April 13  2015, Monday
editorial
Lowering BP No Help in Acute Stroke
Dr KK AggarwalUse of antihypertensive drugs to lower systolic blood pressure by close to 13% as part of acute treatment of ischemic stroke did not reduce early mortality or disability compared with patients who did not receive antihypertensive therapy.

At 14 days after randomization, there were 683 events among patients who received early aggressive antihypertensive therapy versus 681 events in the control group and at 3 months, there were 500 additional events in the treatment arm versus 502 among controls, said Jiang He, MD, PhD, of Tulane University School of Public Health in New Orleans.

He reported the findings from China Antihypertensive Trial in Acute Ischemic Stroke (CATIS) at the American Heart Association scientific sessions here and the results were simultaneously published online by the Journal of the American Medical Association. (MedPage)
IMA,IJCP,HCFI
eMedipics
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213th Meeting of the Central Working Committee of Indian Medical Association at Hotel Radisson Blu, New Delhi.
News
Individuals who take more than 800 mg of calcium daily are almost twice as likely to be diagnosed with age-related macular degeneration (AMD) as those who do not, suggests a new study published online April 9 in JAMA Ophthalmology.
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Diabetes India 2015
Dr YP Munjal, New Delhi
Hypertension and diabetes: Effective management strategies
  • The combination of HT and DM increases the risk of CAD, stroke, nephropathy, retinopathy.
  • Diabetes aggravates the already high risk associated with HT.
  • HT is difficult to treat in diabetics as systolic HT is more common, which is more difficult to control and also is a strong predictor of CV events. Due to higher incidence of depression, adherence to treatment is reduced. Clinical inertia is a big problem, which must be overcome.
  • HT in DM is serious problem, so it has to be managed in an aggressive manner. Treatment of HT checks or delays CVD, CKD, PAD or stroke.
  • 2014 ASH/ISH guidelines for HT with DM: RAAS inhibitors are 1st line drugs for BP control
  • Postural hypotension and diabetic autonomic neuropathy are important in treatment.
  • MAU/ACR is a must for all diabetes to predict CAD, CKD
  • Typically two or more drugs are needed.
  • New beta-blockers, carvedilol, CCBs are add-on drugs
Post breakfast glycemic spikes: The biggest challenge of Indian T2DM
Dr Vipin Mishra, Noida
  • Postprandial period is the 1st step in deterioration of glycemic control; morning period is the 2nd step in deterioration of glycemic control
  • The combined effect of the ‘Dawn’ phenomenon and ‘Extended Dawn’ (phenomenon of glucose derived from the digestion and absorption of breakfast carbohydrates) sustained blood glucose excursions during the morning period.
  • Failing to address these phenomena inadequate overall glycemic control increased risk for development or progression of diabetes complications even in the elderly.
  • Lowering the post breakfast glucose spike is the key to achieve effective blood glucose control across the day.
  • Indians have highest post-breakfast glucose peak
  • With the available evidence, it is clear that post breakfast blood sugar is especially more difficult to manage. This is true more so in Indians
  • Logically and ideally AGIs (Voglibose) should be used more aggressively at breakfast in Indian type 2 diabetics.
BP goals for HT in patients with diabetes: Current understanding
Dr A Muruganathan, Tirupur, Tamilnadu
  • HT is up to twice as common in diabetics as in general population. High BP in T1DM is due to nephropathy; in T2DM, it is mainly due to insulin resistance.
  • HT exacerbates all vascular complications in DM.
  • Night time BP control becomes especially important in diabetics.
  • Overall BP variability is increased in diabetic hypertensives.
  • Understanding the goals for HT management in patients with diabetes is an important first step.
  • Release of multiple guidelines in recent years has somewhat complicated the picture.
  • Diabetics derive more benefit from the same degree of BP lowering than those without diabetes.
  • Regardless of therapy or care or guidelines, targets will be achieved only if patients are motivated to stay on their treatment plan - adopting healthy behaviors.
  • Positive experiences, trust in the clinician and empathy improve patient motivation and satisfaction.
  • All guidelines serves as a guide, facilitate physicians’ treatment decisions on a case by case basis.
  • Physician’s judgment remains paramount, which depends on various factors of disease and the patient.
  • One BP goal or target may not suit all!
BP goals as recommended by various guidelines
  • JNC 8: 140/90 mmHg
  • NICE 2011: 140/90 mmHg
  • ASH: 140/90 mm Hg
  • KDIGO 2012: 140/90 mmHg
  • AHA/ACC: 140/90 mmHg
  • ADA: 140/90 mmHg
  • ESH/ESC: 140/85 mmHg
  • API IGH-III 2013: 140/80 mmHg
  • ISHIB 2010: 135/85 mmHg
  • CHEP 2015: 130/80 mmHg (China and Taiwan)
My views about the 6th World congress of Diabetes
Prof Dr S Arulrhaj, Tuticorin
  • Diabetes is a major noncommunicable disease expanding globally and invading India.
  • It is estimated that there will be 380 million persons with DM in 2025. India will have 80% of the world’s diabetic population.
  • Diabetes and infections are very good partners. Diabetes may be diagnosed initially by presentation of diabetic foot, urinary tract infection and pulmonary infections.
  • Tuberculosis and diabetes are looming in India.
  • Diabetes have 3 to 5 time higher chances of contracting TB because of poor control of blood sugar and altered immunity.
  • TB and Diabetes is peculiar in that of lower lobe (Basal TB, multilobular involvement, multiple cavities may be seen).
  • Sputum may be negative; hemoptysisis more common.
  • Strict control of diabetes with the use of insulin, 4 drug anti-TB regime for at least 9 months.
  • In infections like chronic genitourinary infections and wound discharge, not responding to routine antibiotics, we must suspect diabetes.
Diabetic retinopathy: Some people claim to see INTO the future....but will our patients see IN the future
Dr Sehnaz Karadeniz, Istanbul, Turkey
  • Diabetic retinopathy is a leading cause of preventable blindness in working age population.
  • It is one of the most complex, multifactorial heterogenous disorder.
  • Several factors influence development of an effective screening program such as screening method, population cover, cost and cost effectiveness, guidelines, compliance, quality assurance. We need to make early screening more accessible.
  • Future in screening: Computer aided DR detection, automated identification of DR from color fundus image
  • Laser photocoagulation is effective treatment for PDR. The strongest evidence comes from two RCTs: Diabetic retinopathy study and Early treatment Diabetic retinopathy study.
  • Anti-VEGF treatment was approved by the FDA in 2012.
  • Factors involved in angiogenesis and downstream signaling (PKC, angiopoietins, platelet derived growth factor, Wnt signaling axis) and inflammatory cytokines are other target molecules.
Dr KK Spiritual Blog
How to Remove Negative Thoughts

Darkness is absence of light and similarly negative thoughts are absence of positive thoughts. The answer to negative thoughts is to bring back positive thoughts. An ideal mind is a devil’s workshop and will always think negative.

Here are some ways by which you can remove negative thoughts.
  • Think differently as taught by Adi Shankaracharya. Once Menaka approached Arjuna with lust and said that she wanted to have a son like him with him. Arjuna said that why wait for 25 years consider me as you son from today.
  • Think opposite as taught by Patanjali. For example if you are having a though to steal, silently start thinking of charity.
  • Think positive as taught by Buddha. Make a list of positive actions to be done today as the first thing in the morning and concentrate on that list. Divert your mind to the pending works. It’s a type of behavioral therapy.
Make Sure
Situation: A patient on amlodipine developed severe gum hypertrophy.
Reaction: Oh my God! Why was amlodipine not stopped?
Lesson: Make sure that all patients on amlodipine are watched for gum hypertrophy as its side effect.
Dr Good Dr Bad
Situation: A patient with Mediclaim for the last seven years came for executive checkup.

Dr. Bad: You will have to pay from your pocket.

Dr. Good: You can claim it from Mediclaim.

Lesson: In addition to cumulative bonus, the insured shall be entitled for a reimbursement of the cost of medical checkup once at the end of block of every four underwriting years provided there are no claims reported during the block. The cost so reimbursable shall not exceed the amount of 1% of the total amount of the average sum insured during the block of four claim free underwriting years.

(Copyright IJCP)
Rabies News (Dr A K Gupta)
Can IDRV be given in private hospital?

The ID route has been permitted to be used in selected anti–rabies clinics (ARCs) having an adequate number of patients (at least 5/day) seeking post–exposure prophylaxis against rabies every day to make IDRV viable and cost–effective.
eMedi Quiz
Acantholysis is characteristic of:

1. Pemphigus vulgaris.
2. Pemphigoid.
3. Erythema multiforme.
4. Dermatitis hepetiformis.

Yesterday’s Mind Teaser: The Protein Efficiency Ratio (PER) is defined as:

1. The gain in weight of young animals per unit weight of protein-consumed.
2. The product of digestibility coefficient and biological value.
3. The percentage of protein absorbed into the blood.
4. The percentage of nitrogen absorbed from the protein absorbed from the diet.

Answer for yesterday’s Mind Teaser: 1. The gain in weight of young animals per unit weight of protein-consumed.

Correct Answers received from: Dr Jainendra Upadhyay, Dr.K.Raju, Dr Avtar Krishan,

Answer for 11th April Mind Teaser: 1. The source of infection is mainly clinical cases.
Correct Answers receives: Daivadheenam Jella,  Dr. G. Madhusudhan, Dr Avtar Krishan
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
IMA News
IMA joins chorus against errant doctors
Statesman News Service: Kolkata. 9 April

The issue of disciplinary action not taken against eight errant doctors has gained traction with Indian Medical Association (IMA) arraigning the state medical council for disregarding the directive of the country's highest regulating body in the matter.

Dr KK Aggarwal. General Secretary of IMA. has said that Medical Council of India's (MCI) recommendations to suspend registrations of eight doctors in West Bengal cannot be disputed by the West Bengal Medical Council (WBMC).

Dr Aggarwal's reaction came on Thursday after The Statesman published a report saying that the MCI held the eight doctors responsible for their negligence in treatment, which eventually led to the death of some patients in the state.

The MCI asked the WBMC to suspend their registration for a particular period of time but the state body is yet to take action against the accused doctors.

It may be mentioned that the MCI had already removed their names from the Indian Medical Register. But these doctors allegedly continue their medical practice in different parts of the state as the state medical council is yet to remove their names from the state medical register.

‘The. WBMC cannot challenge or dispute the decision taken by the MCI in this regard.

The MCI's directives can only be challenged in the court of law.

The WBMC should have carried out the recommendations of the MCI, which is the highest regulating body The state medical council must take some steps against the accused doctors if they were found guilty of medical negligence," Dr Aggarwal maintained.
Sonal Namaste
Handwashing is like a "do-it-yourself" vaccine—it involves five simple and effective steps (think Wet, Lather, Scrub, Rinse, Dry) you can take to reduce the spread of diarrheal and respiratory illness so you can stay healthy.
Facts about Tuberculosis (TB)
What happens if a patient develops adverse reaction to the drugs?
 
  • Adverse reactions are uncommon and usually mild in nature like nausea, vomiting, gastritis, itching etc.
  • The DOT providers are trained to identify the adverse drug reactions and take appropriate action as per the protocol.
Diabetes India 2015
Electronic medical record: Practical observations
Dr Santosh Malpani, Nanded
  • Meaningful use of EMR can improve quality of care and practice pattern.
  • Inertia of health care system is main obstacle in implementation of EMR.
  • EMR should be based on requirement of care delivery system’s requirement.
  • People who are using EMR can opt for research very easily.
  • Remove inertia and implement EMR to improve revenue generation from practice.
Type 1 diabetes: The Indian scenario
Dr Banshi Saboo, Ahmedabad
  • An estimated 0.5 million children aged up to 14 years have T1DM (IDF).
  • The developing countries like India will have the largest increase in the diabetes population.
  • Children develop more complications, largely due to ignorance or lack of education; consequently, people remain unaware about the true care of diabetes.
  • Child with T1DM needs to be monitored frequently for hypoglycemia, diabetic ketonuria.
  • Dietary education, regular physical activity, injection technique, sick day management improved management and prevention of complications
  • The optimal insulin regime is basal bolus dose or, if available, insulin pumps.
  • In India, the care for these children is not enough due to lack of access to insulin, psychological needs and challenges of growing children. So, a structured diabetes education program for both patients and providers is necessary for this patient population. Social taboos also come in the way of effective management.
  • Doctors, nurses, dieticians may lack the specific skills for optimal management of T1DM. Or, more often than not, they may not have the time or energy to put these skills into practice.
  • Children with T1DM require more time for counseling and management than type 2 diabetics.
  • As endocrinologists, we have to sensitize our colleagues to special needs of T1DM children, both medical and psychological.
  • Concepts such as patient empowerment, shared decision making behavioral change counseling, motivational interviewing and coping skills training should be translated into real-life practice.
  • IDF program - Life for a Child –supports T1DM services in resource-challenged societies.
Media
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Events
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Inspirational Story
My Mom Only Had One Eye

My mom only had one eye. I hated her… She was such an embarrassment. She cooked for students and teachers to support the family. There was this one day during elementary school where my mom came to say hello to me. I was so embarrassed.

How could she do this to me? I ignored her, threw her a hateful look and ran out. The next day at school one of my classmates said, ‘EEEE, your mom only has one eye!’ I wanted to bury myself. I also wanted my mom to just disappear. I confronted her that day and said, ‘If you’re only going to make me a laughing stock, why don’t you just die?’

My mom did not respond… I didn’t even stop to think for a second about what I had said, because I was full of anger. I was oblivious to her feelings. I wanted out of that house, and have nothing to do with her. So I studied real hard, got a chance to go abroad to study.

Then, I got married. I bought a house of my own. I had kids of my own. I was happy with my life, my kids and the comforts. Then one day, my Mother came to visit me. She hadn’t seen me in years and she didn’t even meet her grandchildren.

When she stood by the door, my children laughed at her, and I yelled at her for coming over uninvited. I screamed at her, ‘How dare you come to my house and scare my children!’ GET OUT OF HERE! NOW!!!’

And to this, my mother quietly answered, ‘Oh, I’m so sorry. I may have gotten the wrong address,’ and she disappeared out of sight. One day, a letter regarding a school reunion came to my house. So I lied to my wife that I was going on a business trip. After the reunion, I went to the old shack just out of curiosity.

My neighbors said that she died. I did not shed a single tear. They handed me a letter that she had wanted me to have.

‘My dearest son,

I think of you all the time. I’m sorry that I came to your house and scared your children. I was so glad when I heard you were coming for the reunion. But I may not be able to even get out of bed to see you. I’m sorry that I was a constant embarrassment to you when you were growing up.

You see……..when you were very little, you got into an accident, and lost your eye. As a mother, I couldn’t stand watching you having to grow up with one eye. So I gave you mine. I was so proud of my son who was seeing a whole new world for me, in my place, with that eye.

With all my love to you,

Your mother’
Quote of the Day
Tell a man he is brave, and you help him to become so. Thomas Carlyle
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Wellness Blog
Skin care
  1. Clean with soap and water.
  2. Moisturizers can make the skin dirty.
  3. Dryness is better than being dirty.
  4. No soap is a better soap.
  5. Glycerin is the safest moisturizer.
  6. One should rub hard but should not cause bruises.
  7. Soap emulsifies, therefore, one should remove 100% of surface part.
  8. Killing the normal flora of the skin is a bad idea. Therefore, do not use antiseptic soaps.
  9. Remember, Dettol does not kill pseudomonas infection.
Can creams and oils penetrate skin?
  1. The answer is no.
  2. . Oil cannot be absorbed.
  3. Nutrition cannot be absorbed from the skin.
  4. Almond cannot be absorbed from the skin.
  5. Unless the skin is damaged, nothing can be absorbed.
  6. For absorption, an occlusive dressing has to be used over a patch with a bandage, only then the drug can be absorbed. The bandage damages the skin because of preparation of moisturizer and heat. Any agent, which is irritating, can cause inflammation, erosion and then only a drug can be absorbed.
  7. If the skin is damaged, it can cause inflammation and can cause dermal pigmentation.
  8. Ultrasound techniques can be used to increase absorption.
  9. Newer drugs are getting absorbed through nano techniques.
Reader Response
Dear Sir, Very informative bulletin. Regards: Dr Kanta
IMA Videos
eIMA Humor
Communication technician

A communication technician drafted by the army was at a firing range. At the range, he was given some instructions, a rifle and 50 rounds. He fired several shots at the target. The report came from the target area that all attempts had completely missed the target. The technician looked at his weapon, and then at the target. He looked at the weapon again, and then at the target again. He then put his finger over the end of the rifle barrel and squeezed the trigger with his other hand. The end of his finger was blown off, whereupon he yelled toward the target area: "It’s leaving here just fine, the trouble must be at your end!"
News on Maps
Medical Fraternity needs to enlist all laws which are freedom to practice
Addressing an IMA leadership gathering of over 300 doctors from across the country, Mr. Mukul Rohatgi, Attorney General of India said that the right to practice once profession is a fundamental right ever citizen has.

If any law of regulation obstructs that principle the same should be brought to the knowledge of the government or challenged in the Supreme Court.

Also the same applies to if there are contradictions in the provisions of the law.

Padma Shri Awardee Dr A Marthanda Pillai National President and Padma Shri Awardee Dr KK Aggarwal Honorary Secretary General Indian Medical Association, posed many questions to him, during the working committee meeting.

Following discrepancies were brought to his notice
1. In PCPNDT act any MBBS can do ultrasound but in the rules you need an exam.
2. In PCPNDT act, you need to fill F16 form, where the information you need to fill is against the ethics. A diagnostic person cannot divert the patient for further investigations without the consent of referral doctor.
3. In the PCPNDT act the onus of proving non guilty lies on the doctor?
4. MCI says doctors are service provider but CPA act says you are a commercial health provider
5. MCI says do not discriminate patients on lines of Nationality but the Human Organs Transplant act says do not give preference to foreigners.
6. MCI says consent is required of both partners in sterility cases but Health Ministry guidelines says only one consent is sufficient.
7. Delhi Medical Council act says the council can give compensation but MCI act has no previsions when it comes to an appeal.
8. MCI says to doctors do not advertise but hospitals can as they are not covered under MCI act.
9. Clinical establishment act says that doctor’s professional fee can be controlled by the government.
10. Whether you are modern medicine expert, Homeopath or Ayurveda expert you can write doctor
11. Even healthcare providers who have no write to prescribe are writing doctor in front of their name: physiotherapists.
12. In MCI act for the appeal against the state medical council order you have to approach health ministry but in MCU rules you can approach the MCI ethics committee.
13. There is no statuary provision in MCIU act that state medical councils have to obey the decisions of MCI
14. Medical profession says one need to get emergency care within four minutes of medical crises but the government norms says you can not practice in residential areas
15. Principals of natural justice say you can get pleaded by a lawyer in any court but Delhi Medical Council says you cannot bring a lawyer when there is a case against you.

Earlier in the day Dr. Jayshreeben Mehta, President Medical Council of India interacted with the delegates.