Medinews e-Newsletter - July 2009 - A service from the IJCP Group of Publications
Editorial 
In This Issue...

Dr K K Aggarwal
Dear Colleagues
The recent one crore judgment of the Supreme Court has opened a way for more legal litigations against the doctors. I am aware of many who are filing cases for more compensation. No case is usually decided unless an expert appointed by the council decides it otherwise. The question then arises, 'who is an expert?'
  • Can there be a single expert?
  • Can an expert be with an experience less than that of the so-called accused?

For example, DMC has provision only for a single medical expert who can decide the fate of any doctor. Let us see what the Supreme Court has to say.

  1. Error of judgment is not a crime.
  2. Difference of opinion is not a crime.
  3. One is not supposed to possess maximum degree of skill and knowledge but an average one.
  4. The opinion of one expert cannot be final if there exists one more opinion contrary to that of an expert.  Study the literature and you will always find different opinions.
  5. One cannot go beyond the consent taken during a surgery. For example, if consent for LSCS has been taken then you cannot go for removal of ovarian cyst, if found on the table.

What is the remedy?

  1. If there is a potential litigation, re-study the case file.
  2. Reply to the council with references, evidence based.
  3. Always respond to the council notices.
  4. If given a chance insist for a postmortem at the time of death.
  5. Appoint your interim enquiry board, hire 2-5 experts from outside and keep an in-house report ready. If you have a report from multiple experts it will be in all fairness to appoint a bigger expert panel by the council.
  6. Always take a next to kin consent during surgery "if during my surgery any additional procedure not consented by me, becomes necessary or is required I hereby authorize ............... to take a decision on by behalf when I am under the influence of anesthesia."

Service Tax enters medical profession
Service Tax : Section 65 (a) Specifically include and define the following services, in the list of taxable services namely: (iii) Cosmetic and Plastic Surgery Services.
In Chapter V : Service Tax under Rule 45 ( c) after sub-clause, the following sub clause be inserted namely, to any person, by any other person, in relation to cosmetic surgery or plastic surgery, but does not include any surgery undertaken to restore or reconstruct anatomy or functions of body affected due to congenital defects, developmental abnormalities, degenerative diseases, injury or trauma.
Loop hole: last three lines. It does not cover any plastic surgery done if the defect is congenital, developmental abnormality, degenerative diseases, injury or trauma. So trauma, cleft lip, cleft palate, degenerative aging disorders, degenerative skin, etc are not covered. But what about breast reconstructive surgery after breast cancer? Hair transplants? Sex change? Penile reconstruction?
Service tax has entered both the medical and legal profession. The lawyers have given their protest. We need to do the same or it will be the entry to this tax in every field of medicine. I think we need to represent the government.

Source: Budget Bulletin 2009 ? Customs, central Excise and Service Tax published by Directorate of Publicity & Public Relations Customs, Central Excise & Service Tax, C.R. Building

 DMC Election update
The elections are likely to be announced soon and are going to be well contested with the existing members trying to retain their seat this time and many more aspirants trying to enter in. With over 30,000 memberships, the next few months are going to be hot. The elections are held at one common place with personal voting. The last elections were held under a high court observer and with electronic machines. This time also one may expect the same.
 BSNL Dil Ka Darbar to offer concessions

BSNL Dil Ka Darbar being organized on 6th September at MAMC by he Heart Care Foundation of India will be an unique question-answer session between the public and the cardiologist and will offer free or very highly subsidized device implantation services to the needy.

 MTNL Perfect Health Mela from 3rd October

MTNL Perfect Health Mela an annual event of Heart Care Foundation together with Dept of Health, Government of Delhi will offer non stop education and fun activities. Look out for more details.

 Chinese technology in Delhi

The electro meridian sensor technology can differentiate whether you are healthy, well or in suboptimal health much before you actually go to the illness stage.

 Doctors die of relations assault

One DNZ member Dr S C Gupta died after he was assaulted by his patient?s grandson. March 2009: Deepak Bilani's grandmother dies after suffering from a cardiac ailment. Dr SC Gupta was treating her. May: Bilani searches the Net for information on her problem and its treatment. Allegedly finds loopholes. June 1: Bilani tricks Dr Gupta into visiting his neighborhood. Attacks him? Doctor in hospital? Bilani gets bail ? Doctor dies....

 FDA approves Effient to reduce the risk of heart attack in angioplasty patients

The U.S. FDA has approved the blood-thinning drug Effient tablets (prasugrel) to reduce the risk of blood clots in patients who undergo angioplasty, a common procedure to unblock a clogged coronary artery.

Dengue facts

Dengue situation, if not tackled in time, can create unnecessary panic. Dengue is a notifiable illness. It is both preventable and manageable. Dengue occurs in people of all ages but is more common in children. Dengue is transmitted by the bite of mosquito, Aedes aegypti. There are four different types of dengue fever 1, 2, 3, and therefore a person in his lifetime can get four attacks of dengue fever or related illnesses. Subsequent attacks are more severe than the earlier ones. Infection from one virus cause lifelong immunity only for that strain. Complications occur in < 1% of dengue cases and, if following facts are known to the public, many deaths from dengue can be avoided.

  • Aedes aegypti is a day-biter; it prefers to bite before breakfast and after lunch and prefers human sites below elbow and below knee.
  • There are four dengue-related illnesses: undifferentiated fever, dengue fever, dengue hemorrhagic fever and dengue shock syndrome. Retro-orbital pain (pain in the eyes or pressure on eye movement) is typical of dengue-related fevers. Fever with chills is often malaria and, fever with joint pains is Chikungunya.
  • IgM blood test may take 5 days to become positive. Therefore in the first 5 days all dengue tests may be negative.
  • The mortality for dengue hemorrhagic fever and dengue shock syndrome is around 1%. There is no mortality in undifferentiated fever and dengue fever. Presence of restlessness (oxygen deficiency in the brain), abdominal pain (indicating internal hemorrhage) and black stools (GI bleeding) signify urgency. Two dangerous clinical signs are falling systolic blood pressure and fall in pulse pressure.
  • Remember the formula of 20 i.e. rise in pulse by more than 20, fall of BP by more than 20,difference between lower and upper BP less than 20, platelet count less than 20, thousand and presence of more than 20 hemorrhages of blood on the arm after tourniquet test suggests high risk people who need medical attention.
  • A platelet count of less than one lakh signifies dengue hemorrhagic fever or dengue shock syndrome. Do not give aspirin in the suspected case of dengue as it can further disturb the platelet functions. Never panic. There is no need for platelet transfusion unless platelet count is less than 20,000 or there is presence of spontaneous bleeding
  • Most complications of dengue occur after the fever is over. Two days after the last episode of the fever are crucial and during this period, a patient should be encouraged to take plenty of oral fluids mixed with salt and sugar. The main complication is leakage of capillaries and collection of blood outside the blood channels leading to intravascular dehydration. Pumping fluids orally or by intravenous routes, if given at a proper time, can save complications.
  • If dengue is reported in one house it becomes customary for the State Health Department to search for the breeding sites around 100 houses so that the disease can be curtailed there and then. Unlike anopheles (mosquito causing malaria) which bites every 3rd day, a dengue mosquito bites 4-5 times in a day. While Anopheles infects one person in 3 days, Aedes mosquito can infect 15 persons in 3 days.
  • Prevention of dengue lies with the public and not with the Government authorities. The dengue mosquitoes are found only in fresh water collected inside or outside the house and not in dirty water in nallas, flowing all over the country. Therefore dengue and malaria are not the indices of the hygiene status of a city. Cholera and typhoid represent the hygiene indices.
Diabetic ED, combine metformin with sildenafil

Insulin-resistant men improve in erectile function when metformin is added to sildenafil. Sildenafil alone fails to improve erectile function, and men who received a placebo in addition to the phosphodiesterase-5 inhibitor continued to have erectile problems, as per Dr Pablo Knoblovits, of Hospital Italiano de Buenos Aires in Argentina. Metformin potentiates the activity of sildenafil by improving insulin resistance and nitric oxide activity in the vascular endothelium of the penis.

Do not combine grape fruit with drugs

Grapefruit juice is an inhibitor of the CYP3A4 isoenzyme, involved in the metabolism of over 50% of commonly prescribed drugs. A case has been reported of verapamil toxicity in a 42-year-old female, which resulted from accidental ingestion of only three tablets of the sustained release preparation (120 mg each) over 24 hours which resulted in severe toxicity. Grapefruit juice can inhibit CYP3A4 irreversibly, whose normal function is to oxidize drugs before they enter the systemic circulation. This inhibitory effect can last up to 72 hours. Concomitant consumption of grapefruit juice increases bioavailability for felodipine by 200%, nifedipine 57% and verapamil by 36%.

Keep Aspirin Dose and INR Low

For patients receiving triple therapy, the dose of aspirin should be kept as low as possible (75mg), clopidogrel should be given at its standard dose of 75 mg/day, and warfarin should be administered under tight control to achieve a slightly lower target INR of 2.0 to 2.5. Protonpump inhibitors should be considered as prophylaxis against gastric bleeds. Use pantoprazole and esomeprazole, which have least interaction with clopidogrel. Dual antiplatelet therapy (aspirin plus clopidogrel) is given routinely in the treatment of acute coronary syndrome and after coronary stent deployment, and anticoagulant therapy might be indicated for stroke prevention in a variety of conditions that include atrial fibrillation and profound left ventricular dysfunction as well as after mechanical prosthetic heart valve replacement. Triple antithrombotic therapy may be needed when a patient has multiple diseases, the most common situations being patients with atual fibrillation (AF) and or mechanical prosthetic heart valves who also have coronary artery disease and require a stent.

'Forever-young' pill, closer to reality

There's a phrase that reads, 'Chance favors the prepared mind', and this anti-aging pill is just an example of it. Anti-aging pill may have come one step closer to reality, with researchers finding that a drug, commonly used in humans to prevent transplanted organs from being rejected, helps extend the expected lifespan of mice by up to 14%. David Harrison, who led the arm of the experiment that took place at the Jackson Laboratory, found that rapamycin, a compound first discovered in the soil of the Easter Island, extended the lives of middle-aged mice by 28-38% - even when given late in life. It was given, mixed in the food of those mice at an age equivalent to 60-year-olds in humans. Matt Kaeberlein, whose group at the University of Washington in Seattle works on aging in mice, yeast and worms, also said that rapamycin might be mimicking the effects of dietary restriction, the only robust way to extend life in mammals until now. However, both Harrison and Kaeberlein are yet to ascertain whether the drug could extend human life.

Source: www.livescience.com/health/.../090708-fountain-youth-pill.html

New kit to know kids' drug abuse by just a lock of hair

Naughty kids can now be detected if they are involved in drugs with just a lock of their hair. The new testing kit is good news for parents. The 40-pound testing kit can detect seven drugs; including cannabis, cocaine, Ecstasy, and heroin. It can detect molecules that remain in the hair for up to 90 days, equipping parents with a valuable new tool for combating substance abuse. The test is much more reliable than saliva and urine tests. Moreover, shampoo, bleach or other external chemicals do not affect the results. Users of the tests, available online, send off a sample for testing and then receive a report on the amount of each drug detected as well as the frequency of use.

Source: news.oneindia.in/.../newkit-to-help-parents-check-kids-drug-abuse-by-testingju.html

Plastic chemical and fertility defects

Exposure to chemical bisphenol A (BPA), commonly found in plastic household items like plastic cans and bottles, can cause fertility defects in adults. A new study on mice revealed this fact. Chronic exposure to low doses of BPA can impair the growth and function of adult reproductive cells. A healthy and mature follicle, called an antral follicle, supports the egg and produces steroid hormones. These are the only follicles that are capable of ovulating and so if they do not grow properly they are not going to ovulate and there could be fertility issues. The study found that the growth of follicle was impaired after 48 hours of being exposed to BPA. Three main key steroid hormones were reduced: 97% less progesterone, 95% less testosterone and estradiol of 85% less, within 120 hours of exposure to BPA. Therefore this new study points to possible concerns in adults as well, Flaws said.

Source:medindia.net/Study-Finds-Plastic-Chemical-may-Cause-Fertility-Defects-in-Adult

Orthorexia: the latest entrant in eating disorders

Orthorexia, also known as orthorexia nervosa, is a new eating disorder characterized by a morbid need to restrict diet to only the healthy foods. Unlike anorexia, where an individual avoids eating, someone will not eat, the orthorexic is obsessed with healthy eating in order to live a healthier lifestyle. In 1997, Colorado physician and alternative medicine expert Dr. Steven Bratman invented the word orthorexia to define an obsession with healthy eating.

FDA approves Peginterferon combination therapy for retreatment of Hepatitis C patients

The FDA will no longer restrict the use of Schering-Ploughs peginterferon alfa-2b and ribavirin combination therapy to treat chronic hepatitis C in treatment-na´ve patients. The indication now includes patients 3 years of age and older with compensated liver disease who have failed previous treatment with interferon, making Pegintron and Rebetol the first and only pegylated interferon combination therapy approved in the US for retreatment.

Source: Gastroenterology & Endoscopy News April 2009

 
 
 


 
Service Tax enters medical profession

DMC election update
Diabetic ED, combine metformin with sildenafil
BSNL Dil Ka Darbar to offer concessions
MTNL Perfect Health Mela from 3rd October 
Chinese technology in Delhi 
Doctors die of relations assault
FDA approves Effient to reduce the risk of heart attack in angioplasty patients
Dengue Facts
Diabetic ED, combine metformin with sildenafil
Do not combine grape fruit with drugs
Keep Aspirin Dose and INR Low
'Forever-young' pill, closer to reality
New kit to know kids' drug abuse by just a lock of hair
Plastic chemical and fertility defects
Orthorexia: the latest entrant in eating disorders 
FDA approves Peginterferon combination therapy for retreatment of Hepatitis C patients

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