July 12  2015, Sunday
eMedinewS
editorial
1% of the population suffers from Vitiligo
Dr KK AggarwalVitiligo is an acquired skin depigmentation occurring in approximately 1 percent of the population.

It results from an autoimmune process directed against the melanocytes and is often associated with other autoimmune disorders, including autoimmune thyroid disease, pernicious anemia, systemic lupus erythematosus and Addison disease.

Types
  • Generalized vitiligo: It is the most common subtype, and is characterized by widespread macules and patches that are often symmetrically distributed
  • Acrofacial vitiligo typically involves areas surrounding body orifices and extensor surfaces
  • Segmental
  • Focal
  • Mucosal
  • Universal
The diagnosis is based upon the clinical presence of depigmented patches of skin. Examination with a Wood lamp is useful for highlighting areas of pigment loss on light skinned patients.

Treatment is based upon repigmentation therapies, which include topical and oral corticosteroids, topical calcineurin inhibitors, ultraviolet light (PUVA and narrowband UVB), and skin grafting techniques.
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eMedipics
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8th June 2015: IMA Mumbai Branch organized a free medical camp for non- communicable diseases for tribal population at village Sakwar Palghar
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TRENDO 2015
The 3rd Annual meeting of the Endocrine Society of Tamil Nadu and Puducherry will be held in Kodaikanal on 11th and 12th of July 2015. TRENDO 2015 is proposed to address latest updates, emerging concepts, clinical applications and controversies in diabetes, thyroid disorders, gonadal problems, pituitary disorders, metabolic bone disease and adrenal diseases.
News
  • The beta-2 adrenergic receptor (AR) agonist formoterol, currently approved for the treatment of asthma, could help prevent hypoglycemia in patients with type 1 diabetes without causing hyperglycemia, suggests a small pilot study published online July 7 in Diabetes Care.
  • Hormonal factors have a similar impact on endometrial cancer risk in women with and without Lynch syndrome, suggest data from the Colon Cancer Family Registry, published online in JAMA.
  • Dose optimization of infliximab is needed much earlier in ulcerative colitis than in Crohn's disease, suggests a single-center retrospective study published online in the Journal of Crohn's and Colitis.
  • A study presented at the American Society of Clinical Psychopharmacology (ASPC) 2015 Annual Meeting suggested that noninvasive neuromodulation with external trigeminal nerve stimulation (eTNS) may be a useful adjunctive treatment for patients with major depressive disorder (MDD) that is not adequately controlled by antidepressant medication.
  • Evidence does not support the common practice of having patients put a combination of topical nonsteroidal anti-inflammatory drugs (NSAIDs) and corticosteroids in the eye before and after cataract surgery to improve visual outcomes, suggests an Ophthalmic Technology Assessment report published online in Ophthalmology.
Top News from ADA 2015
No CV Benefit with Lixisenatide in ELIXA, but Results Reassure

Lixisenatide (Lyxumia), an injectable glucagonlike peptide (GLP-1) agonist, did not show a benefit on cardiovascular outcomes in the 6000 high-risk patients with type 2 diabetes in the ELIXA trial. But in this FDA-required CV safety study, lixisenatide also did not cause any harm in these patients, who had recently suffered an acute coronary event. There was no difference between the lixisenatide and placebo arms in the primary composite outcome of CV death, nonfatal myocardial infarction, nonfatal stroke, or hospitalization for unstable angina. "The effect of lixisenatide was neutral in ELIXA, and this should provide physicians and patients with some reassurance," said lead investigator, Marc Pfeffer, MD, of Brigham and Women's Hospital, Boston, Massachusetts.
Cardiology eMedinewS
  • Common electrocardiographic (ECG) metrics that are automatically reported during standard ECG acquisition are independent risk markers for cardiovascular (CV) death and enhance the ability to predict fatal events in patients with chronic kidney disease (CKD), suggests new research published online July 9 in the Journal of the American Society of Nephrology.
  • An analysis of a subset of patients in the Apixaban for Reduction in Stroke and Other Thromboembolic Events in Atrial Fibrillation (ARISTOTLE) trial who had valvular heart disease revealed that apixaban is as safe and effective as warfarin, even though it is approved only for "nonvalvular" heart disease. The findings are published in Circulation.
Pediatrics eMedinewS
  • Contrary to previous findings, a large, controlled population-based study has found no evidence that maternal use of calcium channel blockers in late pregnancy increases the risk for neonatal seizures. The findings are published in Obstetrics and Gynecology.
  • Currently recommended daily dietary allowances of vitamin D may be insufficient to prevent deficiency in children, suggested a report published in the Journal of Clinical Endocrinology and Metabolism. Researchers noted that children with suboptimal vitamin D blood levels did not reach optimal levels after taking nearly twice the recommended amount of the nutrient daily for six months.
Dr KK Spiritual Blog
Top Characters of Mahabharata

To be in harmony with the body (five elements represented by Draupadi) one must acquire five qualities or in other terms live a focused life, full of strength and not being disturbed with loss or gain and finally working for the welfare of the society without having any partiality towards anyone.
  • Balanced mind: Yudhishtir ("sthir" or balanced in "yudh" or disturbed state of mind)
  • Focused vision (Arjuna)
  • Using internal power or strength (Bhima)
  • Not being partial or remaining neutral (Nakul)
  • Working for the welfare of the society (Sahdev)
With this, one can kill 100 negative qualities that a person can have (the 100 Kauravs). The hundred negative qualities are acquired because of cunningness (Shakuni), not working with the eyes of the soul (Dhritarashtra) and keeping a blind eye to any wrong happening (Gandhari).

The main negative qualities are taking decisions in day–to–day life situations (Duryodhana: dusht in yudha or war) and choosing wrong choices as a ruler (dusshasana: dusht and shasan).

The positive qualities once acquired will also win over other negative qualities like blind faith or undue attachments (Bhishma pitamaha); unrighteous loyalty (Dronacharya) and unrighteous ego (Karna).
Events
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Make Sure
Situation:A patient with dengue fever developed shock.
Reaction: Oh my God! Why was the blood pressure 90/70 ignored?
Lesson: Make sure that a pulse pressure of less than 20 is not ignored. It is an impending sign that the patient is going into shock.
Dr Good Dr Bad
Situation:A diabetic with A1c 6% had a BP of 130/88 mmHg.
Dr Bad: This is very good control of diabetes.
Dr Good: This is very good control but we also need to control BP.
Lesson: Cardiovascular morbidity can only be reduced with aggressive management of hypertension, cholesterol (LDL <100 mg/dL) and aspirin (75–150 mg/day) in patients with or at high risk for cardiovascular disease.

(Copyright IJCP)
eMedi Quiz
A 55 year old lady presenting to out patent department (OPD) with postmenopausal bleeding for 3 months has a 1x1 cm nodule on the anterior lib of cervix. The most appropriate investigation to be done subsequently is:

1. Pap smear.
2. Punch biopsy.
3. Endocervical curettage.
4. Coloposcopy.

Yesterday’s Mind Teaser: The following are true regarding Lyme's Disease, except:

1. It is transmitted by ixodes tick.
2. Erythema chronicum migrans may be a clinical feature.
3. Borrelia recurrentis is the etiological agent.
4. Rodents act as natural hosts.

Answer for yesterday’s Mind Teaser: 3. Borrelia recurrentis is the etiological agent.
Correct Answers received from: Dr G Madhusudhan, Dr R H Gobbur, Dr G Madhusudhan, Dr Poonam Chablani, Raju Kuppusamy, Dr Avtar Krishan.
Answer for 10th July Mind Teaser: 4. IgM
Correct Answers received: Dr Sushma Chawla, Dr Jainendra Upadhyay, Dr K Raju, Dr Nikhil Mohanty.
eMedinewS Humor
As an English professor, my father would often write little notes on student essays. Often he worked late, and as the hours passed, his handwriting deteriorated. One day a student came to him after class with an essay that had been returned.

"Mr. McDonald," he said, "I can’t make out this comment you wrote on my paper."

My father took the paper and, after studying it, sheepishly replied, "It says that you should write more legibly."
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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
Press Release
In life threatening smoke cover your nose with water and cloth

Heart Care Foundation of India and IMA are giving training to every police personnel posted in PCR van in first aid including CPR 10.

Most of time, the police is the first on the scene to reach in an emergency. Training in first aid will not only help them to tackle victims of road traffic accidents, but also victims of electrocution and sudden unexpected deaths at home. This training would also help to build a better police-public relation.

Conducting the camp where training was provided to police personnel, Padma Shri, Dr K K Aggarwal, President Heart Care Foundation of India and Hony. Secretary General, Indian Medical Association said that death is reversible in the first 10 minutes if CPR 10 is provided to the victims of cardiac arrest.

Dr Aggarwal said that it is the police who can reach a victim in 10 minutes. It may not be possible for public to take the victim to the nearest medical establishment in the first 10 minutes.

Besides cardiac arrest, the police personnel were also taught how to handle and provide first aid for choking, electrical deaths, drowning, burns, road traffic injuries, fire, etc.

Giving an example, Dr. Aggarwal said that covering the nose with a cloth wet with water can be the first aid for victims who are trapped in smoke to prevent inhalation of smoke. If both are not available, then one can tear his shirt and use his own urine for the same.

The police personnel were not only taught how to provide first aid but also how to handle a triage where the more serious patients need to be attended first.

Any finger tooth or arm, dislodged from the body can be put in a plastic bag and bag put on ice. If the same is brought to the hospital along with the victim, it can be put back in the body.
eIMA News
Draft Document
Seat Belt Rule: IMA Stand

Dr A Marthanda Pillai and Dr K K Aggarwal


1.   Wearing seat belts while driving reduces fatalities by about 60 per cent and injuries by nearly 50 per cent during mishaps.

2.   It doubles the chances of survival in a serious accident and prevents occupants from being ejected out from the vehicle in case of an impact.

3.   The driver and co-passengers in four wheelers must wear seat belts as it is mandatory under the Indian Motor Vehicles Act.

4.   The penalty for not wearing a seat belt is Rs. 100 for the first offence and Rs. 300 for repeat offences. (138(3) CMVR 177 MVA)

5.   As per sub-rule (2) of the 138 of Central Motor Vehicle Rules, the driver and the person seated on the front seat of the motor vehicle are by law required to wear the seat belts, while the vehicle is in motion.

6.  As per the provisions of sub-rule (3) of Rule 138 of the Central Motor Vehicle Rules, 1989 'in a motor vehicle, in which seat-belts have been provided under sub-rule (1) or sub-rule (1A) of rule 125 or rule 125A, as the case may be, it shall be ensured that the driver, and the person seated in the front seat or the persons occupying front facing rear seats, as the case may be, wear the seat belts while the vehicle is in motion.

7.  Any person contravening these provisions of law and not wearing the seat belt as required shall be punished under Section 177 of the motor Vehicles Act, 1988.

8.   Rule 125 (1) requires the manufacturer of every motor vehicle other than motor cycles and three-wheelers of engine capacity not exceeding 500 cc, shall equip every such vehicle with a seat belt for the driver and for the person occupying the front seat.

9.   Rule 125 (1A) requires the manufacturer of every motor vehicle that is used for carriage of passengers and their luggage and comprising no more than 8 seats in addition to the driver's seat, shall equip it with a seat belt for a person occupying the front facing rear seat.

10.   The provisions in Sub-rule (1) of rule 125 of the Central Motor Vehicles Rules, 1989 stipulate that from 1994 onwards every manufacturer of Motor Vehicles other than Motor Cycles and 3-Wheelers of engine capacity not exceeding 500 CC shall equip every such vehicle with a seat belt for the driver and the person occupying the front seat.

11. In US: In 1983, front seat belt wearing regulations for drivers and passengers (both adult and children) came into force. In 1989, wearing rear seat belts became compulsory for children under 14. In 1991, when it became compulsory for adults to wear seat belts in the back of a car, there was an immediate increase from 10 per cent to 40 per cent in observed rear seat belt wearing. For your own and others’ safety, the law requires you to use a seat belt in all motor vehicles if one is fitted and for children up to 135cms in height to use a child restraint.

12.  Traffic crash mortality can be reduced for rear occupants by approximately 55–75% if they use safety belts. (Inj Prev. 2007 Jun; 13(3): 183–185.)

13.   Safety belt use was associated with a reduced risk of death for rear car occupants: outboard rear seat aRR 0.42 (95% CI 0.38 to 0.46), and center rear seat aRR 0.30 (95% CI 0.20 to 0.44). For rear occupants of light trucks, vans, and utility vehicles, the estimates were: outboard aRR 0.25 (95% CI 0.21 to 0.29), center aRR 0.34 (95% CI 0.24 to 0.48). (Inj Prev. 2007 Jun; 13(3): 183–185.)
IMA wants NCERT to drop paras on private healthcare)
Jul 11, 2015 | Age Correspondent: Finding description of private healthcare facilities objectionable in NCERT textbooks, the Indian Medical Association has demanded deletion of controversial sentences.

The IMA has written to the President, Prime Minister, Union HRD minister, Union health minister and NCERT director demanding deletion of a chapter from the Class 7 social science textbook.

The IMA said that the matter should be taken seriously and NCERT should be directed to delete this chapter and re write this chapter before it is included in the textbook. Objecting to the contents of the chapter, the IMA said that textbook clearly shows that in order to earn more money, private services by doctors encourage practices that are incorrect. At times, cheaper methods, though available, are not used. For example, it is common to find doctors prescribing unnecessary medicines, injections or saline bottles when tablets or simple medicines can suffice.

“In the book, on Page 22-23, a comic strip is also included which writes about the difference in treatment in public and private hospitals. The same is also depicted wrongly. In this it has been shown that cost of the same illness is `3,500 in a private sector and Rs 150 in the government sector,” IMA general secretary, Dr K.K. Aggarwal, said.

Defending cost of treatments in private sector, the IMA cited one of preliminary study done by the Delhi Medical Association in 2005, which was shown that per bed cost of the IMA member owned medical establishment was lower than per bed cost of the government medical college associated hospital in the city of Delhi. “There is no way the cost of government sector can be compared with the cost of private sector without taking into consideration the above factors,” added Dr Aggarwal. Objecting to the phrase “in order to earn more money, these private services encourage practices that are incorrect”, the IMA claimed that the phrase is judgmental and is violent in nature. The IMA suggested that the sentence should have been “in order to earn more money, some private services encourage communication practices that are incorrect.”

“These type of phrases in a NCERT textbook will brainwash the minds of the students and their faith in the private services will go away. At a stage when they are still not in a position to take their own decisions and make judgment, these types of teachings will spoil the patient doctor relationship,” said Dr Aggarwal.
Guj IMA Objects To Portrayal of Pvt Docs In NCERT Textbook
Ahmedabad Mirror | Jul 11, 2015, 02.00 AM IST

Taking forward the fight against discrimination of private doctors in the syllabus of National Council of Educational Research and Training (NCERT), Indian Medical Association (IMA) has sent a notice to Gujarat branch of IMA to join in. A comic strip published on pages 22-23 of Class 7 social sciences textbook by NCERT shows private doctors as fleecing patients. The private doctor is shown as prescribing many medicines, while a government doctor just hands out a pill for a viral infection. The private doctor's bill is Rs 3,500, while the government doctor charges Rs 150.

A portion of chapter 2 on 'Role of Government in health' says, "In order to earn more money, these private services encourage practices that are incorrect. At times cheaper methods, though available, are not used. For example, it is common to find doctors prescribing unnecessary medicines, injections or saline bottles when tablets or simple medicines can suffice." IMA has demanded that the chapter should either be deleted or re-written. "All branches of IMA across the country will join hands to fulfill the demand. We will conduct a meeting and organize a press conference to make people aware of the issue," said Dr Chetan Patel, president of Gujarat IMA.

Dr K K Aggarwal, secretary general, IMA, said, "Before making such incorrect statements, the cost of infrastructure, medical equipment and salary in private hospitals should be calculated. There is no way the cost of government hospitals can be compared with that of private hospitals without taking into consideration those factors." An objection was first raised by IMA Chandigarh which sent letters to the Union Minister for Health and Family Welfare, JP Nadda, and the Minister for Human Resource Development, Smriti Irani, expressing disappointment. "The books were published in 2007 but no one took note of it. Such sweeping statements will brainwash the students and mislead them," said Dr Sandeep Dhavan, IMA president, Chandigarh.
Get Your Facts Right
My letter in Mumbai Mirror 10-7-2015 - Dr E Hemang

This refers to your story `Red-tapism delays final journey of last train blast victim' (MM, July 9). The post-mortem on the body of Parag Sawant was not `un warranted' as it is a medico-legal case, and the death occurred suddenly. Sawant's condition did not give any hint of deterioration, till his oxygen levels fell in the early hours of Tuesday.

The post-mortem not only helps to ascertain the cause of the death, but also rules out any doubt of foul play. Instead of changing the wrong perceptions of lay people, politicians and the media seem to perpetuate misunderstanding.

This is verily the death knell for already precarious doctor-patient relations.

Similar instances of botched autopsies due to pressure, have jeopardised forensic evidences in countless cases of murder and rape. This is deplorable.
News
"The results of our study suggest that the previously reported interaction between clopidogrel and proton-pump inhibitors may be dependent on selection bias and different patient baseline characteristics, as a clinically significant effect was not observed in a randomized/propensity score matched population," report Dr Rhanderson Cardoso (University of Miami/Jackson Memorial Hospital, FL) and colleagues. Based on their analysis of the data, they believe "PPIs are a marker of increased risk rather than a direct cause of worse outcomes."

The results of the study are published online June 30, 2015 in Open Heart. (Medscape)
Inspirational Story
The Talking Bird

There is an old story about a fellow who lived alone and went to a pet store to buy a parrot. He thought the bird might fill some of his lonely hours. The very next day, however, he came back to complain, "That bird doesn’t talk."

The store owner asked if he had a mirror in its cage, and the man said he didn’t. "Oh, parrots love mirrors," he explained. "When he sees his reflection in the mirror, he'll just start talking away." So he sold him a birdcage mirror.The bird owner was back the next day to gripe that his parrot still hadn’t said a word. "That’s very peculiar," allowed the pet expert. "How about a swing? Birds really love these little swings, and a happy parrot is a talkative parrot." So the man bought a swing, took it home, and installed it in the cage.

But he was back the next day with the same story. "Does he have a ladder to climb?" the salesman asked. "That just has to be the problem. Once he has a ladder, he'll probably talk your ear off!" So the fellow bought a ladder.

The man was back at the pet store when it opened the next day. From the look on his face, the owner knew something was wrong. "Didn’t your parrot like the ladder?" he asked. His repeat customer looked up and said, "The parrot died."

"I’m so sorry," the stunned businessman said. "Did he ever say anything?"

"Well, yes. He finally talked just before he died. In a weak little voice, he asked me, "Don’t they sell any bird seed at that pet store?’"

Some of us have mistakenly thought that happiness consists of lining our cages with toys, gadgets, and other stuff. Excessive consumption has become the hallmark of our life. "Whoever has the most toys wins" seems to be the likely candidate to be the bumper sticker for an entire culture. But is it so?

There is a spiritual hunger in the human heart that can’t be satisfied by seeing one’s own image reflected back in vanity mirrors, playing with our grown–up toys, or climbing the corporate ladder. Our hearts need real nourishment. The love of family and friends, relationships over the pursuit of more things, personal integrity, a secure connection to God –– these are the things that feed the soul.

Have you chosen a life course that leads to a destination that matters?
Quote of the Day
Good friends care for each other… close friends understand each other… and true friends stay forever beyond words, beyond time
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Reader Response
  • Dear Sir, Response on NCERT timely and appropriate. I think you should take it up with GOI at appropriate level. Appreciate the work. Do write from HQ.  R V Asokan
  • Sir it is a sad matter. It should be investigated. Yours sincerely. Dr. Anil Ohri
Media
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Wellness Blog
Fever

Fever does not mean presence of infection. There are many situations where there is fever without infection and hence needs no antibiotics.
  • Sepsis is a clinical syndrome, which results from the dysregulation of inflammatory response to an infection. The temperature is between 36°C to 38.30°C. Heart rate is often more than 90 per minute.
  • Symptomatic inflammatory response syndrome means a clinical syndrome, which results from dysregulated inflammatory response to any infections such as inflammation of the pancreas, inflammation of the vessels, clot formations in the veins.
  • Many antibiotics can cause fever; unless they are discontinued, fever will not subside.
  • Hyperthermia is a condition with elevated body temperature but it is not called fever. Examples are exposure to heat or heat stroke and in response to anesthetic drugs and anti–psychotic drugs.
  • Hyperthermia may not respond to anti–fever drugs.
  • When fever is more than 41.5°C, it is acute hyperpyrexia.
  • Hyperpyrexia is usually seen in patients with severe infections but it may also occur in brain hemorrhage. It responds to anti–fever drugs.
  • High temperature without infection is found in condition of hyperfunctioning of the thyroid gland.
  • Recreational drugs such as Ecstasy can also cause fever without any infection.
  • Mild fever can also occur after exertion.
Over 100 doctors attended the IMA Rise & Shine CME on Vitamin D deficiency in Vizag
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Rabies News (Dr A K Gupta)
Is washing of animal bite wound(s) essential?

The risk of rabies reduces by about 50% by just washing of wounds and application of antiseptics.

The maximum benefit of the wound washing is obtained when the fresh wound is cleaned immediately. It is important to remove saliva containing rabies virus at the site of bite by physical or chemical means. This can be done by prompt and gentle thorough washing with ordinary soap or detergent and flushing the wound with running tap water for at least 15 minutes.

Washing of the wound must be done as long as the wound is raw irrespective of the time elapsed since the exposure. Care must be taken not to disturb the scab, if formed.

After washing with water and soap, disinfectants like Povidone Iodine or Surgical Spirit must be applied.

In extraneous circumstances, other alcoholic (>40%) preparations like Rum, Whisky or aftershave lotion may be applied on the wound. If soap or antiviral agent is not available, the wound should be thoroughly washed with water.
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