November 16   2015, Monday
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EDITORIAL
Dr KK AggarwalDr KK Aggarwal To reduce the epidemic of diabetes

• Limit sugar consumption to 5% of total daily calories.

• Ban advertising (and surrogacy bans) of sugary drinks to children and teens, sport sponsorships, and on sales in schools.

• Add sugar tax.

• Promote consumption of leafy vegetables, fruit and clean drinking water.

• One in every 11 adults worldwide has diabetes, totaling 415 million, with about half undiagnosed.

• Diabetes accounts for 12% of global health expenditures, or about $673 billion in US dollars. That's more than the annual US military budget.

• One in seven births worldwide is complicated by gestational diabetes.

• 75% of people with diabetes actually live in low- and middle-income countries, where rapid urbanization and related shifts toward unhealthful diets and sedentary lifestyles are accelerating obesity and diabetes.

• Every 6 seconds a person dies from diabetes, with annual death rates exceeding those from malaria, TB, and HIV combined.
EMEDINEXUS STATEMENT
Mr. Nilesh Aggarwal

We are extremely happy to have been part of IMA Satyagraha campaign and would like to congratulate the Indian doctor community as a whole. We are aiming to be a digital voice of all Indian doctors and will continue to work towards raising such important issues. Currently, we are in our Beta phase and we will soon be introducing features such as interesting cases, online CME's, conference updates etc. Please do register and read eMediNews, eIMANews as well as other engaging content on the website/app. You can also add other doctors to your network, find long lost alumni, chat and discuss cases, post questions for the medical fraternity, create your detailed medical resume and lots more.
Breaking News
• The US Food and Drug Administration (FDA) has approved a new recombinant PEGylated antihemophilic factor for children aged 12 years or older and adults with hemophilia A. The factor VIII therapy is approved both as needed treatment and for prophylaxis.

• The UK National Institute for Health and Care Excellence (NICE) has issued its first-ever guidance on menopause which emphasizes that help and information are available to women suffering from symptoms and that treatment options, such as hormone-replacement therapy (HRT) as well as nondrug treatments, can be discussed with their doctors.
Dr Good Dr Bad
 
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Indian Medical Association National Satyagraha for a Healthy India
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Specialty Updates
• A high intake of red meat appears to increase the risk for end-stage renal disease, and replacement of red meat protein with other sources of protein has the potential to reduce this risk, suggests a new study conducted in people of Chinese origin in the general population of Singapore, presented at the Kidney Week 2015.

• Intra-articular steroid injections are not effective over the long-term for preventing structural damage in knee osteoarthritis, reported a 2-year randomized trial presented at the annual meeting of the American College of Rheumatology.

• University of Florida researchers have found that with the correct dosage, electrical stimulation treatment can help ease back pain in older adults. The findings are published online in The Journal of Pain.

• New research presented at the American Heart Association's Scientific Sessions 2015 reported that obese children had 27% more muscle mass in the left ventricle of their hearts and 12% thicker heart muscles, which are both signs of heart disease.

• The estrogen antagonist oral enclomiphene citrate raises serum total testosterone levels while maintaining normal sperm counts in men with secondary hypogonadism, suggested two new studies published online in BJU International.

• For patients with early breast cancer, taking the angiotensin-receptor blocker (ARB) candesartan cilexetil may decrease the risk of cardiac dysfunction, a common side effect of radiation and certain cancer medications, suggests the Prevention of Cardiac Dysfunction During Adjuvant Breast Cancer Therapy (PRADA) trial presented at the American Heart Association (AHA) 2015 Scientific Sessions.

• Unequal growth between genetically identical monozygotic (MZ) twins in the womb may be triggered in the earliest stages of human embryo development, reported a new study published in the journal Stem Cell Reports.

• Omega-3 fatty acid supplementation is associated with a reduction in follicle-stimulating hormone (FSH) levels in normal-weight women.
eSpiritual
Direct all your energy towards the ‘should’ and not ‘ego’

The epic Mahabharata can also be understood as a science of inner Mahabharata occurring in everybody’s mind. Lord Krishna symbolizes consciousness and the five Pandavas, the five positive qualities of a person namely, righteousness (Yudhishthir), being in focus (Arjuna), power to fight injustice (Bheem), helping others (Sahdev) and learning to be neutral in difficult situations (Nakul). Panchali indicates 5 senses, which can only be controlled when these five forces are together.

Dhritrashtra symbolizes with ignorance, Duhshasan with negative ruling quality (dusht while ruling) and Duryodhana (dusht in yudh) with one who is not balanced in war.

To kill the negativity in the mind, one has to take conscious-based decisions. Every action, if directed towards the consciousness or the soul, is the right action. To kill the 100 Kauravas (the 100 negative tendencies a person can have) controlled by Duryodhan and Duhshasan along with Shakuni (the negative power of cunningness), one has to redirect one’s positive qualities towards the consciousness and take right decisions. The five Pandavas (positive qualities) made soul (Lord Krishna) as their point of reference (Sarthi) and won over the evils (Kauravas). Bhishma Pitamah, Karana and Dronacharya, all had winning powers individually but they all supported negative thoughts and made Duryodhana as their point of reference and ultimately had to die.

The message is very clear – if one directs his or her positive powers towards ego as the reference point in long run, they will be of no use and, in fact, will be responsible for one’s destruction. In Ramayana, Ravana was a great scholar but he directed all his energies and powers towards his ego and ended up in misery. One should cultivate, therefore, positive mental attitude, positive thoughts instead of directing them towards desire, attachment or ego and should direct them to soul/consciousness for a positive outcome.
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Legal Quote
Nizam's Institute of Medical Sciences vs Prasanth S.Dhananka & Ors on 14 May, 2009

“We must emphasize that the Court has to strike a balance between the inflated and unreasonable demands of a victim and the equally untenable claim of the opposite party saying that nothing is payable. Sympathy for the victim does not, and should not, come in the way of making a correct assessment, but if a case is made out, the Court must not be chary of awarding adequate compensation.”
Medicofinance
Developing an Investment Portfolio: Responsibility of Financial Advisors

• Understand the client’s needs and listen to what the client states, relative to what the client means.
• Define realistic investment objectives that can meet the client’s needs - based on agreed upon definitions.
• Establish the right mixture of assets.
• Develop well-reasoned, sensible investment policies designed to achieve the client’s realistic and specified long-term investment objectives

(Source: IJCP)
Media
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eMEDIPICS
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22nd MTNL Perfect Health Mela, the annual flagship event of the Heart Care Foundation of India
1 in 4 Indian diabetics not obese

It is not just the obese who develop diabetes. New research suggests that a number of Indian patients suffering from the disease are non-obese, having a body mass index (BMI) of less than 25 kg/m2. They have high fat in the abdominal region, also referred to as central obesity besides fat in the liver and pancreas. According to Dr Anoop Misra, chairman of Fortis C-Doc, nearly one out of every four diabetics in India are non-obese. "Higher waist circumference, abdominal fat and depositions in the neck and chin area are some of the clinical symptoms to assess the risk factor. Such patients could be at higher risk for diabetes-related complications, for example heart attack, because of high fat in liver," he said… (Times of India – Durgesh Nandan Jha)
World Diabetes Day
The World Diabetes Day (WDD) 2015 campaign marks the second of a three-year (2014-16) focus on healthy eating and diabetes. With the slogan ‘Halt the diabetes epidemic: Make healthy eating a right, not a privilege’, the International Diabetes Federation (IDF) calls for urgent action to improve access and affordability of healthy food choices to reduce the global burden of diabetes and save billions in lost productivity and healthcare costs. The campaign focuses on the importance of healthy eating in preventing type 2 diabetes and in effectively managing all types of diabetes to avoid complications. The key messages of the campaign are:

1. Act to change your life today: Healthy eating is an important part of managing all types of diabetes.

2. Act to change the world tomorrow: Access to affordable healthy food is essential to reducing the global burden of diabetes and ensuring global sustainable development.

(Source: IDF)
Maternal deaths fell 44% since 1990: UN
Maternal mortality has fallen by 44% since 1990, United Nations agencies and the World Bank Group reported. Maternal deaths around the world dropped from about 532 000 in 1990 to an estimated 303 000 this year, according to the report, the last in a series that has looked at progress under the Millennium Development Goals (MDGs). This equates to an estimated global maternal mortality ratio (MMR) of 216 maternal deaths per 100 000 live births, down from 385 in 1990. The analyses contained in Trends in Maternal Mortality: 1990 to 2015 – Estimates by WHO, UNICEF, UNFPA, World Bank Group and the United Nations Population Division are being published simultaneously in The Lancet. Despite global improvements, only 9 countries, Bhutan, Cabo Verde, Cambodia, Iran, Lao People’s Democratic Republic, Maldives, Mongolia, Rwanda and Timor-Leste, achieved the MDG 5 target of reducing the maternal mortality ratio by at least 75% between 1990 and 2015. Despite this important progress, the MMR in some of these countries remains higher than the global average.
India launches 'climate action' website ahead of Paris meet
India has launched a comprehensive website detailing its plans to cut greenhouse gas emissions in a transparent manner ahead of the global climate change summit scheduled to begin in Paris on November 30. The website (www.justclimateaction.org) offers a 'preview" of the country's climate action plan that aims to reduce carbon emission intensity by 35% by 2030… (Economic Times)
PPIs may increase risk of dying in hospitalized patients
Proton-pump inhibitors are often used in admitted patients to prevent GI bleeding, but may increase the risk of dying. Matt Pappas, MD, MPH, from the Veterans Affairs Ann Arbor Healthcare System and the Department of General Internal Medicine at the University of Michigan Health System in Ann Arbor, and colleagues say the increased risk for death comes because reducing acid in the stomach increases the risk for infections, especially pneumonia and Clostridium difficile (CDI), both of which pose a serious risk to hospitalized patients. (November 9 in the Journal of General Internal Medicine)
Facts about noise pollution
Get concerned if:

• You have difficulty talking or hearing during routine conversation done to back round sound.
• The sound hurts the ears.
• The ears are ringing after hearing the sound.
• Other sounds are muffled after you leave an area where there is a loud sound.
eWellness
Early (Wet) vs late (Dry) winter

Winter can be divided as either wet or dry winter. Wet winter is characterized by fall in temperature along with high humidity. Environmentally, we see fog and smog during this season. Dry or late winter on the other hand is characterized by absence of fog, smog and presence of chilly airy winds.

Most hypothermia illnesses occur in dry late winter. The transition phase between wet and dry winter is on Lohri. In terms of Ayurveda, it means shifting from Kapha to Vata atmosphere. The onset of dry winter is also the time for accelerated movement disorders in the body. Accelerated hypertension, arrhythmias, paroxysmal atrial tachycardia (PAT), brain hemorrhage, heart attack etc. all occur at the start of dry late winter. Unpublished compilation of data has also shown that maximum temporary pacemakers are also put during this season. The correct lifestyle in this season has been defined in Ayurveda and it involves reducing consumption of stringent, bitter and pungent foods.
Bioethical issues in medical practice
Living wills

Smita N Deshpande

Head, Dept. of Psychiatry, De-addiction Services
PGIMER-Dr. Ram Manohar Lohia Hospital
Park Street, New Delhi

This dilemma arises from two issues- living wills, and the problem of old couples living alone together.

A 65-year-old man is brought to emergency with subarachnoid hemorrhage. With aggressive and timely treatment he is shifted to the ventilator. Over the next few days his condition deteriorates and he is declared brain dead. He has left a living will saying that if he is incapacitated or comatose, his life should not be artificially extended. His tearful wife however insists that the doctor keeps trying and ‘give him another chance’ as she has read about cases recovering from coma after years. The hospital too will not mind as the ventilator will be paying for itself. What should the treating doctor do in these circumstances?

a) Leave well enough alone, continue treatment as usual, and continue charging for his and the hospital’s services.

b) Insist on application of the living will in letter and spirit- in which case he may face action for shifting the patient to the ventilator in the first place

c) Involve the hospital ethics committee in the decision

d) Approach the court

Any other suggestions and solutions? Do write in!

Adapted from: Bioethics Case Studies (AUSN and EEI, November 2013): http://www.eubios.info/
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Inspirational Story
The Cross Room

The young man was at the end of his rope. Seeing no way out, he dropped to his knees in prayer. "Lord, I can't go on," he said. "I have too heavy a cross to bear." The Lord replied, "My son, if you can't bear its weight, just place your cross inside this room. Then open another door and pick any cross you wish."

The man was filled with relief. "Thank you, Lord," he sighed, and did as he was told. As he looked around the room he saw many different crosses; some so large the tops were not visible. Then he spotted a tiny cross leaning against a far wall. "I'd like that one, Lord," he whispered. And the Lord replied, "My son, that's the cross you brought in."
eMedi Quiz
A 60-year-old male presented to the emergency with breathlessness, facial swelling and dilated veins on the chest wall. The most common cause is:

1. Thymoma
2. Lung cancer.
3. Hodgkin's lymphoma.
4. Superior vena caval obstruction.

Yesterday’s Mind Teaser:  Which one of the following is a recognized x-ray feature of rheumatoid arthritis?

1. Juxta-articular osteosclerosis.
2. Sacroilitis.
3. Bone erosions.
4. Peri-articular calcification.

Answer for Yesterday’s Mind Teaser: 3. Bone erosions.

Answers received from: Dr Jainendra Upadhyay, dr poonam chablani, Dr.K.Raju, Dr Avtar Krishan, Dr.Bitaan Sen & Dr.Jayashree Sen,

Answer for 13th November Mind Teaser: 2. Interstitial lung disease.

Answers received from: Raju Kuppusamy, Dr Janiendra Upadhyay, Takaram Pagad, Dr Avtar Krishan.
Humor
Backseat driving

A wife was making a breakfast of fried eggs for her husband. Suddenly, her husband burst into the kitchen. ‘Careful,’ he said, ‘CAREFUL! Put in some more butter! Oh my Gosh! You’re cooking too many at once. TOO MANY! Turn them! TURN THEM NOW! We need more butter. Oh my Gosh! WHERE are we going to get MORE BUTTER? They’re going to STICK! Careful. CAREFUL! I said be CAREFUL!

You NEVER listen to me when you’re cooking! Never! Turn them! Hurry up! Are you CRAZY? Have you LOST your mind? Don’t forget to salt them. You know you always forget to salt them. Use the salt! USE THE SALT! THE SALT!’

The wife stared at him. ‘What in the world is wrong with you? You think I don’t know how to fry a couple of eggs?’

The husband calmly replied, ‘I just wanted to show you what it feels like when I'm driving.’
Readers column
Dear Sir, reading emedinews is very informative. Regards: Dr Suruchi
Press Release
The need for capping of compensation on alleged medical negligence cases

75 percent doctors reveal that they have faced violence at some point in their lives; either by the disgruntled relatives of a patient or someone else

While the medical profession is considered an extremely noble one, it is also the most vulnerable to acts of violence and false allegations. The reasons for this include the inability of people to understand that while a doctor saves lives, he is also a human and can only do his bit to save someone and cannot change what is inevitable. Subjecting a profession as crucial as this to the Consumer Protection Act is detrimental to its effective functioning for it creates unnecessary fear amongst the doctors and distrust amongst the patient community. As per the laws presently any amount of compensation can be provided for a medical negligence case and the law favors the most affluent section of the society.

Recently the Supreme Court of India awarded an amount of 11 crore rupees as compensation for medical negligence in a case. This judgment has caused a sense of panic among the medical professionals in our country. Subsequently in three more cases, the compensation awarded has been more than a crore. This has already resulted in a huge increase in the number of cases filed (several of which are on frivolous grounds) as well as a significant increase in the premiums paid to insurance companies.

Expressing their concern, Padma Shri Awardee Dr. A Marthanda Pillai – National President and Padma Shri Awardee Dr. KK Aggarwal, Honorary Secretary General IMA in a joint statement said, “Indian Medical Association (IMA) considers this as a very serious matter, and we fear that this may even result in increase in the expenses on medical care.A review of the literature by IMA shows that the process of capping of compensation of medical practice lawsuits has been well established in developed countries, and India needs to adopt the policies being practiced in developed countries to its requirements and can benefit greatly from their experience. In this regard, we have appealed to the Health Ministry who in return has set up an inter-ministerial committee to look into this matter in the coming six weeks. We are hopeful that this will help bring about amendments in the present act to cap the maximum allowable compensation in any case of medical negligence. Whilethere is a capping of Rs 2 lakhs for sterilization deaths and Rs 30,000 for sterilization failure, the government should devise solution for other kinds of medical negligence as well. ”.

IMA also feels that the following are important while dealing with medical negligence cases

• Mandatory screening of cases of medical negligence, before the case is admitted in the consumer court

• Mandatory provision of seeking expert medical opinion by the court before giving verdict on the technical issues

• Defining/ triaging the complaints into frivolous/ injurious/ grievous, etc. before submitting to the court of law

• Provision of penalty (to the Doctor/hospital) to be proportionate to the amount of compensation claimed

• The compensation is awarded on the basis of the income of the complainant. But irrespective of the income of the patient, the hospital always charges the same amount for services. Hence, the compensation should only be decided on the basis of the cost of the treatment.

• Healthcare Arbitrator: Just like insurance disputes are sent to arbitrators, an alternative dispute resolution mechanism can be looked into. The provision will be for providers and patients to submit disputes over alleged malpractice to a third party other than a court. This will help compensate victims faster, more equitably and with lower transaction costs (As of now the administrative cost of such lawsuits is approximately 53% of the total compensation claimed).

• Administrative Compensation Systems: It proposes to replace the current tort system with an administrative compensation system. The “health courts” model substitutes a specially trained judge as the finder of fact and arbitrator of law for the current system’s generalist judges and juries

• Judicial audits of the lower courts to assess fairness and judicious application of mind by the lower court

• A comparative analysis of the outcome of judicial verdicts given in past should also be carried out for a better understanding of the effectiveness of the compensations awarded to date.

• The legal profession is kept out of the ambit of consumer court. Hence, medical services should also be excluded from the consumer court.