November 18   2015, Wednesday
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EDITORIAL
Dr KK AggarwalDr KK Aggarwal AAP takes a stand against nontherapeutic use of antibiotics in animals

The use of antimicrobial agents in food animals is a less commonly recognized cause of antibiotic resistance. But, now a technical report by the American Academy of Pediatrics (AAP) has described how the use of antibiotics in livestock as growth stimulants and not for treating illnesses, contributes to the threat of antimicrobial resistance and potential infection through the food supply, especially among young children who are most vulnerable to infection.

This is the first report from the AAP on this subject. Jerome Paulson, MD, of the Committee on Environmental Health and co-author of the report said, “It's a document that we as pediatricians and the Academy as an organization can use to make the argument to stop the large-scale use of antibiotics in animal feed and water and decrease the use of antibiotics in animals for growth promotions and other nontherapeutic purposes.”

Overprescribing of antibiotics is common in the agriculture and food business, and these drugs can be given to food animals without a prescription or veterinary oversight unlike with humans. The report notes that about 80% of the overall tonnage of antimicrobial agents sold in the United States in 2012 was for animal use, and approximately 60% of those agents are considered important for human medicine.

This issue will ultimately be resolved by either the FDA and the Department of Agriculture or by the marketplace, with large purchasers of meat and poultry telling agricultural business that they will not buy products that have been treated with antibiotics.

The report titled ‘Nontherapeutic Use of Antimicrobial Agents in Animal Agriculture: Implications for Pediatrics’ is published in the journal Pediatrics.
EMEDINEXUS STATEMENT
Amit Sharma and Nilesh Aggarwal

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Breaking News
WHO survey reveals widespread public misconceptions about antibiotic resistance

A WHO multi-country survey, conducted in 12 countries, sheds light on gaps in understanding and misconceptions about antibiotic resistance. The countries included Barbados, China, Egypt, India, Indonesia, Mexico, Nigeria, Russian Federation, Serbia, South Africa, Sudan and Viet Nam. Some of these are:

• 64% know antibiotic resistance is an issue that could affect them and their families, but how it affects them and what they can do to address it are not well understood.

• 64% of respondents believe antibiotics can be used to treat colds and flu, despite the fact that antibiotics have no impact on viruses.

• 32% believe they should stop taking antibiotics when they feel better, rather than completing the prescribed course of treatment.

• 76% of respondents think that antibiotic resistance happens when the body becomes resistant to antibiotics.

• 66% believe that individuals are not at risk of a drug-resistant infection if they personally take their antibiotics as prescribed

The survey findings coincide with the launch of a new WHO campaign ‘Antibiotics: Handle with care’—a global initiative to improve understanding of the problem and change the way antibiotics are used… (WHO)

9% children suffering from TB resistant to key drug

A study covering Chennai, Hyderabad, Kolkata and Delhi has found that almost 90% of children with TB are resistant to rifampicin, one of the first-line drugs used in the treatment of the infectious disease. This is 6% more than what was previously estimated. The project, initiated last year by the Revised National TB Control Programme (RNTCP), found that 8% of the 22,000 suspected paediatric TB cases (0-14 years) tested positive, of which nearly 9% were resistant to rifampicin. Dr Amar Shah, National consultant for HIV/TB for RNTCP said, “Our survey showed a staggering 9%, which is quite high. It's surprising because many of them haven't been exposed to antibiotics before, which means they are acquiring the infection in the MDR form at the time of transmission." Delhi had the highest incidence of TB at 12.2% and the least in Chennai at 5.4%. Rifampicin resistance was seen most in Kolkata at 12%. Chennai had the least number of cases at 2.9%. (ET Healthworld - Ekatha Ann John)
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Specialty Updates
• Peripheral thermometers lack clinically acceptable accuracy and should not be used when precise measurement of core body temperature will influence clinical decisions, suggested a meta-analysis published online November 16 in the Annals of Internal Medicine.

• New findings, presented at the American Heart Association (AHA) 2015 Scientific Sessions, suggest that patients with type 2 diabetes and established CVD who received the antidiabetic sodium-glucose cotransporter 2 (SGLT2) inhibitor empagliflozin, had a reduced risk of being hospitalized for heart failure or dying from CVD during a median follow-up of 3.1 years, even if they had HF at baseline, in comparison with placebo.

• Women with knee pain had a significantly increased risk of all-cause and cardiovascular disease mortality, with or without radiographic osteoarthritis (ROA), but not with ROA alone, suggested new research published in the Annals of the Rheumatic Diseases.

• New research has identified how Salmonella infections that have spread to the blood and organs can lead to life-threatening thrombosis. Researchers stated that these systemic infections trigger the development of inflammation, which then leads to thrombosis. The findings are published in the Journal of Clinical Investigation.

• Laparoscopic cholecystectomy can effectively prevent recurrent attacks of idiopathic acute pancreatitis (IAP), suggests new research published in the November issue of the Annals of Surgery.

• The risk for epilepsy was higher in children with hospital-diagnosed pertussis infections compared with the general pediatric population; however, the absolute risk for epilepsy was low, reported a population-based cohort study published in JAMA.

• Endometrial and ovarian cancer can be detected by analysis of uterine lavage fluid, reported a proof-of-concept study published online in the Journal of Clinical Oncology.

• The combination of ombitasvir, paritaprevir, and ritonavir plus dasabuvir, with or without ribavirin, appears to be safe and effective in patients with compensated cirrhosis caused by genotype 1 hepatitis C infection. The preliminary results from the phase 3b TOPAZ-II trial were presented at the Liver Meeting 2015.
eSpiritual
Why do we put on Tilak on the forehead?

The Tilak is a mark of auspiciousness and invokes a feeling of respect in the wearer and others. It is recognized as a religious mark. Its form and color vary according to one’s caste, religious sect or the form of worship of the person in question.

Tilak is applied on the forehead with sandal paste, sacred ash or kumkum, a red turmeric powder. In a wedding, a Kumkum tilak is applied on the forehead of both the bride and groom.

In earlier times, the four castes (based on varna or color) – Brahmana, Kshatriya, Vaishya and Shudra – applied marks differently. The Brahmin applied a white chandan mark signifying purity, as his profession was of a priestly or academic nature. The Kshatriya applied a red kumkum mark signifying valor as he belonged to the warrior race. The Vaishya wore a yellow kesar or turmeric mark signifying prosperity as he was a businessman or trader devoted to creation of wealth. The Shudra applied a black bhasma, kasturi or charcoal mark signifying service as he supported the work of the other three castes.

The devotees of Shiva apply sacred ashes (Bhasma) on the forehead as a Tripundra (three parallel horizontal lines); the devotees of Vishnu apply sandal paste (Chandan) in the shape of "U" and the worshippers of Devi or Shakti apply Kumkum.

The tilak is applied in the spot between the eyebrows, which is the seat of memory and thought. It is known as the Aajna Chakra in the language of Yoga. The Tilak is applied with the prayer – "May I remember the Lord. May this pious feeling pervade all my activities. May I be righteous in my deeds." Even when we temporarily forget this prayerful attitude, the mark on another reminds us of our resolve. The tilak is thus a blessing of the Lord and a protection against wrong tendencies and forces. The entire body emanates energy in the form of electromagnetic waves – the forehead and the spot between the eyebrows especially so. That is why worry generates heat and causes a headache. The tilak cools the forehead, protects the wearer and prevents energy loss. Sometimes the entire forehead is covered with chandan or bhasma.

Using plastic reusable "stick bindis" is not very beneficial, even though it serves the purpose of decoration.
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Legal Quote
Ms Nisha Priya Bhatia vs Government of NCT of Delhi on 23 July, 2014

“The Commission is of the view that the patient's right to obtain his medical record is not only protected under RTI Act, but also under the regulation of Indian Medical Council, which is based on world medical ethics, and also as a 'consumer' under Consumer Protection Act, 1986...”
Medicofinance
What to Look for in an Investment

• Cost sharing arrangement
• Structure of investment and what flexibility is offered
• Substance, not pretty pictures, promises or endorsements
• How the investment will react to economic changes over time?
• How it will be valued in the future?

(Source: IJCP)
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22nd MTNL Perfect Health Mela, the annual flagship event of the Heart Care Foundation of India
Will provide all support for research on medicinal properties of Ganga water for holistic health: J P Nadda

To further investigate the claim made through various existing research and studies that the waters of Ganga river have medicinal properties which destroy various kinds of bacteria and microbes, in order to use it for holistic human health, the Union Minister for Health & Family Welfare Shri J P Nadda has assured all support for this research including financial assistance. He stated this at the workshop organised today at AIIMS, New Delhi on the “Non-putrefying properties of Ganga Water”… (PIB)
Government to incentivise companies to produce bulk drugs likely
The government is working on a package to incentivise both state-run and private companies to produce ingredients that are used in making medicines as part of a plan to reduce dependence on China and boost the 'Make in India' program. As part of the package, the government is mulling revival of two sick public sector units involved in production of active pharmaceutical ingredients (APIs) or bulk drugs, besides inviting private companies to set up manufacturing units…(ET Healthworld - Kirtika Suneja)
A new clinical sign

Dr Krishna Kumar R
Consultant Spine Surgeon & Clinical Associate Professor
Amrita Institute of Medical Sciences, Cochin

I have recently described a new clinical sign termed ''Sternum into Abdomen Deformity'' along with world renowned Spine surgeon Dr Lawrence G Lenke, which was published in the leading International journal 'Spine' http://www.ncbi.nlm.nih.gov/pubmed/26020846. This term is descriptive of the resultant severe kyphosis due to osteoporotic spinal fractures with prominent abdominal wall crease from sternal/lower rib cage pressure on the abdomen, causing gastrointestinal dysfunction severe enough to cause weight loss.

This article describes a patient who had severe thoracolumbar kyphosis causing compression of his stomach by his sternum with lower rib cage, resulting in reduced gastric volume and leading to early satiety in spite of a good appetite. The patient became cachectic because of inadequate food intake and lost 25 lb of body weight. The patient was offered surgical realignment of his spinal deformity through an all posterior approach and was able to take adequate food and regained weight. One must be mindful of gastric disturbances when treating patients with osteoporotic compression fractures.
UK Nurse who had Ebola relapse now free of virus
A Scottish nurse who was hospitalized last month after she suffered a relapse of Ebola is now free of the deadly virus and was transferred from the Royal Free Hospital in London to Queen Elizabeth University Hospital in Glasgow. Pauline Cafferkey was diagnosed with Ebola after returning from Sierra Leone. She was treated at the Royal Free Hospital and discharged in January. However, she was readmitted to the hospital last month for treatment of meningitis the developed due to lingering Ebola in her body. She is in stable condition, according to Queen Elizabeth University Hospital. Ebola can remain in the body for months, even after patients have recovered, experts say. In West Africa, thousands of Ebola survivors have lingering health problems... (Medscape)
India to adopt injectable polio vaccination
India will join global efforts to introduce injectable polio vaccine (IPV) in the country’s routine immunisation programme in a phased manner. In the first phase, six States Assam, Bihar, UP, Punjab, Gujarat and Madhya Pradesh will be covered with three-month-old babies to be given a single shot of IPV. These States have over 50 per cent of the total population of 2.8 crore kids in the country. The IPV will be given along with the Oral Polio Vaccine (OPV) drops which are being presently administered in children in the age group of 0-5 years in the country’s universal immunisation programme. “IPV will be introduced in all the States within next six months as per the WHO’s Polio Eradication and Endgame Strategic Plan 2013-2018,” said a senior official from the Union Health Ministry which oversees the polio eradication programme in the country. As per the WHO plan, at least one dose of IPV will be introduced into routine immunisation programmes globally by 2015, after which trivalent oral polio vaccines (OPV) will be replaced with bivalent OPV in all OPV-using countries - setting the stage for eventually ending bOPV use by 2020… (The Pioneer – Archana Jyoti)
Pediatric syringes reduce blood loss in the ICU
New research presented at the American Society for Clinical Pathology 2015 Annual Meeting says that for patients in critical care units, blood can be drawn with a pediatric syringe instead of a standard 3 mL syringes. "When overdone, phlebotomy can lead to transfusion and anemia, and transfusions have a lot of complications associated with them. We changed from using a 3cc syringe to a 1cc syringe, and in the last year, we saved patients in our cardiovascular intensive care unit alone about 25,000 mL of blood — which is a lot of blood," said Phill Jensen, laboratory manager at University of Utah Health Sciences in Salt Lake City. Daily phlebotomy in the ICU steals a mean of 40 to 70 mL of blood… (Medscape)
NIH Scientists identify potential molecular target for reducing obesity-related inflammation
Overeating by individuals with obesity often triggers inflammation, which has been linked to such diseases as asthma and Type 2 diabetes. In the study, published in The Journal of Clinical Investigation (Nov. 3, 2015) the investigators found that a protein called SIRT3 provides resistance to this inflammatory response and could potentially prevent or reverse obesity-associated diseases of inflammation. Previous research has shown that intermittent fasting or intermittent calorie restriction — by way of eating fewer calories for a few days a month — reduces inflammation.
eWellness
Sodium phosphate enemas in the elderly should be avoided

Sodium phosphate enemas are used in the treatment of constipation and for preparation for flexible sigmoidoscopy. Sodium phosphate enema use in older adults (mean age 80 years, range 61 to 89 years) is associated with hypotension, volume depletion, hyperphosphatemia, hypo– or hyperkalemia, metabolic acidosis, severe hypocalcemia, renal failure and EKG changes (prolonged QT interval). In patients over the age of 70 years use warm water enemas rather than sodium phosphate enemas.
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/

Response received

The doctor should tell her that brain dead persons can never be revived. Once dead always dead if brain is dead. He should tell her it was his last wish to donate his organs and if she agrees then the organs be donated and if not she should be politely requested to take his body. Dr BR Bhatnagar

Response received for the case scenario ‘Rights and duties of a parent’ published on 15th Nov

The pregnancy must be terminated before it is too late. An intellectually deficient woman may insist on continuation of pregnancy, but she is not medically fit to take any decision. She will be unable to take care of the new born and even of herself, who will bear the responsibility of both for whole life. Finding the person and holding him responsible is too theoretical an approach, a person of substance would not have done such a heinous crime, forget his owning and taking responsibility, and what if he is already married. Not terminating the pregnancy to save a life is too idealistic a view in this case. Why make the new arrival suffer punishment and live a cursed life, he/she will curse the father, pity the mother and pity the self, suffer a stigma and mental torture. Dr (Col) R N Kothari, Prof & Head, Dept of Ophthalmology, SBKS MI&RC, Vadodara
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Inspirational Story
Follow your dream

Once upon a time, there was a large mountainside, where an eagle’s nest rested. The eagle’s nest contained four large eagle eggs. One day an earthquake rocked the mountain causing one of the eggs to roll down the mountain, to a chicken farm, located in the valley below. The chickens knew that they must protect and care for the eagle’s egg, so an old hen volunteered to nurture and raise the large egg. One day, the egg hatched and a beautiful eagle was born. Sadly, however, the eagle was raised to be a chicken. Soon, the eagle believed he was nothing more than a chicken.

The eagle loved his home and family, but his spirit cried out for more. While playing a game on the farm one day, the eagle looked to the skies above and noticed a group of mighty eagles soaring in the skies. "Oh," the eagle cried, "I wish I could soar like those birds." The chickens roared with laughter, "You cannot soar with those birds. You are a chicken and chickens do not soar." The eagle continued staring, at his real family up above, dreaming that he could be with them. Each time the eagle would let his dreams be known, he was told it couldn't be done. That is what the eagle learned to believe. The eagle, after time, stopped dreaming and continued to live his life like a chicken. Finally, after a long life as a chicken, the eagle passed away.

Moral of the story: You become what you believe you are. So if you ever dream to become an eagle follow your dreams, not the words of a chicken.
eMedi Quiz
A 20-year-old man complains of difficulty in reading the newspaper with his right eye. Three weeks after sustaining a gunshot injury to his left eye. The most likely diagnosis is:

1. Macular edema.
2. Sympathetic ophthalmia.
3. Optic nerve avulsion.
4. Delayed vitreous hemorrhage.

Yesterday’s Mind Teaser:  A vitreous aspirate has been collected in an emergency at 9 pm what advice you like to give to the staff on duty regarding the overnight storage of the sample.

1. The sample should be kept at 4° C.
2. The sample should be incubated at 37°C.
3. The sample should be refrigerated deep freezer.
4. The sample should be refrigerated for the initial 3 hours and then incubated at 37°C.

Answer for Yesterday’s Mind Teaser: 1. The sample should be kept at 4° C.

Answers received from: Dr Rajesh S Joshi, Dr Jainendra Upadhyay, Daivadheenam Jella, Dr B R Bhatnagar, Dr K V Sarma, Dr Bitaan Sen & Dr Jayashree Sen, Dr Prasad Salunkhe, Dr K Raju, Dr Avtar Krishan, Dr Poonam Chablani.

Answer for 16th November Mind Teaser: 4. Superior vena caval obstruction.

Answers received from: Dr K V Sarma, Dr K Raju, Dr Avtar Krishan, Dr Jainendra Upadhyay, Daivadheenam Jella, Dr B R Bhatnagar, Dr A C Dhariwal.
Humor
High Blood Pressure

When a physician remarked on a new patient's extraordinarily ruddy complexion, he said, "High blood pressure, Doc. It comes from my family." "Your mother's side or your father's?" the doctor asked. "Neither," he replied. "It's from my wife's family."

"Oh, come now," the doctor said. "How could your wife's family give you high blood pressure?" He sighed. "You oughta meet 'em sometime, Doc!
Readers column
Dear Sir, Very informative news. Regards: Dr Kartik
Press Release
What is epilepsy and how it affects an individual’s quality of life?

Out of 50 million people suffering from epilepsy worldwide, almost 10 million reside in India The high incidence of the disease in India can attributed to the lack of knowledge about antiepileptic drugs, limited financial resources and conventional cultural beliefs

Epilepsy is often characterized as a neurological disorder causing sensory disturbance and seizures in the brain. To elaborate further, a seizure is a sudden change in behavior, which is caused by brain dysfunction. In addition to this, some seizures are provoked i.e. one that occur in metabolic derangements, stimulated by consumption of drugs or alcohol and in situations like acute paralysis or acute encephalitis. Such patients are not considered to have epilepsy because these seizures wouldn’t occur in the absence of the sources of provocation.

According to research, less than 50 percent of epilepsy patients have reported identifiable causes of the disease like head trauma, paralysis, infection, and brain tumor or brain malformation. In addition to this, it is believed that having one seizure does not always mean that the patient would always get a seizure.

Speaking on the topic, Padma Shri Awardee Dr. K K Aggarwal, Honorary Secretary General, IMA and President, HCFI said, “Hospitalization is not recommended in all the cases. A patient requires medical assistance in the first seizure only if it is associated with prolonged post seizure altered level of consciousness. In majority of the cases, medical experts have advised that patients with unprovoked seizure should not be allowed to drive for some time. Unlike adults, in children, a seizure can occur with high-grade fever. In adults, the first episode of seizure may be due to worms in the brain. In such a situation, an individual should go for an MRI test, ECG test or a CT scan. Unlike common misconceptions, a patient with seizure can get married, live a normal life and produce children. The disease has its own medical roots that stimulate its occurrence and should not be stereotyped as a form of insanity or mental illness and subjected to associated social superstitions”.

“In addition to this, individuals belonging to a traditional household setting suggest that putting fingers inside the patient’s mouth might revive him of his unconscious state, instead it is recommended that a spoon is used to prevent a n nn ykuuk6rtukiiiu43tongue bite. Using fingers can injure a patient and as well as the individual who is helping the patient,” he added.

A patient who has developed epilepsy fall will have stiffness in his body; as compared to a patient with a loss of consciousness will have his body fall loose. In both the cases, if the seizure lasts for more than 5–10 minutes requires specialized attention and immediate medical intervention.

When should a person be hospitilized?

• If a person doesn’t get back to normal breathing or consciousness after the seizure stops
• In case he suffers a second seizure immediately after the first one
• If an individual reports high temperature/fever
• In case a person suffers from heat exhaustion
• In case of a pregnant woman
• In case of a diabetic patient
• If a person has suffered an injury during seizure
• If the seizure lasts more than 5-10 minutes

Although there are no definite causes of epilepsy, medical experts have estimated its possible causes. A head trauma or a head injury happened in the past due to an accident or any other reason can cause a person to have a seizure. Brain strokes and tumors are the most common reason for adults older than 35 years of age developing the diseases. Thirdly, diseases like AIDS and viral encephalitis can aggravate chances of a person developing epilepsy. Lastly, prenatal injuries such as poor nutrition, oxygen deficiency, genetic and development disorders stand a strong chance of causing a person to suffer from the disease.

Certain risk factors like ageing; dementia, brain infections and seizures in childhood can put an individual at an increased risk of the disease.

Points to keep in mind:

• Take medications regularly
• Consult your doctor before switching to a new medicine regime and type
• Notify your doctor if you suffer any of the systems or notice mood shifts and depression feeling
• Communicate with your doctor in case you suffer migraine as well
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