June 15  2015, Monday
eMedinewS
editorial
Neck Artery Wall Thickness and Plaque Area to diagnose early heart diseases
Dr KK Aggarwal Treadmill, stress echocardiography, Thallium and Angiography do not detect early blockages. Treadmill can miss blockages up to 70%; stress echocardiography up to 60% and angiography up to 40%.

Most heart attacks occur because of a plaque rupture in patients with blockages of less than 50%. If the blockage is more than 70%, the patient usually presents with heart pain and not massive heart attack.

The only way to detect heart blockages before they cause symptoms or are detected in conventional tests is to measure the wall thickness of the neck artery or the leg artery. Normally, the wall thickness is less than 0.5mm. If the wall thickness is more than 0.75mm, it is suggestive of underlying heart blockages and if it is more than 1mm, it is suggestive of blockages in all three arteries of the heart.

Any thickness of more than 1mm is called as a plaque and a plaque area calculated by high resolution ultrasound is a new marker for heart blockages, progression as well as regression.

If the artery wall is thick in both the neck artery and the leg artery, it is very likely that the patient will also have blockages in the arteries of the heart.

All high risk individuals, therefore, should have their neck and leg artery wall thickness assessed. Only 2% of patients with blockages in all three arteries of the heart have a neck artery wall thickness of less than 1mm and 94% of patients with a neck artery wall thickness of more than 1.15mm will have multiple blockages in the heart.
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IMA Past Presidents Meet 2015
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News
  • IAP Health Phone, is an initiative conducted under the aegis of Indian Academy of Pediatrics, in partnership with the Ministry of Women and Child Development, UNICEF, with support from Vodafone.
  • Psychotropic medications, including antidepressants, benzodiazepines, and particularly opiate and nonopiate analgesics, are associated with a significantly increased risk for homicide (Jari Tiihonen, MD, PhD, professor, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden).
  • In colorectal surgery patients, a care bundle can dramatically reduce the risk for surgical-site infections, according to a nurse practitioner. "Colorectal surgery patients are at a high risk for surgical-site infections. Some subsets of patients have a risk as high as 40%. Our goal was a 50% reduction, but we actually achieved a 77% reduction," said Donna Lester, DNP, a surgical clinical nurse practitioner at the Lakeland Regional Medical Center in Florida (Medscape).
  • Endurance runners adapted to a low-carbohydrate diet can burn up to 1.54 g of fat per minute, which is at least 50% more than the highest previous estimate. A new study provides evidence that endurance athletes can perform at high levels without consuming carbohydrates during competitions, said Patrick Davitt, PhD, from Mercy College in Dobbs Ferry, New York (Medscape).
Dr KK Spiritual Blog
Importance of silence

True silence is the silence between thoughts and represents the true self, consciousness or the soul. It is a web of energized information ready to take all provided there is a right intent. Meditation is the process of achieving this silence.

Observing silence is another way of getting benefits of meditation. Many yogis in the past have recommended and observed silence now and then. Mahatma Gandhi used to spend one day of each week in silence. He believed that abstaining from speech brought him inner peace and happiness. On these days, he communicated with others only by writing on paper.

Hindu principles also talks about a correlation between mauna (silence) and shanti (harmony). Mauna Ekadashi is a ritual followed traditionally in our country. On this day the person is not supposed to speak at all and keep complete silence throughout day and night. It gives immense peace to the mind and strength to the body. In Jainism this ritual has a lot of importance. Nimith was a great Jain saint, who long ago, asked all Jains to observe this vrata. Some people recommend that on every ekadashi one should observe silence for few hours in a day if not the whole day.

Deepak Chopra in his book 7 Laws of Spiritual Success talks in great detail about the importance of observing silence in day to day life. He recommends that everyone should observe silence for 20 minutes every day. Silence helps to redirect our imagination towards self from the outer atmosphere. Even Swami Sivananda in his teachings has recommended daily observation of mauna for 2 hours for ekadashi, milk and fruits every day, studying one chapter of Bhagwad Gita daily, regular charity and donating one–tenth of the income in the welfare of the society. Ekadashi is the 11th day of Hindu lunar fortnight. Ekadashi is the day of celebration occurring twice a month, meant for meditation and increasing soul consciousness.

Vinoba Bhave was a great sage of our country who is known for this bhoodaan movement. He was a great advocator and practical preacher of mauna vrata.

Mauna means silence and vrata means vow; hence, mauna vrata means vow of silence. Mauna was practiced by saints to end enmity. Prolonged silence as a form of silence is observed by rishi munis.

Silence is a source of all that exists. Silence is where conscious dwells. There is no religious tradition that does not talk about silence. It breaks outward communication and forces a dialogue towards inner communication. This is one reason why all prayers, meditation and worship or any other practice whether we attune our mind to the spiritual consciousness within are done in silence. After the death of a person it is a practice to observe silence for two minutes. The immediate benefit is that it saves a tremendous amount of energy.

Silence is cessation of both sensory and mental activity. It is like having a still mind and listening to the inner mind. Behind this screen of our internal dialogue is the silence of spirit. Meditation is the combination of observing silence and the art of observation.
Make Sure
Situation:A patient with acid peptic disease was denied any painkiller for his distressing illness.

Reaction: Oh, my God! Why did you not give him nimesulide?

Lesson: Make sure to prescribe nimesulide as it is safe in acid peptic disease.
Dr Good Dr Bad
Situation: A pregnant dead lady needed immediate LSCS to deliver the baby. 

Dr Bad: Make a horizontal incision. 

Dr Good: Make a vertical incision. 

Lesson: A vertical skin incision provides fast entry, adequate uterine exposure and access to the diaphragm, which may be useful for further resuscitative interventions.

(Copyright IJCP)
eMedinewS Humor
Military Medical Clinic

During a visit to a military medical clinic, I was sent to the lab to have blood drawn. The technician there was friendly and mentioned that his mood improved every day because he was due to leave the service in two months. As he applied the tourniquet on my arm, he told me that taking the blood wouldn’t hurt much. Then, noticing my Air Force T–shirt, he asked me what my husband did.

When I replied that he was a recruiter, the technician smiled slyly and said, "This might hurt a little more than I thought."
Events
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eMedi Quiz
Injury to radial nerve in lower part of spiral groove:
1. Spares nerve supply to extensor carpi radialis longus.
2. Results in paralysis of anconeus muscle.
3. Leaves extension at elbow joint intact.
4. Weakens pronation movement.

Yesterday’s Mind Teaser: The cells belonging to the following type of epithelium are provided with extra reserve of cell membrane:
1. Transitional
2. Stratified squamous
3. Stratified cuboidal.
4. Stratified columnar.

Answer for yesterday’s Mind Teaser: 1. Transitional
Correct Answers received from:Dr.K.Raju, Dr Jainendra Upadhyay, Dr. G. Madhusudhan, Dr Avtar Krishan, Dr Pandit Hantodkar
Answer for 13th June Mind Teaser: 3. Lateral rectus and abducent nerve.
Correct Answers received: Dr G Madhusudhan, Dr Avtar Krishan.
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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
5% of high risk patients get heart attacks during perioperative period

Patients with underlying heart blockages or those with risk factors are at increased risk for perioperative heart attacks. Perioperative period is the time period extending from when the patient enters the hospital for surgery until the time he/she is discharged home, said 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 Indian Medical Association.

A study of over 8000 patients in the randomized POISE trial of perioperative beta-blocker therapy has shown that at 30 days after the surgery the incidence of heart attack is 5 percent and 71 percent of these occur within 48 hours of surgery.  Approximately 65 percent of patients with heart attack do not have symptoms.

Therefore, perioperative heart attack is not uncommon and occurs with increasing frequency as the number of identified risk factors increases.  Both short- and long-term survival are decreased in patients who have sustained a perioperative heart attack.

Treatment for perioperative heart attack is the same as for any heart attack in the general population. However, anticlotting drugs should be started carefully.

Perioperative heart attack is detected by presence of an elevated heart muscle injury blood test (troponin) and one or more of the following: ischemic ( heart pain) symptoms, ECG changes in two contiguous leads, coronary artery intervention (balloon dilatation or stenting), or evidence of heart attack on cardiac echocardiography or autopsy.

All high-risk patients should be screened with cardiac troponin both before and after non cardiac surgery in order to detect a perioperative heart attack. Cardiac troponin levels should be measured in patients with symptoms or ECG changes suggestive of ischemia or heart attack (2 or 3 serial biomarkers) or those at high cardiac risk (at 6 to 12 hours, and days 1, 2, and 3 after surgery)

A 12-lead ECG in the perioperative period should be done for all patients with symptoms of myocardial ischemia and all patients with risk factors for perioperative heart attack (baseline and daily for two, and possibly, three days)
eIMA News
IMA sets up register for rare blood groups
Jun 14, 2015, Age Correspondent, New Delhi

On the eve of the World Blood Donor Day, the Indian Medical Association has started an online voluntary register of rare blood groups bank, where a list of all rare blood groups will be displayed. The IMA said that people with rare blood groups can often be given blood, when needed, only from people with the same blood group and in life-threatening situations, such a website will come handy to save lives.

For the purpose, the IMA has appealed to all 2.5 lakh member doctors and their patients with rare blood groups, especially the Bombay blood group, to pass on their names, addresses, emails and mobile numbers so that the same can be uploaded online or they can also log in and submit these on the website.

The IMA said that rare nature of a blood type may vary from one country to another and therefore a rare blood type 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 in 10,000. These patients are universal (ABO) donors.

Talking about the benefits of initiatives, IMA secretary-general Dr K.K. Aggarwal said that it will help an individual having Bombay blood group. “One can look at the IMA website for potential donor in that city and get blood tests done of all your relatives and one of them may be Bombay blood group,” added Dr Aggarwal. A rare blood is the one that, on the basis of the blood group characteristics, which is found in a frequency of 1:1,000 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. Besides, a blood that lacks multiple common antigens may also be considered as a rare since such donor’s blood may be useful for the transfusion recipient who has developed multiple antibodies to corresponding antigen.
Blood donation drive collects 1,024 units
TNN | Jun 13, 2015

GURGAON: The Gurgaon deputy commissioner, T L Satyaprakash, was among a large number of residents who donated over 1,024 units of blood in a drive held over five days in the DLF Cyber City area. The event was organized ahead of World Blood Donor Day, which falls on June 14. The collected units of blood were sent to different hospitals of Delhi-NCR like AIIMS, Safdarjung Hospital, Ram Manohar Lohia Hospital and Red Cross Society.

The blood donation camps were organized from June 8-12 at nine different locations in Cyber City jointly by DLF Foundation and SABIC in association with BloodConnect. The 'World Blood Donor Day' is held every year on June 14 to raise awareness on the need for safe blood and blood products and to thank blood donors for their voluntary blood donation.
India takes first step towards regulating medical devices
Mumbai, June 12, 2015: India plans to set up a regulator to oversee the country's $4 billion medical device industry, according to a draft policy released this month, the country's first effort to regulate an industry that covers everything from thermometers to prostheses. The policy document, welcomed by many in the industry despite concerns over a lack of detail, also outlines plans to boost local manufacturing and reduce reliance on imports. While India is the world's third-largest pharmaceutical market, its share of the medical devices market is way behind. More than 70 percent of medical equipment sold in the country is imported, mostly from the United States.

The draft policy issued by the central Department of Pharmaceuticals proposes an autonomous National Medical Device Authority tasked with promoting the local industry and ensuring adherence to safety standards. It also proposes price controls for devices including surgical instruments, implants and diagnostic equipment -- a step that raised some eyebrows among manufacturers, as the country's pharmaceutical industry is already in a legal wrangle with the government over price caps on drugs.

(Source: http://www.deccanherald.com/content/483100/india-takes-first-step-towards.html
  • Undergoing cataract surgery appears to have more benefits than just improving vision -- it may also allow patients to get better sleep and to have better cognitive function according to a new research from Nara Medical University School of Medicine presented at SLEEP 2015, the annual meeting of the Associated Professional Sleep Societies.
  • Current recommendations, released by the American Academy of Sleep Medicine and the Sleep Research Society, are that adults get at least 7 hours of relatively uninterrupted sleep each night; teens and young adults should get 8-10 hours, with more than 9 hours "appropriate" in this age group. As teens progress through their adolescent years, their average sleep duration falls by about 10 minutes each year.
  • Patients with psoriasis who experience physical injuries involving bones and joints are at increased risk for developing psoriatic arthritis, according to a population-based cohort study by Thorvardur J. Love, MD, of Landspitali University Hospital in Reykjavik, Iceland.
  • The proportion of ischemic strokes treated with thrombolysis ranged from 0% in the bottom fifth of regions to 9.3% in the top fifth, with an overall rate of 3.9%, James F. Burke, MD, of the University of Michigan in Ann Arbor, and colleagues reported online in Stroke.
  • The FDA has released draft guidance on the development of drugs for Duchenne muscular dystrophy (DMD) and related conditions.
  • Mepolizumab is a monoclonal antibody targeting interleukin-5 receptors, a key signaling pathway driving eosinophil production. Phase III studies showed that the injectable drug cut exacerbations and reduced daily oral corticosteroid needs in patients with severe eosinophilic asthma. (Medpage)
Results of Meetings during the 200th Council Session
WMA Statement on Non-Discrimination in Professional Membership and Activities of Physicians

Adopted by the 37th World Medical Assembly, Brussels, Belgium, October 1985
and editorially revised by the 170th WMA Council Session, Divonne-les-Bains, France, May 2005

The World Medical Association is in favour of equality of opportunity in medical association activities, medical education and training, employment, and all other medical professional endeavours regardless of race, colour, religion, creed, ethnic affiliation, national origin, sex, age or political affiliation.

The World Medical Association is unalterably opposed to the denial of membership privileges and responsibilities in National Medical Associations to any duly registered physician because of race, colour, religion, creed, ethnic affiliation, national origin, sex, age or political affiliation.

The World Medical Association calls upon the medical profession and all individual members of National Medical Associations to exert every effort to prevent any instance in which such equal rights, privileges or responsibilities are denied.
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Inspirational Story
Benefits of Struggling

A man found a cocoon of a butterfly. One day a small opening appeared, he sat and watched the butterfly for several hours as it struggled to force its body through that little hole.

Then it seemed to stop making any progress. It appeared as if it had gotten as far as it could and it could go no farther. Then the man decided to help the butterfly, so he took a pair of scissors and snipped off the remaining bit of the cocoon. The butterfly then emerged easily.

But it had a swollen body and small, shriveled wings. The man continued to watch the butterfly because he expected that, at any moment, the wings would enlarge and expand to be able to support the body, which would contract in time.

Neither happened!

In fact, the butterfly spent the rest of its life crawling around with a swollen body and shriveled wings.

It was never able to fly.

What the man in his kindness and haste did not understand was that the restricting cocoon and the struggle required for the butterfly to get through the tiny opening were God’s way of forcing fluid from the body of the butterfly into its wings so that it would be ready for flight once it achieved its freedom from the cocoon.

Sometimes struggles are exactly what we need in our life. If God allowed us to go through our life without any obstacles, it would cripple us. We would not be as strong as what we could have been.

And we could never fly.
Wellness Blog
Top 5 Pain Interventions to Avoid

In response to a call from the American Board of Internal Medicine (ABIM) Foundation for recommendations on the most overused interventions, the American Society of Anesthesiologists (ASA) has issued a list of top 5 tests and therapies that are of questionable usefulness in the field of pain medicine.

The list includes the following recommendations for doctors:
  • Don’t prescribe opioid analgesics as first–line therapy to treat chronic non–cancer pain. Consider multimodal therapy, including nondrug treatments, such as behavioral and physical therapies, before pharmacologic intervention. If drug therapy appears indicated, try nonopioid medication, such as nonsteroidal anti–inflammatory drugs, or anticonvulsants, before starting opioids.
  • Don’t prescribe opioid analgesics as long–term therapy to treat chronic non–cancer pain until the risks are considered and discussed with the patient. Inform patients of the risks of such treatments, including the potential for addiction. Review and sign a written agreement identifying both your and the patient’s responsibilities (e.g., urine drug testing) and the consequences of noncompliance with the agreement. Be cautious in coprescribing opioids and benzodiazepines. Proactively evaluate and treat, if indicated, the nearly universal adverse effects of constipation and low testosterone or estrogen.
  • Avoid imaging tests, such as MRI, CT, or radiography, for acute low back pain without specific indications. Avoid these interventions for low back pain in the first 6 weeks after pain begins if there are no specific clinical indications (e.g., history of cancer with potential metastases, known aortic aneurysm, progressive neurologic deficit). Most low back pain doesn’t require imaging, and performing such tests may reveal incidental findings that divert attention and increase the risk of having unhelpful surgery.
  • Don’t use intravenous sedation, such as propofol, midazolam, or ultra–short–acting opioid infusions for diagnostic and therapeutic nerve blocks, or joint injections, as a default practice. (This recommendation does not apply to pediatric patients.) Ideally, diagnostic procedures should be performed with local anesthetic alone. Intravenous sedation can be used after evaluation and discussion of risks, including interference with assessing the acute pain–relieving effects of the procedure and the potential for false–positive responses. Follow ASA Standards for Basic Anesthetic Monitoring in cases where moderate or deep sedation is provided or anticipated.
  • Avoid irreversible interventions for non–cancer pain, such as peripheral chemical neurolytic blocks or peripheral radiofrequency ablation. Such interventions may be costly and carry significant long–term risks of weakness, numbness, or increased pain.
Quote of the Day
Nearly all men can stand adversity, but if you want to test a man's character, give him power. Abraham Lincoln
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Letter to Editor
Dear Dr KK ji

Hats off to entire IMA Team for initiating this noble humanitarian activity across India. I am one of the most Regular Blood Donors and feel obliged that I have donated my blood and platelets through Aphaeresis 230 times. Tomorrow I will donate 231 St time in Noida.
Reference your inputs in this eMedicalnews, I
Would like to communicate that :-

1. In India the time interval between two consecutive whole blood donations is 90 Says ( not 56 days that is in USA)

2. We still do not have Our FDA/ DCGA approval for collection of Two Units of Packed Red Cells. Though Apollo and AIIMS conducted few trials a couple of years back, when I also had the privilege to donate at AIIMS. Therefore, my humble request to IMA would be to get this Protocol also introduced as it will help a lot multi transfused patients and save donors for other patient

3. Rational Use of Blood where one collected unit is converted into atleast Three Components and help Three patients SHOULD become A WAY OF OUR Clinical Colleagues who are the prescribers.

4. My humble suggestion is that such an important subject must become a part of Theory and Practical Training of Our MBBS and PG Curricula with interns and Resident Doctors getting exposure of actual training experience in Blood Banks for atleast a fortnight. There are many more suggestions that I will feel obliged to be communicated if desired. Once again Thanks for The Initiative.

Regards.
Dr. N. K. Bhatia

Medical Director
Mission Jan Jagriti Blood Bank
(RBTC South West Delhi)
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If RIG is inadequate to infiltrate extensive wounds, what should be done?

If RIG is inadequate to infiltrate extensive wounds, the RIG should be diluted with normal saline. This is a particular issue in children, whose body weight may be small in relation to the size and number of wounds.