December 18   2015, Friday
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EDITORIAL

Dr KK AggarwalDr KK Aggarwal Now Biosimilar Insulin Glargine

The US FDA gave final approval to a copycat version of insulin glargine injection (Basaglar) for diabetes that is called a follow-on product by the agency and is a biosimilar in other parts of the world.

Eli Lilly won approval for its new diabetes drug by demonstrating that it was similar enough to another insulin glargine injection on the market (Lantus, sanofi-aventis) to justify trust in its effectiveness and safety. Basaglar is administered subcutaneously with the manufacturer's KwikPen injector once daily at any time of day as long it is the same time every day.

Breaking News

Benefits of carfilzomib in multiple myeloma persist across subgroups

The benefits of adding carfilzomib to dexamethasone, compared with adding bortezomib - seen in the ENDEAVOR study among patients with relapsed and refractory multiple myeloma - persist regardless of age, cytogenetic risk status or number of prior therapy lines. The study, together with the three prospective planned subgroup analyses, was presented at the 57th annual meeting of the American Society of Hematology, held in Orlando, FL, December 5th-8th 2015.

Avoid applying olive and sunflower oil to healthy newborns' skin

A study, led by the University of Manchester in the UK, suggests that applying olive or sunflower oil to the skin of healthy newborn babies may do more harm than good. In their study, the researchers found it can delay the development of the barrier that prevents water loss and protects against allergy and infection. The findings of the study, published in the journal Acta Dermato-Venereologica goes against the advice normally given by many midwives, who recommend olive or sunflower oil for dry skin in young babies.
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Specialty Updates
Pediatrics

Infectious Diseases

Surgery


Managing uncomplicated appendicitis in children with antibiotics instead of an operation is an effective strategy, as long as it is chosen by the parents, suggests a report published in JAMA Surgery. It also incurs less illness and lower costs.

Good outcomes when families choose antibiotics to treat appendicitis

Managing uncomplicated appendicitis in children with antibiotics instead of an operation is an effective strategy, as long as it is chosen by the parents, says a report in JAMA Surgery. It also incurs less illness and lower costs.

Acute appendicitis accounts for approximately 11% of pediatric emergency department admissions; more than 70,000 children are hospitalized for appendicitis every year in the US.

Nutrition/Diet

A new study suggests that consuming more fruits, vegetables, dairy and seafood could be harmful to the environment. Researchers stated that these foods have high resource uses and greenhouse gas (GHG) emissions per calorie. The study is published in the journal Environment Systems and Decisions.

Does a vegetarian diet contribute to climate change?

Health care professionals have proclaimed the health benefits of eating a vegetarian diet in recent years. But a new study questions such a diet's effects on the environment, with researchers warning that consuming more fruits, vegetables, dairy and seafood could be harmful to the environment. The study is published in the journal Environment Systems and Decisions and was conducted by researchers from Carnegie Mellon University in Pennsylvania.

Cardiology

No matter the type of cardiac rehabilitation (CR) program prescribed by clinicians, women with CAD are often not following through with attendance, which may lead to lower improvements in functional capacity, suggests the randomized Cardiac Rehabilitation for Heart Event Recovery (CR4HER) study published online in Mayo Clinic Proceedings.

Cardiac Rehab Adherence Low for Women Despite Program Type

TORONTO, ON — No matter the type of cardiac rehabilitation (CR) program prescribed by clinicians, women with CAD are often not following through with attendance, which may lead to lower improvements in functional capacity, new research suggests[1]. The randomized Cardiac Rehabilitation for Heart Event Recovery (CR4HER) study showed that only 55% of its 169 female participants completed 24 prescribed rehab sessions.

Infectious Diseases

According to investigators from the Centers for Disease Control and Prevention (CDC), patients recovering from Ebola virus disease (EVD) may have persistent clinical symptoms and could benefit from subspecialty care. These findings were presented in a letter to the editor published December 17 in the New England Journal of Medicine.

Symptoms Persist Despite Recovery From Ebola Virus

According to investigators from the Centers for Disease Control and Prevention (CDC), patients recovering from Ebola virus disease (EVD) may have persistent clinical symptoms and could benefit from subspecialty care. These findings were presented in a letter to the editor published in the December 17 issue of the New England Journal of Medicine.

In March 2015, investigators from the CDC in Atlanta, Georgia, administered a questionnaire to all eight survivors treated for EVD who were treated in the United States in 2014.The median interval from time of discharge from the hospital to survey administration was 5 months, and all survivors reported at least one symptom during recovery.

Psychiatry

Results of a new study show an increased risk of mania and bipolar disorder in patients taking antidepressants. The findings are published in BMJ Open.

Antidepressant usage linked to bipolar and mania

A new study investigates the links between antidepressant medication and the eventual onset of manic episodes and bipolar disorder. Despite the steady growth of depression in America and beyond, the treatment for this, the most common psychological disorder in the Western world, still has much room for improvement.
....................................................................................

The results did indeed show an increased risk of mania and bipolar disorder in the patients taking antidepressants.

Diabetes

Cardiology


Alogliptin curbs carotid atherosclerosis in patients with type 2 diabetes, suggested an open-label trial from Japan published online in Diabetes Care.

Alogliptin Cuts Atherosclerosis in Diabetics

Trial in Japan finds vascular benefit from DPP-4 inhibitor

NEW YORK (Reuters Health) -- Alogliptin (Nesina, Takeda) curbs carotid atherosclerosis in patients with type 2 diabetes, according to an open-label

trial from Japan. "Our data demonstrated the efficacy and benefits of alogliptin used at the early stage of disease in preventing the progression of atherosclerosis," Tomoya Mita, MD, from Juntendo University Graduate School of Medicine in Tokyo told Reuters Health by email.

Obstetrics and Gynecology

Endocrinology


Elevated testosterone levels may raise women's risk for developing uterine fibroids, suggest new data published online December 15 in the Journal of Clinical Endocrinology & Metabolism.

Testosterone Levels May Play Part in Uterine Fibroid Risk

Elevated testosterone levels may raise women's risk for developing uterine fibroids, new data show. Jason YY Wong, ScD, of Stanford University School of Medicine, California, and colleagues found that women who have high levels of both testosterone and estrogen in midlife may face a greater risk of developing the benign tumors than women with low levels of the hormones. The study was published online December 15 in the Journal of Clinical Endocrinology & Metabolism.

Dermatology

Orthopedics

Infectious Diseases

Emergency Medicine

The standard practice of wound cleaning with soap and water in open arm or leg fractures is actually less effective than just using saline water, suggests new research published in the New England Journal of Medicine.

Saline water better than soap and water for cleaning wounds, researchers find
Many scientific advances have been made in the delivery of care and infection prevention for open fractures, but the standard practice of wound cleaning with soap and water before surgery has remain the unchanged. Now, an international team of researchers led by McMaster University in collaboration with the Research Institute of the McGill University Health Centre has found that soap and water is actually less effective than just using saline water.

The findings, which were published in the New England Journal of Medicine, could lead to significant cost savings, particularly in developing countries where open fractures are particularly common.

Oncology

The benefits of adding carfilzomib to dexamethasone, compared with adding bortezomib - seen in the ENDEAVOR study among patients with relapsed and refractory multiple myeloma - persist regardless of age, cytogenetic risk status or number of prior therapy lines, suggested new research presented at the 57th annual meeting of the American Society of Hematology.

Benefits of carfilzomib in multiple myeloma persist across subgroups

The benefits of adding carfilzomib to dexamethasone, compared with adding bortezomib - seen in the ENDEAVOR study among patients with relapsed and refractory multiple myeloma - persist regardless of age, cytogenetic risk status or number of prior therapy lines. The study, together with the three prospective planned subgroup analyses, was presented at the 57th annual meeting of the American Society of Hematology, held in Orlando, FL, December 5th-8th 2015.

"Taken together, the results from the ENDEAVOR study suggest an important role for carfilzomib-based regimens for patients with relapsed or refractory multiple myeloma," wrote Meletios Dimopoulos, from the National and Kapodistrian University of Athens, Greece, and coauthors in The Lancet Oncology.

Surgery

Anesthesia

The U.S. Food and Drug Administration approved Sugammadex injection to reverse the effects of neuromuscular blockade induced by rocuronium bromide and vecuronium bromide, used during certain types of surgery in adults.

FDA approves Bridion to reverse effects of neuromuscular blocking drugs used during surgery First drug approved in new class of medications.

The U.S. Food and Drug Administration has approved Bridion (sugammadex) injection to reverse the effects of neuromuscular blockade induced by rocuronium bromide and vecuronium bromide, which are used during certain types of surgery in adults. Rocuronium bromide and vecuronium bromide are neuromuscular blocking drugs that cause temporary paralysis by interfering with the transmission of nerve impulses to the muscle and are used to paralyze the vocal cords when patients require an artificial airway or breathing tube for surgery, a process called tracheal intubation. They can also be used to prevent patients from moving during surgery while they are receiving general anesthesia. Neuromuscular blocking drugs are also sometimes used to prevent the body from breathing automatically when a patient has to be placed on a ven
eSPIRITUAL
You look at people the same way as you are

Honest people look everybody as honest and dishonest people look everybody as dishonest. It all depends on the type of people you interact with. If you do not take bribe, nobody will come and offer bribe to you and you will feel everybody is honest. If you take bribe then everybody will come to you to offer bribe and you will feel that everybody in the society is dishonest.

Never judge people with you personal experience. I recall one of the doctors said that every doctor takes and gives bribe because he was running an imaging centre and every doctor who approached him asked for a bribe. But he did not take into consideration the doctors who did not approach him.
Legal Quote
Martin F. D'Souza vs Mohd. Ishfaq, SCI: 3541 of 2002, dated 17.02.2009

“The Courts and Consumer Fora are not experts in medical science, and must not substitute their own views over that of specialists.”
2015 American Geriatrics Society Beers Criteria for Potentially Inappropriate Medication Use in Older Adults
Psychotropics, analgesics linked to increased risk for homicide
 
Central nervous system
Organ System, Therapeutic Category, Drugs
Rationale
Recommendation
Quality of Evidence
Strength of Recommendation
Anticholinergics
Antidepressants,
alone or in combination
Amitriptyline
Amoxapine
Clomipramine
Desipramine
Doxepin >6 mg/d
Imipramine
Nortriptyline
Paroxetine
Protriptyline
Trimipramine
Highly anticholinergic, sedating, and cause orthostatic hypotension; safety profile of low-dose doxepin (=6 mg/d) comparable with that of placebo
Avoid
High
Strong
Antipsychotics, first- (conventional)
and second- (atypical) generation
Increased risk of cerebrovascular accident (stroke) and greater rate of cognitive decline and mortality in persons with dementia Avoid antipsychotics for behavioral problems of dementia or delirium unless nonpharmacological options (e.g., behavioral interventions) have failed or are not possibleand the older adult is threatening substantial harm to self or others
Avoid, except for schizophrenia, bipolar disorder, or short-term use as antiemetic during chemotherapy
Moderate
Strong
Barbiturates
Amobarbital
Butabarbital
Butalbital
Mephobarbital
Pentobarbital
Phenobarbital

Secobarbital
High rate of physical dependence, tolerance to sleep benefits, greater risk of overdose at low dosages
Avoid
High
Strong
Benzodiazepines
Short- and
intermediate- actingAlprazolam
Estazolam
Lorazepam
Oxazepam
Temazepam
Triazolam
Older adults have increased sensitivity to benzodiazepines and decreased metabolism of long-acting agents; in general, all benzodiazepines increase risk of cognitive impairment, delirium, falls, fractures, and motor vehicle crashes in older adults
Avoid
Moderate
Strong
Long-acting
Clorazepate
Chlordiazepoxide (alone or in combination with amitriptyline or clidinium)
Clonazepam
Diazepam
Flurazepam
Quazepam
May be appropriate for seizure disorders, rapid eye movement sleep disorders, benzodiazepine withdrawal, ethanol withdrawal, severe generalized anxiety disorder, and periprocedural anesthesia
 
 
 
Meprobamate
High rate of physical dependence; very sedating
Avoid
Moderate
Strong
Nonbenzodiazepine, benzodiazepine receptor agonist hypnotics
Eszopiclone
Zolpidem
Zaleplon
Benzodiazepine-receptor agonists have adverse events similar to those of benzodiazepines in older adults (e.g., delirium, falls, fractures);increased emergency department visits and hospitalizations; motor vehicle crashes; minimal improvement in sleep latency and duration
Avoid
Moderate
Strong
Ergoloid mesylates (dehydrogenated ergot alkaloids)
Isoxsuprine
Lack of efficacy
Avoid
High
Strong

Source: Medscape
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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
• FDA Lifts Restriction on Rosiglitazone: Agency sees no need for restrictions after easing them 2 years ago. The FDA is doing away with the Risk Evaluation and Mitigation Strategy (REMS) for the type 2 diabetes medication that contain rosiglitazone. The REMS was "no longer necessary to ensure that the benefits" of the drug outweigh its risks, the FDA announced on its website today. The drug has been under scrutiny since 2007, when a meta-analysis found that rosiglitazone was linked to risk of myocardial infarction.

• A new study suggests that playing three-dimensional (3D) video games can stimulate the hippocampus and boost the formation of memories. The study was published online December 9 in the Journal of Neuroscience.

• Ketamine, used for analgesia and sedation in the hospital setting, is increasingly being used to treat refractory status epilepticus (RSE), but only for the most critically ill children, a new study of billing information shows.[ American Epilepsy Society (AES) 69th Annual Meeting.]

• Disclosure of information under Right to Information act: Regarding the question on disclosure of information under Right to Information Act, the following may kindly be noted: 1. Medical information regarding treatment is bound by Confidentiality agreement and could not be disclosed under usual circumstances and does not come under the purview of RTA. 2. However, such information could be requested and availed under the Medical Council Regulation Act. But in that case either the patient or the authorized representative could only claim such information. In case, the patient is no more, and as such cannot request information nor can authorize anyone anymore, then the legal heir/authorized representative or the lawyer- ( to be proved by due certification by authorities) could ask for such information in the case of any legal issue. In such case the information could be furnished to the court without violating confidentiality agreement. Dr.V.Mohanan Nair , CWC Member from Kerala
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http://module.ima-india.org/ima/jima/2015/September/
Bioethical issues in medical practice
Protecting the privacy and confidentiality of patients

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

You are a member of an informal discussion group of doctors who meet regularly to discuss difficult cases. At all these discussions, the conversation is frank and detailed, with all details of the patients, social situation, family issues etc. are discussed threadbare. Sometimes this discussion spills over into the hospital lifts, corridors and canteens. When these issues are really interesting, you discuss them at home with your spouse- a doctor- as well. Many times the name, address, and other details of patients are discussed as well.

a) Do such discussions breach medical confidentiality?
b) At which places should medical cases be discussed?
c) Should interesting medical cases be discussed at home?

Any suggestions? Do write in!

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

Responses received

Medical discussions of difficult cases are very important from the doctor’s point of view and also from the patient’s point of view. They should definitely be discussed at home, in medical get-togethers, but not in lifts, hotels and public places. Medical science is based on discussions and exploration of the knowledge what one has. Dr BR Bhatnagar
eWELLNESS
12 Steps to tackle Heartburn

• Eat smaller meals, but more often.
• Eat in a slow, relaxed manner.
• Remain upright after meals.
• Avoid late–night eating (last meal three hours before sleep)
• Don’t exercise immediately after meals.
• Tilt your torso with a bed wedge.
• Stay away from carbonated beverages.
• Find the foods that trigger your symptoms and avoid them (fatty foods, spicy foods, tomatoes, garlic, milk, coffee, tea, cola, peppermint, and chocolate.)
• Chew sugarless gum after a meal which promotes salivation and neutralizes acid.
• Check your drugs that can loosen the lower esophageal sphincter (LES) or cause acid reflux or inflammation of the esophagus.
• Lose weight if you need to.
• Avoid hurry, worry and curry.
WP(C) No.8706/2015 titled “Indian Medical Association Vs. Union of India & Anr (NCERT)” Delhi High Court, New Delhi

Click here to read the proposed changes
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Inspirational Story
A most important lesson

During my second month of nursing school, our professor gave us a pop quiz. I was a conscientious student and had breezed through the questions, until I read the last one: "What is the first name of the woman who cleans the school?"

Surely, this was some kind of joke. I had seen the cleaning woman several times. She was tall, dark-haired and in her 50s, but how would I know her name? I handed in my paper, leaving the last question blank.

Just before class ended, one student asked if the last question would count toward our quiz grade."Absolutely," said the professor. "In your careers, you will meet many people. All are significant. They deserve your attention and care, even if all you do is smile and say 'hello'."

I've never forgotten that lesson. I also learned her name was Dorothy.
eMEDI QUIZ
The exaggerated lepromin test seen in cases of lucin phenomenon is known as

a. mitsuda's reactionion
b. medina ramirez reaction
c. fischer's test
d. fernandez reacto


Yesterday’s Mind Teaser: Olfeck's phenomenon is seen due to which component

a. Joint psoriasis
b. Mucosal psoriasis
c. Nail psoriasis
d. Pustular psoriasis

Answer for Yesterday’s Mind Teaser: c. Nail psoriasis

Answers received from: Dr Mahantappa, Dr.J.Daivadheenam, Dr Avtar Krishan,

Answer for 16th December Mind Teaser: c. Pyoderma gangrenosum

Answers received from: Dr.Bitaan Sen & Dr.Jayashree Sen, Dr.K.V.Sarma, Dr Kailash Chandra Sharma, Dr.K.Raju,
Readers column
Dr. K. K. Aggarwal. Thanks for the good endeavo.r. My whole hearted support with the association. Regards. Dr. P. Banerjee, Berhampore, West Bengal.
Humor
Letter writing
I am well here and hope you are also in the same well.
Press Release
Tips to stay healthy this winter

New Delhi, Dec 17, 2015: Winter comes with its own share of health hazards. Keeping this in mind, it is essential to educate Delhi residents on ways in which they can protect themselves from diseases and enjoy the cold temperatures.

Speaking about the importance of staying healthy during the winter months, 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, “It is a known fact that the number of deaths due to heart attacks, cardiac arrests and strokes increase during the winters. There are several reasons for this; firstly the reduction in the daylight hours affects the hormonal balance of the body and causes Vitamin D deficiency a common trigger for heart attacks. Additionally, cold temperatures cause the heart arteries to condense thereby restricting the blood and oxygen flow to the heart. This often causes a rise in the blood pressure. The cold weather also triggers bouts of depression especially amongst the elderly population causing an increase in stress levels and hypertension. People suffering from winter depression are also seen indulging in high sugar, trans fat and sodium comfort food, which can be extremely dangerous for the diabetic and hypertensive population. It is thus very important for doctors to counsel their patients about ways in which they can stay healthy during winter months.”

A few ways in which people can stay healthy this winter include

• For good health, it is important to consume a diet rich in both soluble and insoluble fibres. Soluble fibres are found in foods such as psyllium husk, apples, oat bran and legumes (chickpeas, lentils). Sources of insoluble fibre include whole grains, broccoli, nuts, seeds and vegetable skins. Fibre plays an important role in helping to prevent serious health conditions. Fibre can also help manage the digestive complaints associated with irritable bowel syndrome (IBS).

• Staying well hydrated is key during the winter months since it gives you more energy, mental clarity and an enhanced digestive function. Start your day by consuming 500ml of water before breakfast and ensure that you consume water after every few hours for good health.

• Make an effort to include raw foods such as fruits, vegetables, sprouts, nuts, seeds and fresh herbs in your diet. Raw foods provide enzymes, vitamins and disease protective antioxidants.

• Get enough Sunlight. 80-90% Indians are Vitamin D deficient, a major risk factor for winter depression, increased joint pain as well as a decrease in immunity. Each person must ensure that they get adequate amounts of sunlight during the winter months.

• An ideal diet is one, which contains a mixture of seven colours and six tastes in every meal. Each food colour represents a type of vitamin so red apples are a source of lycopene, green leafy vegetables and fruits provide the body with B complex and orange food items are a source of vitamin C. Similarly, the sweet, sour and salt taste promotes weight gain and, on the contrary, pungent, astringent and bitter tastes reduce weight.

• Quit smoking! Winter Asthma and respiratory illnesses are very common amongst smokers which also puts them at high risk of heart attacks
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