March 16  2015, Monday
editorial
5 Ways to Stop A–Salting Your Kidney
Dr KK AggarwalEating white salt is like a slow poison. If the amount of salt is reduced to less than one teaspoon per day, a large percentage of people with high blood pressure will have normal blood pressure. High salt intake by increasing blood pressure leads to kidney damage over a period of time and kidney failure. Consume less of anything, which is artificially white such as white sugar, white maida and white rice.

Most people who have high salt in their body will have characteristic features of liking for both ice cold as well as boiling beverages.

5 tips to reduce salt in your diet
  1. Make reading food labels a habit. Sodium content is always listed on food labels. Sodium content can vary from brand to brand, so compare and choose the lowest sodium product. Certain foods do not taste particularly salty but are actually high in sodium, such as cottage cheese, so it is critical to check labels.
  2. Stick to fresh meats, fruits and vegetables rather than their packaged counterparts, which tend to be higher in sodium.
  3. Avoid spices and seasonings that contain added sodium, for example, garlic salt. Choose garlic powder instead.
  4. Many restaurants list the sodium content of their products on their websites, so do your homework before dining out. Also, you can request that your food be prepared without any added salt.
  5. Try to spread your sodium intake out throughout the day; it’s easier on your kidneys than eating lots of salt all at once.
eMedipics IMA,IJCP,HCFI
Health Check Up and CPR 10 Camp at S K V I.A.R.J Pusa Road School 2nd February 2015
News
  • It has been suggested that e-cigarette advertisements might promote smoking habit. A lot of money is invested in United States on these advertisements. A recent study has observed that these ads abate abstinence in smokers.
  • A research has concluded that our genome comprise of genes that are not passed down from our ancestors. These genes might get incorporated in human genome through horizontal transfer from species like bacteria.
  • A UN led campaign for tobacco free world - Experts have proposed UN to lead the efforts for attaining a world free of tobacco. It has been estimated that a world without tobacco can be achieved in less than 3 decades.
  • A study has found cochlear implants to benefit cognitive function in elderly with impaired hearing. Improvement in cognitive tests scores were observed after the use of implant. The device activates the auditory nerve in the ear.
Dr KK Spiritual Blog
Science behind regrets

In a US–based study, dying people were asked about their regrets, if any. The top five regrets were:
  1. I wish I had the courage to live a life I wanted to live and not what others expected me to live.
  2. I wish I had worked harder.
  3. I wish I had the courage to express my feelings.
  4. I wish I had stayed in touch with my friends.
  5. I wish I had let myself to be happier.
Regrets are always based on suppression of emotions or non–fulfillment of desires and needs. These need-based desires can be at the level of physical body, mind, intellect, ego or the soul. Therefore, regrets can be at any of these levels.

I did a survey of 15 of my patients and asked them a simple question that if they come to know that they are going to die in next 24 hours, what would be their biggest regret.

Only one of them, a doctor said that she would have no regrets.

Only one person expressed a physical regret and that was from a Yoga expert who said that her regret was not getting married till that day.

Mental regrets were two.
  1. A state trading businessman said, "I wish I could have taken care of my parents."
  2. A homeopathic doctor said, "I wish I could have given more time to my family."
Intellectual regrets were three.
  1. A lawyer said, "I wish I could have become something in life."
  2. A businessman said, "I wish I could have helped more people."
  3. A retired revenue inspector said, "I wish I had married off my younger child."
Egoistic regrets were two.
  1. One fashion designer said, "I wish I could have become a singer."
  2. A housewife said, "I wish I could have become a dietician."
Spiritual regrets were six.
  1. A Consultant Government Liaison officer said, "I wish I could have made my family members happy."
  2. A businessman said, "I wish I could have meditated more."
  3. A Homeopathic doctor said, "I wish I could have spent more time with my family."
  4. A reception executive said, "I wish I could have spent more time with my parents."
  5. An entertainment CEO said, "I wish I could have taken my parents for a pilgrimage."
  6. A fashion designer said, "I wish I could have worked more for the animals."
In a very popular and successful movie, Kal Ho Na Ho, the hero was to die in the next 40 days. When asked to remember the days of his life, he could not remember 20 ecstatic instances in life.

This is what happens with each one of us where we waste all our days and cannot remember more than 50 or even 20 of such instances. If we are given 40 days to live and if we live every day ecstatically, we can get inner happiness. Therefore, we should learn to live in the present instead of having a habit of postponing everything we do.

We should learn to prioritize our work and do difficult work first or else we would be in a state of constant worry till that work is over.

I teach my patients that they should practice confession exercise and one confession is to talk about your regrets and take them as challenge and finish before the next Tuesday. When working, there are three things which are to be remembered – passion, profession and fashion. Profession is at the level of mind, ego and spirit.

We should convert our profession in such a manner that it is fashionable and passionate. Passion means working from the heart and profession means working from mind and intellect and fashion means working the same at the level of ego which is based on show–off.
IMA,IJCP,HCFI
Cardiology eMedinewS
  • A post hoc analysis of data from the global EXAMINE (EXamination of CArdiovascular OutcoMes: AlogliptIN vs. Standard of CarE in Patients with Type 2 Diabetes Mellitus and Acute Coronary Syndrome) cardiovascular (CV) safety outcomes trial has suggested that in patients with type 2 diabetes and recent acute coronary syndrome (ACS), dipeptidyl peptidase 4 (DPP-4) inhibitor alogliptin compared to placebo did not increase the risk of heart failure (HF) outcomes. The findings are published in the Lancet.
  • New research shows that patients having heart surgery do not benefit if doctors wait until a patient has become substantially anemic before giving a transfusion. The data are published in the New England Journal of Medicine.
Pediatrics eMedinewS
  • Smoking marijuana daily for 3 years as a teen is linked with having an abnormally shaped hippocampus and long-term memory problems, suggests a new study published online in the journal Hippocampus.
  • A new stem cell study offers hope for children born with severe combined immunodeficiency disease (SCID) and other deadly genetic blood disorders. The findings are published online in Cell Stem Cell.
Make Sure
Situation: A patient with dengue fever developed shock.
Reaction: Oh my God! Why was the blood pressure of 90/80 ignored?
Lesson: Make sure that a pulse pressure of less than 20 is not ignored, it is an impending sign that the patient is going into shock.
Medicolegal
(Contributed by Dr Sudhir Gupta, Prof & Head, Forensic Medicine & Toxicology, AIIMS)

Sudden death – Autopsy

Left ventricular hypertrophy is the second leading cause of sudden cardiac death in adults in India
  • Longstanding high blood pressure causes secondary damage to the wall of the left ventricle, the main pumping chamber of the heart. Hypertrophy is associated with cardiac arrhythmias.
  • The mechanism of death in a majority of patients dying of sudden cardiac death is ventricular fibrillation and as a consequence there may be no prodromal symptoms associated with the death.
  • These patients may be going about their daily business and suddenly collapse without the typical features of myocardial infarction such as chest pain and shortness of breath. There are a number of cases in which patients feel the effect of myocardial ischemia. (Myocardial ischemia is associated with referred pain, classically to the front of the chest, the left arm and the jaw. Patients may feel generally unwell, with nausea, dizziness and vomiting).
  • These symptoms may precede the death for any length of time between a few minutes and several hours.
I had conducted the postmortem examination of four cases who were found dead in toilet during daily pursuits; these were cases of left ventricular hypertrophy that led to sudden death.
Dr Good Dr Bad
Situation: A patient with Mediclaim wanted angiography.
Dr. Bad: Get admitted for 24 hours.
Dr. Good: You can go home after six hours.
Lesson: If you can justify that due to technological advances, hospitalization is required for less than 24 hours, Mediclaim will be applicable.

(Copyright IJCP)
IJCP Book of Medical Records
IJCP’s ejournals
Wellness Blog

Don’t start if you do not drink; if you cannot stop, limit your intake
  • The definition of a standard drink differs in countries: US = 14–15 gm alcohol equivalent to 12 oz beer, 5 oz wine and 1.5 oz 80 proof liquor; UK 8 gm alcohol, Japan 19.75 gm alcohol and India 10 gm alcohol
  • A standard drink usually means a US drink.
  • Alcohol contents: Beer 5%; Malt liquor 7%; Table wine 12%; Fortified wine (sherry, port) 17%; Cordial liquor (aperitif) 24%; Brandy (single jigger) 40% and 80 proof gin, Vodka, whisky 40%
  • 10 ml of alcohol (hard liquor) = 0.8 gm of alcohol
  • 1oz = 30 ml
  • 12 oz of beer = 360 ml of beer (360×5% = 18 ml of alcohol = 14.4 gm of alcohol)
  • 18oz of beer = 8 to 9 oz of malt liquor = 5 oz of table wine = 3–4 oz of 45 wine = 2–3 oz of cordial liquor=1.5 oz of brandy=1.5 oz hard liquor
  • Binge drinking means 4 or more drinks at one time (women) or 5 or more at one time (men)
  • Heavy drinking means more than 7 drinks per week or 3 drinks per occasion (women) or more than 14 drinks per week or 4 drinks per occasion (men).
  • Moderate drinking means less than 2 drinks per day (women) and less than 3 drinks per day (men) and for people aged more than 65, less than two drinks per day
  • Safe limits: No level of alcohol compensation can be 100% safe for some people.
  • Contraindications: Pregnancy, present or strong family history of alcoholism, previous paralysis because of brain hemorrhage, liver disease, pancreas disease, running potentially dangerous equipment or machinery
  • Limit alcohol in acute gastritis, esophagitis, strong family history of breast cancer and pre cancerous GI lesions.
  • Ideal dose of alcohol = 6 gm per day
  • 10–15gm of ethanol is found in one glass of wine, one can or bottle of beer or one mixed drink.
  • One should not take more than two drinks (men), one drink daily (women).
  • Men under the age of 45 may experience more harm than benefit from alcohol consumption.
  • Alcohol benefits for the heart are only in 45+ people.
IMA,IJCP,HCFI
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

eMedi Quiz
High resolution computed tomography of the chest is the ideal modality for evaluating:

1. Pleural effusion

2. Interstitial lung disease

3. Lung mass

4. Mediastinal adenopathy

Yesterday’s Mind Teaser: The extent to which ionization of a drug takes place is dependent upon pKa of the drug and the pH of the solution in which the drug is dissolved. Which of the following statements is not correct?

1. pKa of a drug is the pH at which the drug is 50% ionized.

2. Small changes of pH near the pKa of a weak acidic drug will not affect its degree of ionization.

3. Knowledge of pKa of a drug is useful in predicting its behavior in various body fluids.

4. Phenobarbitone with a pKa of 7.2 is largely ionized at acid pH and will be about 40% non-ionized in plasma.

Answer for yesterday’s Mind Teaser: 4.Phenobarbitone with a pKa of 7.2 is largely ionized at acid pH and will be about 40% non-ionised in plasma.

Correct Answers received from: Dr Virendra Kharpate, Dr Shangarpawar, Dr Poonam Chablani, Dr Avtar Krishan, Dr KV Sarma, Raju Kuppusamy

Answer for 14th March Mind Teaser: c. Nail psoriasis

Correct Answers receives: Dr KV Sarma, Dr Poonam Chablani, Raju Kuppusamy, Dr Jainendra Upadhyay
Rabies News (Dr A K Gupta)
Should modern rabies vaccines meant for use in man be given to animals?

It is advisable to use human vaccines for human use and use the veterinary vaccines for animals.
Quote of the Day
Excellence is a continuous process and not an accident. APJ Abdul Kalam
Reader Response

Most doctors do not respond to mandatory notification for TB cases. This is the reality. Please think of a way out. Dr PK Majee.
IMA NEWS
Facts about Tuberculosis (TB)
What is the difference between TB infection and TB disease?
  • In most people who breathe in TB bacteria, the body's immune system is able to fight the TB bacteria and stop them from multiplying. This is called TB infection. People who are infected with TB do not feel sick, do not have any symptoms and cannot spread TB.
  • If an infected person's immune system cannot stop the bacteria from multiplying, the bacteria eventually cause symptoms of active TB, which is called TB disease. Only 10% of all people with TB infection may suffer from the TB disease.
  • People with conditions like HIV, diabetes mellitus, malnutrition and those on treatment with immunosuppressant drugs (anti-cancer, corticosteroids etc) are at a greater risk of developing TB disease once infected.
EIMA NEWS
Bar code on drug packaging to help track and trace authenticity
Sushmi Dey | 14 March 2015, 12:35 PM IST
NEW DELHI: To ensure medicines sold are genuine products, the health ministry has developed a `Track and Trace' mechanism which will enable consumers to check safety and authenticity of a drug through the internet.

Under the system, the primary , secondary and tertiary packs of medicines will carry a unique bar code, which will be allotted to each manufacturer. Consumers, buying medicines from retail pharmacy store, can use the bar code on the pack on internet to check information about the source of manufacturing of the product, whether it is an approved drug, it's date of expiry as well as price fixed by the government etc.

The move is significant because of the highly fragmented In dian pharmaceutical market, pegged at around Rs 89,000 crore annually. The huge size of the market makes it difficult for regulators and monitoring agencies to track medicines, mainly in rural areas and distant villages. This leads to a potential risk of spu rious, inefficacious and low quality medicines being sold in the market.

The government is yet to finalize a date for launching the 'Track and Trace' system in the local market. "Rules for implementing the Track and Trace mechanism will be framed and will be operationalized after allowing a reasonable period for transition," Union health minister J P Nadda said. He added, compliance will be mandatory for all drug manufacturers.

Following allegations from some international markets that spurious medicines are making their way from India, the commerce ministry in 2012 had made it mandatory for pharmaceuticals exporters to have barcoding for secondary and tertiary packaging on their export consignments.

Now, the government is also working to create an integrated database with all details of a product, which will enable tracking and monitoring of these products.

'Government does not pay heed to our demands until we strike'
Ritwika Mitra

Doctors say strike is the last resort and often triggered by attacks on them Doctors’ going on strike is not uncommon. But with OPD services paralysed and patients being turned away from the OPDs at short notice raises questions of ethics.

Most doctors claim that the administration turns a deaf ear to their demands till the time they go on strike. Seeking appointments with the officials in the Health Department to communicate their problems itself is a “major challenge”.

A strike, they say, is the last resort and often triggered by attacks on doctors.

“It may not be sound to go on strike from an ethical point of view. But the government does not pay heed to our demands. In a letter to Union Health Minister J P Nadda in February, we underlined our demands for better security measures and infrastructure in these hospitals. But nothing has changed so far,” says Dr Balwinder Singh, president, Federation of Resident Doctors Association (FORDA).

“Three Delhi Police personnel have been deployed in the premises of Safdarjung Hospital since the strike at GTB, which will not serve any purpose in case of an emergency,” says Dr Singh.

The situation remains the same across other hospitals as well, he added.

FORDA had given a two-week notice that if the situation did not improve they would go on strike from March 2.

The strike was, however, deferred after the government sought more time to put things in place.

“When resident doctors go on strike, they do not stop senior consultants from attending to patients. Also, a notice is served beforehand. So this is not unethical,” says Dr Shashank Pooniya, general secretary, Resident Doctors Association, AIIMS.

“We want the administration to address issues like doctors working for 48 hours at a stretch, extra pay for more work hours and better hostel facilities,” says Dr Pooniya. With any number of attendants coming in along with patients, female doctors are often molested.

“Several cases have been reported from the state-run hospitals in which female doctors were abused and molested. The spate of assault cases on doctors are also on the rise. The apathy of the administration in taking corrective measures forces resident doctors to go on strike,” says Dr S K Poddar, Honorary State Secretary, Delhi Medical Association (DMA).

When doctors at GTB Hospital were on strike for five days, state Health Minister Satyendra Jain promised to deliver on their demands.

With a strike apparently being the only time when administration considers a dialogue, it is often seen by doctors as a “solution” to resolve their problems.

Resident doctors said they have been trying to highlight the issues faced by patients and doctors alike at the hospital for the past six months, but in vain.

During the recent strike, with other prominent hospitals joining in with a one-day strike, few hospitals managed to run basic OPD services and pressed the consultants into emergency services. Resident doctors are considered the backbone of government hospitals.

In cases where RDAs give notices to the administration, it is important that the hospitals plan ahead so that “services go on uninterrupted”.

“In a case where Safdarjung doctors had gone on strike, the Delhi Medical Council had issued an advisory that doctors should not resort to strikes. Cases of medical negligence reported due to doctors going on strike is not acceptable. There should be no impact of the strike on emergency services,” says Dr Girish Tyagi, Registrar, Delhi Medical Council (DMC).

People for Better Treatment, an NGO, had earlier filed a PIL seeking action against doctors in Safdarjung Hospital alleging that the strike had resulted in several cases of medical negligence.

The recent strike also attracted flak from within the doctors’ community with a section of resident doctors saying strikes would not help resolve the issues.

“In turn, it will bring the entire community a bad name,” says a resident doctor at a civic-body-run hospital.

According to Dr K K Aggarwal, Honorary General Secretary, Indian Medical Association, the resident doctors cannot be blamed alone.

“In case of any medical negligence, the medical superintendents and the senior consultants also will be held responsible. If doctors are giving a notice before going on strike, the onus is on the hospital administration to arrange for alternative options,” says Agarwal.

“The Medical Council of India ethics guidelines clearly state the patient should not suffer under any circumstances,” he adds.

The Union Ministry of Health and Family Welfare on Saturday issued a letter addressing the demands of the FORDA.

According to the letter, security services at hospitals will be improved and medical superintendents have been asked to resubmit the redevelopmemt plans of hostel infrastructure.

The issue of extra pay for additional work hours will be addressed too, it says.
WMA News

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Event
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Inspirational Story
Cure for Sorrow

There is an old Chinese tale about a woman whose only son died. In her grief, she went to the holy man and said, "What prayers, what magical incantations do you have to bring my son back to life?"

Instead of sending her away or reasoning with her, he said to her, "Fetch me a mustard seed from a home that has never known sorrow. We will use it to drive the sorrow out of your life." The woman went off at once in search of that magical mustard seed. She came first to a splendid mansion, knocked at the door, and said, "I am looking for a home that has never known sorrow. Is this a place? It is very important to me."

They told her, "You’ve certainly come to the wrong place," and began to describe all the tragic things that recently had befallen them.

The woman said to herself, "Who is better able to help these poor, unfortunate people that I, who have had misfortune of my own?" She stayed to comfort them, and then went in search of a home that had never known sorrow. But wherever she turned, in hovels and in other places, she found one tale after another of sadness and misfortune. She became so involved in ministering to other people’s grief that ultimately she forgot about her quest for the magical mustard seed, never realizing that it had, in fact, driven the sorrow out of her life.
All contact of TB cases should be identified at the earliest
24th March World TB day One sputum positive case of TB can spread the infection to ten others said Padma Shri Awardee Dr A M Pillai national President and Padma Shri Awardee Dr KK Aggarwal Honorary Secretary General IMA. A person who is sputum positive for TB is considered to have been contagious beginning three months prior to the first smear-positive sputum or the onset of symptoms, whichever is earlier. For individuals with AFB smear-negative TB, the contagious period is considered to have begun one month prior to onset of symptoms.

IMA release said that in the last one year IMA has been able to notify one lac additional new cases of TB in the society and thus has been able to stop the spread of TB to atleast ten lac persons in the society.

Al contacts of TB patients should also be investigated promptly to identify secondary cases of active and latent tuberculosis. Contacts should include family members and other close contacts in the community.

Within a healthcare facility, contact investigation should also be done if a patient with active TB received care prior to prompt institution of infection control measures. Contact investigation is also warranted if a healthcare worker who has had exposure to others in a healthcare setting is diagnosed with active TB.

Person-to-person transmission of TB occurs via inhalation of droplet nuclei. Individuals with active untreated pulmonary or laryngeal disease are contagious, particularly when cavitary disease is present or when the sputum is TB smear positive. Patients with sputum smear-negative, culture-positive pulmonary TB can also transmit infection.

Suspected or confirmed cases of TB should be reported promptly to the local public health department in order to expedite contact investigation and plan outpatient follow-up.

Infectious patients (eg, patients with AFB smear-positive sputum) may be discharged to home, provided there are no household members who are immuno-compromised or younger than four years of age.

Infectious patients should remain at home as much as possible; when receiving visitors or leaving home, patients should wear a surgical mask (not an N95 mask; surgical masks are designed to prevent the respiratory secretions of the person wearing the mask from entering the environment).
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A Following Person

A teacher was sitting at her desk grading papers when her first–grade class came back from lunch. Alice informed the teacher, "Paul has to go to the principal’s office."

"I wonder why," the teacher mused.

"Because he’s a following person," Alice replied.

"A what?" the teacher asked.

"It came over the loudspeaker: ‘The following persons are to go to the office.’"
The type of food you eat also matters
Everyone needs a mix of proteins, carbohydrates, and fats, plus enough vitamins and minerals for optimal health. But some of the food choices within these categories are better than others, 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 IMA.
  1. Added sugar: Whether it’s white granulated sugar, brown sugar, high–fructose corn syrup, corn sugar, or honey, sugar contains almost no nutrients and is pure carbohydrate and full of empty calories, causing blood sugar to rise and fall like a roller coaster. Soft drinks and other sugar–sweetened beverages are the primary source of added sugar in the diet and a major contributor to weight gain. One extra 12–ounce can of a typical sweetened beverage a day can add on 15 pounds in a year. Those liquid calories aren’t as satisfying as solid food.
  2. Dairy fat. Ice cream, whole milk, and cheese are full of saturated fat and some naturally occurring trans fat both bad for the heart. The healthiest milk and milk products are low–fat versions, such as skim milk, milk with 1% fat and reduced–fat cheeses.
  3. Baked sweets. Cookies, snack cakes, doughnuts, pastries etc are packed with processed carbohydrates, added sugar, unhealthy fats and often salt.
  4. White carbohydrates. Bread, pasta, potatoes, rice, cookies, cake, or pancakes are bad. One should opt for whole–grain versions. One can choose homemade cookies or bars using grains such as oatmeal, and less sugar and unhealthy fats.
  5. Processed and high–fat meats. Meats like bacon, ham, pepperoni, hot dogs, and many lunch meats are less healthy than protein from fish, skinless chicken, nuts, beans, soy and whole grains. Fresh red meat should be eaten sparingly and the leanest cuts selected.
  6. Salt. Current dietary guidelines recommend reducing sodium to 1,500 mg per day and not exceeding 2,300 mg per day. But most of us get 1½ teaspoons (or 8,500 mg) of salt daily. That translates to about 3,400 mg of daily sodium.