may simply be woven into other forms of exercise, such as tai chi, yoga, and Pilates.
Rabies News (Dr A K Gupta)
How is rabies transmitted?

Rabies is transmitted by infected secretions. Most commonly, transmission to humans takes place through exposure to saliva following a bite by an infected animal. Rabies virus can be excreted in saliva, urine, nasal discharge and respiratory secretions.
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