June 12  2015, Friday
eMedinewS
editorial
Woman delivers baby after ovarian tissue transplant
Dr KK Aggarwal Researchers released the first-ever case report of a patient who carried a pregnancy to term after her ovaries were removed as a teenager and then reattached as an adult, reports MedPage.

Isabelle Demeestere, of the Université Libre de Bruxelles in Belgium, and colleagues reported that a 27 year-old woman whose ovarian tissue was cryogenically preserved when she was 14 years of age had a successful ovarian graft and finally, more than 2 years later, a spontaneous pregnancy and the birth of a healthy baby. Reporting the case in the journal Human Reproduction, the researchers wrote that this was the first instance of a live birth following transplantation of ovarian tissue that was harvested prior to a patient beginning menstruation.
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“World No Tobacco Day” Observed by IMA, Nagpur Branch
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News
  • Statin use is associated with a significant reduction in cancer mortality, report two separate studies, one in women and the other in men. Both the studies were presented at the American Society of Clinical Oncology (ASCO) 2015 Annual Meeting.
  • Lithium, the cornerstone treatment for bipolar disorder, is associated with a decline in renal function, hypothyroidism, and hypercalcemia, suggests new research published online in the Lancet.
  • A personalized exercise program integrated into routine dialysis can improve strength, endurance, and quality of life, suggested new research presented at the European Renal Association–European Dialysis and Transplant Association 52nd Congress.
  • Individuals with sleep apnea tend to have a greater rate of on-the-job injuries when compared with workers who did not have sleep-related breathing disorders, suggests new research presented at the annual meeting of the Associated Professional Sleep Societies.
  • Brain inflammation caused by chronic nerve pain can affect signaling in the regions of the brain associated with mood and motivation, suggests new research published in the Journal of Neuroscience.
Dr KK Spiritual Blog
Ganesha, the Stress Management Guru

If Lord Krishna was the first counselor who taught the principles of counseling, Lord Ganesha taught us the principles of stress management.

We should worship Lord Ganesha and become like him whenever we face any difficulty or are stressed out.

The elephant head of Lord Ganesha symbolizes that when in difficulty, use your wisdom, intelligence and think differently. It can be equated to the Third Eye of Lord Shiva. Elephant is supposed to be the most intelligent animal in the kingdom. Here, wisdom means to think before speaking. Lord Buddha also said that don’t speak unless it is necessary and is truthful and kind.

The big elephant ears of Lord Ganesha signify listening to everybody when in difficulty. Elephant ears are known to hear long distances. Elephant eye see a long distance and in terms of mythology, it denotes acquiring the quality of foreseeing when in difficulty. The mouth of Lord Ganesha represents speaking less and hearing and listening more.

The big tummy of Lord Ganesha represents digesting any information gathered by listening to people in difficulty. The trunk denotes using the power of discrimination to decide from the retained information. It also indicates doing both smaller and bigger things by yourself. The elephant trunk can pick up a needle as well as a tree.

The teeth, broken and unbroken, signify to be in a state of balance in loss and gain. This implies that one should not get upset if the task is not accomplished and also not get excited if the task is accomplished. In times of difficulty, Ganesha also teaches us not to lose strength and control one’s attachments, desires and greed.

The four arms of Lord Ganesha represent strength. Ropes in two hands indicate attachment; Laddoo or Sweet in one hand represents desires and mouse represents greed. Riding over the mouse indicates controlling one’s greed.

Lord Ganesha is worshipped either when a new work is initiated or when one finds it difficult to complete a job or work. In these two situations, these principles of Lord Ganesha need to be inculcated in one’s habits.
Wellness Blog
FODMAPS free diet

Symptoms of IBS and inflammatory bowel disease may be at least in part related to impaired absorption of carbohydrates.

Fermentable oligo–, di– and monosaccharides and polyols (FODMAPs) in patients with IBS or IBD may enter the distal small bowel and colon where they are fermented, leading to symptoms and increased intestinal permeability (and possibly inflammation).

Examples of FODMAPs include:
  • Fructans or inulins (wheat, onions, garlic, and artichokes)
  • Galactans (beans, lentils, legumes, cabbage, and Brussels’ sprouts)
  • Lactose (dairy)
  • Fructose (fruits, honey, high fructose corn syrup)
  • Sorbitol
  • Xylitol
  • Mannitol
  • Polyols (sweeteners containing sorbitol, mannitol, xylitol, maltitol, stone fruits such as avocado, apricots, cherries, nectarines, peaches, plums)
Avoidance of carbohydrates has been a long–popularized non–pharmacologic approach to reducing symptoms in IBS (and possibly modifying disease in IBD).
Cardiology eMedinewS
  • Proton pump inhibitors (PPIs) appear to have a negative effect on vascular function, thus increasing the risk for myocardial infarction (MI) in the general population, suggested a data-mining study published online June 10 in PLoS One.
  • The Endocrinologic and Metabolic Drugs Advisory Committee (EMDAC) of the US FDA voted 11-4 to recommend that the PCSK9 inhibitor evolocumab may be appropriate for some groups, stating that the drug's cholesterol-lowering benefits exceeded its risk in one or more populations.
Pediatrics eMedinewS
  • New research looking at fetal stem cells has found that in utero, an obese mother may program a child's cells to accumulate extra fat or develop different metabolic patterns that could later lead to insulin resistance. The findings were presented at the American Diabetes Association 2015 Scientific Sessions.
  • The rotavirus vaccine appears to have been highly effective in reducing all-cause gastroenteritis hospitalizations among young children and the benefit has increased over time, suggests new research published in the June 9 issue of JAMA.
Make Sure
Situation: A patient with dengue fever developed shock.

Reaction: Oh my God! Why did you ignore the 90/80 blood pressure?

Lesson: Make sure that a pulse pressure of less than 20 is not ignored in patients with dengue; it is an impending sign that the patient is going into shock.
Dr Good Dr Bad
Situation:A patient with albumin in the urine was to go for bypass surgery.

Dr Bad: There is no risk. 

Dr Good: There is a risk of kidney injury. 

Lesson:
 A simple urine test for presence of proteins before heart surgery can predict which patients may develop kidney–related complications. A study reported in J Am Soc Nephrol. 2011 Jan;22(1):156-63 concluded that preoperative proteinuria is a predictor of cardiac surgery-associated acute kidney injury  among patients undergoing CABG.

(Copyright IJCP)
eMedinewS Humor
Jealousy

The guy approached a beautiful looking woman in a mall and asked, "You know, I’ve lost my wife here in the mall. Can you talk to me for a couple of minutes?"

"Why?" she asks.

"Because every time I talk to a beautiful woman, my wife appears out of nowhere."
Inspirational Story
The House with the Golden Windows

The little girl lived in a small, very simple, poor house on a hill. She would play in the small garden and as she grew she was able to see over the garden fence and across the valley to a wonderful house high on the hill – and this house had golden windows, so golden and shining that the little girl would dream of how magic it would be to grow up and live in a house with golden windows instead of an ordinary house like hers.

And although she loved her parents and her family, she yearned to live in such a golden house and dreamed all day about how wonderful and exciting it must feel to live there.

When she got to an age where she gained enough skill and sensibility to go outside her garden fence, she asked her mother if she could go for a bike ride outside the gate and down the lane. After pleading with her, her mother finally allowed her to go, insisting that she kept close to the house and didn’t wander too far. The day was beautiful and the little girl knew exactly where she was heading! Down the lane and across the valley, she rode her bike until she got to the gate of the golden house across on the other hill.

As she dismounted her bike and leaned it against the gate post, she focused on the path that led to the house and then on the house itself…and was so disappointed as she realized all the windows were plain and rather dirty, reflecting nothing other than the sad neglect of the house that stood derelict.

So sad she didn’t go any further and turned, heartbroken as she remounted her bike… As she glanced up she saw a sight to amaze her…there across the way on her side of the valley was a little house and its windows glistened golden …as the sun shone on her little home.

She realized that she had been living in her golden house and all the love and care she found there was what made her home the ‘golden house’. Everything she dreamed was right there in front of her nose!
Quote of the Day
Success is no accident. It is hard work, perseverance, learning, studying, sacrifice and most of all, love of what you are doing or learning to do. Pelé
Events
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eMedi Quiz
A lesion of ventrolateral part of spinal cord will lead to loss (below the level of lesion) of:

1. Pain sensation on the ipsilateral side.
2. Proprioception on the contralateral side.
3. Pain sensation on the contralateral side.
4. Proprioception on the ipsilateral side.

Yesterday’s Mind Teaser: 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.

Answer for yesterday’s Mind Teaser: 2. Hypovolemia.

Correct Answers received from: Dr K Raju, Dr Poonam Chablani, Daivadheenam Jella, Kapil Roy, Dr N SRI HARI, Dr G Madhusudhan, Dr K C Sharma.

Answer for 10th June Mind Teaser: 3. Atracurium.

Correct Answers received: Dr Jainendra Upadhyay, Dr Jainendra Upadhyay, Daivadheenam Jella, Dr K Raju, Dr Poonam Chablani.
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Rabies News (Dr A K Gupta)
Is there a need to alter the dose or schedule of any concomitant medication during IDRV?

There is no need to alter the dose or schedule of any concomitant medication during IDRV.
IJCP Book of Medical Records
IJCP’s ejournals
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
  • An FDA advisory committee voted 13-3 on Tuesday in favor of recommending approval for alirocumab (Praluent), an injectable cholesterol-lowering agent.
  • The target population includes statin-intolerant patients or those "for whom a statin is not considered clinically appropriate." 
  • PCSK9 inhibitors such as alirocumab work by identifying and knocking out PCSK9 enzymes in the liver. This action lowers the amount of low density lipoprotein (LDL) cholesterol in the blood, potentially reducing the risk of clogged arteries and heart attacks.
Documents reaffirmed by the 200TH Council Session
WMA Declaration of Lisbon on the Rights of the Patient

Adopted by the 34th World Medical Assembly, Lisbon, Portugal, September/October 1981
and amended by the 47th WMA General Assembly, Bali, Indonesia, September 1995
and editorially revised by the 171st WMA Council Session, Santiago, Chile, October 2005
and reaffirmed by the 200th WMA Council Session, Oslo, Norway, April 2015


PREAMBLE

The relationship between physicians, their patients and broader society has undergone significant changes in recent times. While a physician should always act according to his/her conscience, and always in the best interests of the patient, equal effort must be made to guarantee patient autonomy and justice. The following Declaration represents some of the principal rights of the patient that the medical profession endorses and promotes. Physicians and other persons or bodies involved in the provision of health care have a joint responsibility to recognize and uphold these rights. Whenever legislation, government action or any other administration or institution denies patients these rights, physicians should pursue appropriate means to assure or to restore them.

PRINCIPLES
  1. Right to medical care of good quality
    • Every person is entitled without discrimination to appropriate medical care.
    • Every patient has the right to be cared for by a physician whom he/she knows to be free to make clinical and ethical judgements without any outside interference.
    • The patient shall always be treated in accordance with his/her best interests. The treatment applied shall be in accordance with generally approved medical principles.
    • Quality assurance should always be a part of health care. Physicians, in particular, should accept responsibility for being guardians of the quality of medical services.
    • In circumstances where a choice must be made between potential patients for a particular treatment that is in limited supply, all such patients are entitled to a fair selection procedure for that treatment. That choice must be based on medical criteria and made without discrimination.
    • The patient has the right to continuity of health care. The physician has an obligation to cooperate in the coordination of medically indicated care with other health care providers treating the patient. The physician may not discontinue treatment of a patient as long as further treatment is medically indicated, without giving the patient reasonable assistance and sufficient opportunity to make alternative arrangements for care.
  2. Right to freedom of choice
    • The patient has the right to choose freely and change his/her physician and hospital or health service institution, regardless of whether they are based in the private or public sector.
    • The patient has the right to ask for the opinion of another physician at any stage.
  3. Right to self-determination
    • The patient has the right to self-determination, to make free decisions regarding himself/herself. The physician will inform the patient of the consequences of his/her decisions.
    • A mentally competent adult patient has the right to give or withhold consent to any diagnostic procedure or therapy. The patient has the right to the information necessary to make his/her decisions. The patient should understand clearly what is the purpose of any test or treatment, what the results would imply, and what would be the implications of withholding consent.
    • The patient has the right to refuse to participate in research or the teaching of medicine.
  4. The unconscious patient
    • If the patient is unconscious or otherwise unable to express his/her will, informed consent must be obtained whenever possible, from a legally entitled representative.
    • If a legally entitled representative is not available, but a medical intervention is urgently needed, consent of the patient may be presumed, unless it is obvious and beyond any doubt on the basis of the patient's previous firm expression or conviction that he/she would refuse consent to the intervention in that situation.
    • However, physicians should always try to save the life of a patient unconscious due to a suicide attempt.
  5. The legally incompetent patient
    • If a patient is a minor or otherwise legally incompetent, the consent of a legally entitled representative is required in some jurisdictions. Nevertheless the patient must be involved in the decision-making to the fullest extent allowed by his/her capacity.
    • If the legally incompetent patient can make rational decisions, his/her decisions must be respected, and he/she has the right to forbid the disclosure of information to his/her legally entitled representative.
    • If the patient's legally entitled representative, or a person authorized by the patient, forbids treatment which is, in the opinion of the physician, in the patient's best interest, the physician should challenge this decision in the relevant legal or other institution. In case of emergency, the physician will act in the patient's best interest.
  6. Procedures against the patient's will Diagnostic procedures or treatment against the patient's will can be carried out only in exceptional cases, if specifically permitted by law and conforming to the principles of medical ethics.
  7. Right to information
    • The patient has the right to receive information about himself/herself recorded in any of his/her medical records, and to be fully informed about his/her health status including the medical facts about his/her condition. However, confidential information in the patient's records about a third party should not be given to the patient without the consent of that third party.
    • Exceptionally, information may be withheld from the patient when there is good reason to believe that this information would create a serious hazard to his/her life or health.
    • Information should be given in a way appropriate to the patient's culture and in such a way that the patient can understand.
    • The patient has the right not to be informed on his/her explicit request, unless required for the protection of another person's life.
    • The patient has the right to choose who, if anyone, should be informed on his/her behalf.
  8. Right to confidentiality
    • All identifiable information about a patient's health status, medical condition, diagnosis, prognosis and treatment and all other information of a personal kind must be kept confidential, even after death. Exceptionally, descendants may have a right of access to information that would inform them of their health risks.
    • Confidential information can only be disclosed if the patient gives explicit consent or if expressly provided for in the law. Information can be disclosed to other health care providers only on a strictly "need to know" basis unless the patient has given explicit consent.
    • All identifiable patient data must be protected. The protection of the data must be appropriate to the manner of its storage. Human substances from which identifiable data can be derived must be likewise protected.
  9. Right to Health Education
    Every person has the right to health education that will assist him/her in making informed choices about personal health and about the available health services. The education should include information about healthy lifestyles and about methods of prevention and early detection of illnesses. The personal responsibility of everybody for his/her own health should be stressed. Physicians have an obligation to participate actively in educational efforts.
  10. Right to dignity
    • The patient's dignity and right to privacy shall be respected at all times in medical care and teaching, as shall his/her culture and values.
    • The patient is entitled to relief of his/her suffering according to the current state of knowledge.
    • The patient is entitled to humane terminal care and to be provided with all available assistance in making dying as dignified and comfortable as possible.
  11. Right to religious assistance The patient has the right to receive or to decline spiritual and moral comfort including the help of a minister of his/her chosen religion.
News
  • For sleep-deprived night owls, eating less during late night hours may help curb the deficits in concentration and alertness that accompany sleep deprivation. Senior investigator David F. Dinges, PhD, head of the Division of Sleep and Chronobiology, University of Pennsylvania Perelman School of Medicine (UPenn), Philadelphia, noted that adults consume approximately 500 additional calories during late-night hours when they are sleep (Medscape).
  • The role of adalimumab for treatment of Crohn’s disease is evolving, and its use is becoming more widespread based on the efficacy data above and evidence that its use is cost-effective. One should advance to anti-tumor necrosis factor (TNF)-alpha therapy (including adalimumab or infliximab) in patients who have demonstrated failure or intolerance to a course of glucocorticoids and/or immunosuppressive agents, who are steroid dependent despite immunosuppressants, or who have failed glucocorticoids and are too sick to wait for the effects of methotrexate or azathioprine.
  • Bioresorbable vascular scaffolds (BVS), which do not have a metal stent backbone, have been developed with the hope of lowering the rate of clinical restenosis following percutaneous coronary intervention with stenting. In the EVERBIO II trial, 240 patients with stable or unstable disease were randomly assigned in a 1:1:1 ratio to a bioresorbable vascular scaffold, an everolimus-eluting stent, or a biolimus-eluting stent. Comparing the BVS to the two other current generation stents, there was no significant difference at 9 months in the rates of the primary outcome of late lumen loss or the rates of major clinical events between patients. BVS are approved for use in the coronary circulation in Europe and remain investigational in the United States. [UPTODATE]
  • Blood Donor Protection: Indications for deferral of the donor include a hemoglobin less than 12.5 g/dL for both men and women, temperature above 37.5°C, blood pressure above 180 mmHg systolic or 100 mmHg diastolic, pulse outside the established limits of 50 to 100 beats/minute, certain arrhythmias detected on pulse examination, and a variety of medical conditions. Some blood centers recommend that certain groups of donors (pre-menopausal females, frequent repeat donors) consider oral iron supplementation.
  • Minimizing post blood donation vasovagal reactions: Post-donation reactions can be minimized by restricting donation to less than 15 percent of a donor's estimated blood volume (for younger donors, estimated blood volume must be >3500 mL in order to be accepted for donation), encouraging applied muscle tension during donation, providing approximately 500 mL of water before donation, making sure the donor feels well before being allowed to walk to the refreshment table, and encouraging the donor to stay at the table for at least 10 to 15 minutes for observation and fluid replenishment. 
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Reader Response
IMA medical review and knowledge to us. This kind of CME was long awaited with latest updating. Congratulations and all appreciations to our saint Dr.K K Agarwal for wonderful spiritual knowledge Showering every day. We must meditate and live Aesthetic to overcome all stress and strain of life. Dr. Shrawan Pathak
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Press Release
14th June is World Blood Donor Day

IMA Rare Blood Group Online Blood Bank Directory Launched


The Indian Medical Association (IMA) has started an online voluntary rare group blood bank, where a list of all rare blood groups will be displayed.

IMA has appealed to all its 2.5 lakh doctor members and their patients with rare blood groups, especially the Bombay blood group to pass on their names, addresses, email and mobile numbers so that the same can be uploaded on the IMA website. They can also log in directly and submit the information at IMA website http://www.ima-india.org/rare/ under section IMA e-connect.

Giving details, Padma Shri Awardee Dr A Marthanda Pilli National President and Padma Shri Awardee Dr K K Aggarwal Honorary Secretary general IMA, said that people with rare blood groups can often be given a blood, when needed, only from people with the same blood group. And in life threatening such a website will come handy to save lives.

A rare blood is one, on the basis of the blood group characteristics, which is found in a frequency of 1: 1000 random samples in a given population. From blood transfusion point of view, a rare blood is the one with red cells lacking a high-frequency blood group antigen. Blood that lacks multiple common antigens may also be considered as rare since such donor's blood may be useful for the transfusion recipient who has developed multiple antibodies to corresponding antigen.

Rare nature of a blood type may vary from one country to another and therefore a blood type rare in one country may not be considered rare in another.  The commonest rare blood group in India is Bombay blood group.  The Bombay phenotype is found almost exclusively in individuals from India, with an incidence of 1/10,000. These patients are universal (ABO) donors.

For detection, tests would show them to be O, unless further tests are performed. Cross matching of blood from an individual with this phenotype will show hemolysis with all group O screening cells and panel cells, alerting the blood bank to the need for further investigation.

If an individual with the Bombay phenotype needs blood in an acute emergency and blood from a Bombay phenotype donor is not available, then the following options may be considered. 
  • Look up the IMA website for potential donor in that city
  • Get blood group test done of all your relatives; one of them may be Bombay Blood Group.
  • Artificial blood could be used instead.
  • Autologous blood can be obtained by apheresis prior to a surgical procedure
Other IMA guidelines
  • Defer blood donation if hemoglobin is less than 12.5 g/dL for both men and women, temperature is above 37.5°C, blood pressure is above 180 mmHg systolic or 100 mmHg diastolic, pulse is outside the established limits of 50 to 100 beats/minute, certain arrhythmias are detected on pulse examination, and if a systemic disease is present.
  • Consider oral iron supplementation for certain groups of donors (premenopausal females, frequent repeat donors).
  • To minimize post-donation reactions, restrict donation to less than 15 percent of a donor's estimated blood volume (for younger donors, estimated blood volume must be >3500 mL in order to be accepted for donation), encourage applied muscle tension during donation, provide 500 mL of water before donation, make sure the donor feels well before being allowed to walk to the refreshment table and encourage the donor to stay at the table for at least 10 to 15 minutes for observation and fluid replenishment. 
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