July 15  2015, Wednesday
eMedinewS
editorial
Cough Hygiene
Dr KK Aggarwal
  • When you cough or sneeze, you tend to expel out respiratory waste, which can be droplets (larger than 5 microns) or airborne droplets less than 5 microns; both have different implications.
  • Droplets remain suspended in the air only for a limited period and exposure of less than 3 feet is usually required for human to human transmission of droplet–borne respiratory organisms. In flu, this can be upto 6 feet. The examples of droplet infections are patients with meningitis, influenza, rubella (German measles) etc.
  • No precautions need to be taken by a person, who is at a distance of 6–10 feet away from the patient. But, if a person is sitting or working even at a distance of 3–6 feet, the non–coughing person should wear simple mask.
  • In contrast, airborne droplet nuclei, which carry respiratory secretions smaller than 5 microns can remain suspended in the air for extended period and can cause infections to people who are standing even more than 10 feet away. The example of airborne droplet nuclei infections are TB, measles, chickenpox and SARS.
  • Patients with these diseases need to be placed in an isolation room. And, all those people who are looking after these patients must use a safe N95 mask.
  • In normal house with open windows, there is a constant exchange of air, which prevents spread of infections but in rooms with air conditioners (ACs) with no air exchange, infections can spread from one person to another.
  • When sitting in an air conditioned atmosphere, the setting of the AC should be such that the same air is not circulated and fresh air is allowed to exchange. Split ACs, therefore, are more dangerous than the window ACs.
  • In an office with split AC, if one employee is suffering from any of the droplet nuclei disease, he/she can transmit infection to others. Therefore, patients with confirmed TB, measles, chickenpox and SARS should not be allowed to work in offices with split ACs.
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eMedipics
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Women Doctors Wing of IMA Kancheepuram branch organized Adolescent Health Awareness Program on Sunday, 12th July. About 150 students actively participated and benefited in this community services program.
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News
  • The US Food and Drug Administration (FDA) has approved brexpiprazole for adults with schizophrenia and as an adjunctive therapy to antidepressant medication in adults with major depressive disorder (MDD).
  • Exposure to secondhand smoke (SHS) raises the risk for stroke by about 30%, which is independent of demographic characteristics, socioeconomic factors, smoking history, Framingham Stroke risk factors, and C-reactive protein (CRP) concentration, suggests new research published online in the American Journal of Preventive Medicine.
  • Patients with distal rectal cancer could safely undergo intensive chemoradiotherapy and watchful waiting as an alternative to abdominoperineal resection, potentially avoiding undesirable outcomes, suggested a new Danish study published online in The Lancet Oncology.
  • Early antiretroviral therapy improves survival in HIV-infected adults with newly diagnosed tuberculosis and higher degrees of immunosuppression, suggested a systematic review and meta-analysis published in Annals of Internal Medicine.
  • A large, Swedish, population registry study suggests that nulliparous women, >35 years of age, are at greater risk for stillbirth compared with both younger women and similarly aged parous women. The study is published in the August issue of Obstetrics & Gynecology.
Top News from ADA 2015
Proof-of-Concept: Reduce glucose variability without changing HbA1c

The FLAT-SUGAR trial provides proof of concept that glucose variability (GV) can be reduced while maintaining similar glycated hemoglobin (HbA1c) levels through use of a GLP-1 agonist, rather than prandial insulin. A larger trial is required to see whether targeting GV improves clinical outcomes in diabetes, say the researchers, led by Irl B Hirsch, MD, of the University of Washington, Seattle. HbA1c, while associated with diabetes complications, does not reflect GV, which may contribute to vascular disease by inducing inflammation, oxidative stress, and cardiac arrhythmias.
Cardiology eMedinewS
  • A community-based study demonstrated that a higher percentage of premature ventricular contractions predicted a drop-off in LV ejection fraction and a greater risk of incident heart failure and mortality in a long-term follow-up of >1100 participants. The report is published in the July 14 issue of the Journal of the American College of Cardiology.
  • A paper published in Nature Communications suggests that a new emerging technique using sodium fluoride tagged with a tiny amount of radioactive tracer is the only imaging platform that can noninvasively detect the early stages of calcification in unstable atherosclerosis.
Pediatrics eMedinewS
  • Despite nearly 20 years of recommendations to perform a skeletal survey on infants and toddlers with injuries associated with abuse, hospital personnel failed to conduct such surveys in roughly half of suspected abuse cases, reported the results from a study published online July 13 in Pediatrics.
  • The most severe injuries in high school soccer occur from "heading the ball," but the risk seems to vary by sex, suggests a large longitudinal study of high school sports injuries published in JAMA Pediatrics. While a lower percentage of girls experience concussions from heading compared to boys (25.3% versus 30.2%), the concussion rate is higher for girls than boys.
Dr KK Spiritual Blog
Values, Morals and Ethics

Values
  • Values are our fundamental beliefs. They are the principles we use to define that which is right, good and just.
  • Values provide guidance to determine the right versus the wrong and the good versus the bad.
  • They are our standards.
  • When we evaluate anything we compare it to a standard.
  • Typical values include honesty, integrity, compassion, courage, honor, responsibility, patriotism, respect and fairness.
  • Ethics are universal.
Morals
  • Morals are values which we attribute to a system of beliefs, typically a religious system, but it could be a political system of some other set of beliefs.
  • These values get their authority from outside the individual– a higher being or higher authority (e.g. society).
  • Right as defined by a higher authority.
  • By that definition one could categorize the values listed above (honesty, integrity, compassion …) as "moral values" – values derived from a higher authority.
Ethics
  • Ethics is about our actions and decisions.
  • When one acts in ways that are consistent with our beliefs (whether secular or derived from a moral authority) we characterize that as acting ethically.
  • When one’s actions are not congruent with our values – our sense of right, good and just – we view that as acting unethically.
  • The ethics of our decisions and actions is defined socially, not individually.
Events
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Wellness Blog
CT not required in appendicitis

When a patient has all the signs of acute appendicitis, waiting to get a CT scan to confirm the diagnosis is not required.

Compared with a straight–to–surgery approach, the CT strategy is linked to delayed surgery and increased risk of a burst appendix.

Pre–operative CT is not necessary in cases with straightforward signs and symptoms of appendicitis. If, after a thorough physical examination, the diagnosis is still in question, then patients should be scanned. These patients tend to be older, female and have symptoms that are not typical for acute appendicitis.
Make Sure
Situation: An asthmatic patient became worse after receiving a painkiller.

Reaction: Oh my God! Why was he not put on a leukotriene receptor antagonist?

Lesson: Make sure that a patient with asthma is not given aspirin or he is put on a leukotriene receptor antagonist.
Dr Good Dr Bad
Situation: A pregnant lady developed hypotension with respiratory distress immediately after delivery.

Dr Bad: This is an internal bleed.

Dr Good: It looks like AFES.

Lesson: Amniotic fluid embolism syndrome (AFES) is a catastrophic condition that occurs during pregnancy or shortly after delivery. It is characterized by the abrupt and fulminant onset of hypotension due to cardiogenic shock, hypoxemia, respiratory failure, and disseminated intravascular coagulation. Clinicians should suspect AFES whenever shock or respiratory compromise develops during labor and delivery, or immediately postpartum. Other causes of sudden intrapartum or postpartum cardiorespiratory failure must be excluded.

(Copyright IJCP)
eMedi Quiz
A case of gestational trophoblastic neoplasia belongs to a high risk group if disease develop after:

1. Hydatidiform mole.
2. Full term pregnancy.
3. Spontaneous abortion.
4. Ectopic pregnancy.

Yesterday’s Mind Teaser: A primigravida at 37 week of gestation reported to labor room with central placenta praevia with heavy bleeding per vaginum. The fetal heart rate was normal at the time of examination. The best management option for her is:

1. Expectant management.
2. Cesarean section.
3. Induction and vaginal delivery.
4. Induction and forceps delivery.

Answer for yesterday’s Mind Teaser: 2. Cesarean section.

Correct Answers received from: Dr K Raju, Dr Poonam Chablani, Dr K V Sarma, Dr G Madhusudhan, Dr Shangarpawar, Dr Lopa Dalal, Dr B V Ravichandra, Daivadheenam Jella.

Answer for 13th July Mind Teaser: 2. Medical Management.

Correct Answers received: Dr G Madhusudhan, Daivadheenam Jella.
eMedinewS Humor
The teacher, during an English lesson, asked her students: "Now tell me, what do you call a person who keeps on talking when people are no longer interested?"

Little Johnny, in the back row, raised his hand. "Yes, Johnny," said the teacher.

"A teacher!"
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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 cardiac arrest, do not wait for doctor to arrive

When someone suffers a sudden cardiac arrest, most people waste time waiting for the doctor to arrive.

Cardiac arrest is a condition when the heart has stopped functioning, but the brain is still alive.

In this situation, every minute matters. With each passing minute, the chances of revival reduce by 10%. “If the revival process is started within one minute of sudden death, the chances of revival are 90%” said Padma Shri Awardee, Dr K K Aggarwal, President, Heart Care Foundation of India and Honorary Secretary General, Indian Medical Association (IMA). He was conducting a training workshop on CPR for Delhi PCR Van Staff.

The workshop is being conducted by Heart Care Foundation of India jointly with Indian Medical Association, Delhi Red Cross Society and Delhi Police with an aim of training 100 percent of PCR Staff by 14th August.

Dr K K Aggarwal said “Every second counts. If you find no evidence of breathing, make the person lie down flat on his back on a hard surface and compress the centre of the chest with your hands by 1 to 2 inches for the next at least 10 minutes with a speed of 100 compressions per minute until the person gets revived.”

The public must remember that to do a CPR, you need not be certified as a qualified CPR provider.

“A PCR van can reach the spot within a few minutes. So, they have the best chance of saving a life using CPR 10 technique,” said Padma Shri Awardee, Dr A Marthanda Pillai, National President, IMA.

In her message, Padma Shri Awardee and renowned Bharatanatyam dancer, Ms. Geeta Chandran said “Everybody should be aware of and learn the technique of CPR. You never know whose life you may be able to save.”
eIMA News
Draft for adoption by IMA, more inputs needed
Medicolegal issues in Kidney Transplantation: with updates in HOTA amendments 2014
  • Human organs are part of national resources of a country.
  • Organs cannot be sold or bought, organs can only be donated for therapeutic purposes. This rule of donation is applicable internationally. No country permits organ trafficking.
  • Doctors are doing organ sale / purchase in countries where laws regulating transplantation are lenient. This has given birth to the lucrative business of transplant tourism. Indian patients in need of kidney transplant are going to Sri Lanka & Bangladesh.
  • Several issues hinder the process of organ transplantation.
    • Medical issues: HIV infection is a contraindication for kidney donation. But HIV positive donor can donate to HIV positive CKD recipient; likewise for hepatitis B and C infection.
    • Legal issues: Illegal organ sale & purchase.
    • Ethical issues: When a trauma patient suddenly dies during treatment, the treating doctors may think it very unethical to ask the grieving relatives, who are in panic state, for removal of organs.
    • Social issues: Poverty compels donors to sell their kidney to rich CKD patients.
    • Nationality issues: Transplant tourism is popular in Nigerian & Turkish youths to combat poverty.
    • Religious issues: Some Hindus have false belief that removal of an organ just after death will remain as defect in next birth e.g. a cadaveric cornea donor will be born blind in the next birth.
    • Jehovah’s Witnesses refuse all sorts of transplantation; they will die of anemia/blood loss but will never agree for even blood transfusion.
  • Risk factors that are highly suggestive of a kidney donation scam and/or foul play in organ transplantation: When the donor is a recently married wife (transplant marriage just for kidney); donor is not a near relative; inadequate documentary proof; DNA profile/ HLA mismatch; donor appears to be of poor financial status; donor complains of cheating and denial by Authorization Committee in other hospital / state.
  • Why is kidney organ transplant scam is the most reported?: Pair of vital organs, but one can compensate another functionally; easily removable surgically; does not hamper the routine life of poor donor unlike pair of eye/ear/lungs and lifesaving for wealthy ESRD patients. So they hunt for donors in small city hospitals via touts/agents and sometimes marry the poor donor for kidney.
  • Donating kidney is limited to middle-class families to their dear ones. Upper class buys from lower class kidneys illegally for 5-10 lakhs.
  • What is the only legally permissible reason for organ donation? Donor donates one kidney “Out of affection” for the organ recipient.
  • Famous Kidney scams: Visakhapatnam Kidney scam, April 2014; Sri Lanka – India scam, 2013; Gurgaon Kidney scam, 2008 and Amritsar Kidney scam, 2003
  • Transplantation – WHO guidelines: Brain death; Consent; Transplant Authorisation Committee; Condemn organ trafficking for money; Promote non-remunerated donation and Donor advocate – NGO transplant coordinators.
  • Transplantation of Human Organs Act (THOA) is a special act, made by centre. Health is a state subject, each state has to adopt THOA, by passing legislation under Article 252 of constitution. Few states have adopted THOTA amendments 2014 e.g. Tamil Nadu, Goa, Delhi, West Bengal, Maharashtra, Himachal Pradesh & all union territories. THOA was initially binding in Maharashtra, Himachal Pradesh, Goa and all union territories, because they initiated the law on transplantation. THOA is still not adopted by Andhra Pradesh (?) and Jammu and Kashmir.
  • 1994 : Transplantation of Human Organs Act (THOA) passed
  • No doctor or hospital will advertise that they are doing organ transplantation.
  • ‘Donor’- means any person, not less than 18 years, who voluntarily authorizes the removal of any of his organs for therapeutic purposes.
  • ‘Near relative’ means persons related to each other genetically, especially son, daughter, father, mother, brother, or sister. It also includes grandparents and grandchildren.
  • ‘Next of kin’ means the ‘closest living relative’ linked by direct relationship from either blood or marriage.
  • No payment to donor by recipient. The cost of removing, transporting, preserving of kidney will be paid by the recipient to the hospital doing surgery. Cost incurred on maintenance of the body of brain-stem dead person for the purpose of retrieval of organs and/or tissues, will be paid by recipient.
  • ‘Brain-stem death’ means the stage at which all functions of the brainstem have permanently & irreversibly ceased and it is so certified by panel of medical experts (other than the treating doctor)- neurologist.
  • 2008: THOA Amendment (Transplantation of Human Organs & Tissues) THOTA: Tissue means a group of cell, except blood. Tissue that can be donated include the eyes, skin, bone, heart valves, eardrum, ear bones and tendons.
  • 2014: THOTA New Rules & Amendments

    Brain death can be certified by physician/surgeon/ anesthetist/ intensivist (who are not in team of transplant surgery) in the panel of medical experts.

    Transplant allowed in MLC Cases too, & guidelines set for police & Hospitals in procuring organs from unclaimed dead bodies (Hospital/prison) after 24 hours.

    No human organs or tissues shall be removed from the body of child<18yrs or mentally challenged person (includes person with mental illness or mental retardation) before his death, for transplantation.

    Transplant swapping guidelines for mutual exchange among 2 donor families with HLA matching.

    Guidelines for international donors & recipients for transplant tourism. When the proposed donor or the recipient or both are foreigners:- (i) A senior Embassy official of the country of origin has to certify the relationship between the donor and the recipient as per Form 14C. In case a country does not have an Embassy in India, the certificate of relationship, in the above format, shall be issued by the Government of that country. (ii) Authorization Committee shall examine the cases of all Indian donors consenting to donate organs to a foreign national (who is a near relative), including a foreign national of Indian origin, with greater caution.
  • ‘No Objection Certificate’ (NOC). When the donor is unrelated and the donor and/or recipient belong to a State/Union Territory other than the State/Union Territory, where the transplant is intended to take place, , then the domicile state of the donor or recipient as the case may be, would provide the No Objection Certificate in respect of legal and residential status of donor / recipient as the case may be; while the approval for transplantation would be considered by the authorization committee of the State/District/hospital (as the case may be) where the transplantation is intended to be done. “No Objection Certificate” will not be required for near relatives including cases involving swapping of organs (permissible between near relatives only).
  • If the relationship is not conclusively established in donation between husband & wife, even after evaluating the documentary evidence of relationship e.g. birth certificates of children, family photographs and marriage certificates, Authorisation Committee may in its discretion, direct further medical tests- Deoxyribonucleic Acid (DNA) Profiling of kids, from a laboratory accredited with NABL.
  • In case the proposed transplant is between unrelated persons. Form 16 is to be provided as income proof or last 3years Bank Statement, as appropriate evidence of vocation and income of the donor as well as the recipient for the last 3 years.
  • Whom to appeal if approval not granted by committee? Appeal to the State Government within 30days. If not granted- appeal to the central Government.
  • In cases of research involving Donation/Transplantation of Human Organs: Donation from a live donor should be restricted to renewable tissues like bone marrow or to a paired organ whose removal will not greatly alter physiological functions, such as the kidney. The Institutional Ethics Committee has a very important role in safeguarding the rights of the research subjects.

    There must be no element of commercialization or exploitation in the donation.

    HOTA doesn’t regulate bone-marrow transplant or Blood donation for Blood-banks, or sperm donation for sperm-banks in IVF, or Placental-tissue banking. They are regulated under Drug & Cosmetics act.
Laws applicable: Transplant Surgeons & Medical Superintendent are charged under IPC sections 120 (B), 342, 468, 471, 34 of IPC and section-18 & 19 of the transplantation of Human Organs and Tissues Act, 1994.

S.18 of THOTA- Doctor Punished for doing illegal transplantation- 10 years prison with 20 lakhs-1crore fine and penal erasure from Register of State Medical council for 2 years for the 1st offence & permanently for the subsequent offence.

S.19A of THOTA- Punishment for abetting false documents, negotiates or receive money, advertises or supplies organs for getting illegal transplantation- 2years prison with Rs. 10,000/- fine.

Section 120B Indian Penal Code: Punishment of criminal conspiracy

(1) Whoever is a party to a criminal conspiracy to commit an offence punishable with death, 2[imprisonment for life) or rigorous imprisonment for a term of two years or upwards, shall, where no express provision is made in this Code for the punishment of such a conspiracy, be punished in the same manner as if he had abetted such offence.

(2) Whoever is a party to a criminal conspiracy other than a criminal conspiracy to commit an offence punishable as aforesaid shall be punished with imprisonment of either description for a term not exceeding six months, or with fine or with both.)

Section 342 IPC. Punishment for wrongful confinement. Whoever wrongfully confines any person shall be punished with imprisonment of either description for a term which may extend to one year, or with fine which may extend to one thousand rupees, or with both.

Section 468 IPC. Forgery for purpose of cheating: Whoever commits forgery, intending that the *(document or Electronic Record forged) shall be used for the purpose of cheating, shall be punished with imprisonment of either description for a term which may extend to seven years, and shall also be liable to fine.

Section 471 IPC. Using as genuine a forged document or electronic record: (to prove donor a 'near-relative'): Whoever fraudulently or dishonestly uses as genuine any *(document or electronic record) which he knows or has reason to believe to be a forged (document or electronic record), shall be punished in the same manner as if he had forged such (document or electronic record).

Section 34 IPC: Acts done by several persons in furtherance of common intention. When a criminal act is done by several persons in furtherance of the common intention of all, each of such persons is liable for that act in the same manner as if it were done by him alone.) (Input: Dr Vivekanshu, Medanta - The Medicity, Gurgaon)
CPR training can save several lives: Anita Roy - Additional DCP Training PCR
New Delhi, Mon, 13 Jul 2015 Newstrack India

Over 1500 police PCR van staff trained in CPR 10 today in New Delhi, Ms. Anita Roy - Additional DCP Training PCR, said that the aim was to train 100% of the Delhi Police PCR van staff in the life-saving technique of hands only CPR 10 for revival after sudden cardiac arrest by 14th August, 2015.

Heart Care Foundation of India jointly with the Indian Medical Association, Delhi Red Cross Society and Delhi Police has trained over 1500 police PCR staff in a span of one week. Addressing a press meet at the IMA today, Padma Shri Awardee Dr K K Aggarwal- President of Heart Care Foundation of India and Honorary Secretary General of IMA and Ms. Anita Roy - Additional DCP Training PCR, said that the aim was to train 100% of the Delhi Police PCR van staff in the life-saving technique of hands only CPR 10 for revival after sudden cardiac arrest by 14th August, 2015.

“One does not need a certification or degree to learn or practice hands only CPR. It is a first aid method which can be performed by anyone. It is imperative that each one of us learn this technique for you never know, when you will be able to save someone's life. For best results, CPR must be performed within a ten minutes of a person’s death. The earlier it is preformed, the higher the chances of reviving the person" said Padma Shri Awardee and noted poet Sh. Ashok Chakradhar.

Adding to this, Dr KK Aggarwal said, "Only a neighbourhood PCR van can reach an accident site within the first few minutes. Given the cruciality of each minute that passes after a person collapses from a sudden cardiac arrest, the PCR van staff can play an important role in helping save lives. CPR must be performed only on patients who are clinically dead and not breathing. The important thing to remember is to compress the center of the chest, about one to two inches deep in between their two nipples, with a speed of at least 100 per minute (not more than 125)."

One must remember that CPR should only be performed on a hard surface. The victim should be made to lie on the floor, face towards the ceiling. The person performing CPR must stand on his knees, elbows straight and hands interlocked.

Ms. Anita Roy added, "Over 250 emergency health calls are attended by the PCR vans each day. With each and every PCR van staff being trained in Hands only CPR 10, several lives can be saved."

Continuous compression only CPR compresses the heart between the sternum and the backbone and builds up the pressure that keeps the oxygenated blood flowing to the brain and keeps the person alive until a defibrillator becomes available or expert medical help arrives. Therefore, if you see someone collapse from sudden cardiac arrest, acting promptly can save his or her life. It is important to act quickly for every minute lost reduces the chances of revival by 10%. So, if you wait 5 minutes, the chances of surviving are 50% less. The earlier you give CPR to a person in cardiac arrest, the greater the chance of a successful resuscitation.
Inspirational Story
Keep Marketing You

Rejection and job searching go hand in hand. As a writer, I can tell you something about disappointment. I had enough "reject" slips from New York publishers to start a bonfire. Then one day, an editor said, "Yes," and my world was drastically transformed.

Ken Taylor began re–writing the Bible in a contemporary translation and had more than 60 rejections. He finally decided to self–publish "The Living Bible" and it became one of the greatest best–sellers in publishing history.

If you’re qualified for a particular job, never stop interviewing –– even if you return to the same companies five or six times. Meanwhile, you need to accept an interim position to keep yourself gainfully employed. When you add lack of funds to job rejection, it’s a double–whammy.

Never overlook working for a "temporary" employment agency. It gives you a chance to demonstrate your skills to a number of companies and can open some exciting doors. As a last resort, start free–lancing your skills. Who knows? You may wind up with your own business and be your own boss!
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Quote of the Day
If you’re not using your smile, you’re like a man with a million dollars in the bank and no checkbook. Les Giblin
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Reader Response
  • Dear Dr Aggarwal, I wholeheartedly endorse the stand taken by IMA. Dr AK Grover.
  • Dear Sir, It is highly objectionable and unacceptable that a text book states that private health care sectors are doing in correct practices to earn more money. How can they make such statement about the Private health sector, which is taking care of 70% of the health care delivery of this country? The Private Sector, on one hand, is considered as an industry, and on the other hand we are projected as a service Sector without any grants or concessions. We also face all taxes and many agencies control the Private Sector including the Pharma, equipments and other overheads. The CPA is one factor leading the private sector to carry out investigations like CT scan, which is often asked by the Lawyers in the Courts. It is the Government and other Agencies who are making the Private Health Sector costlier and not the Doctors. We need to fight tooth and nail against these Planned Assassinations on the Medical Community. Thank You, With Best Regards, Dr CN Raja, Hony. State Secretary, IMA TNSB
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Rabies News (Dr A K Gupta)
Can vaccinated dog succumb to rabies following bite by rabid animal?

Following severe and extensive bites, which means injection of very high challenge dose of virulent virus by a rabid dog, a vaccinated dog can still succumb to rabies.
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