April 18  2015, Saturday
editorial
In conversation with Dr Robert Wah, President AMA
Dr KK AggarwalDr Veena Aggarwal, Oslo, Norway,

The President of the largest medical association of the world is a very charming, easy to talk to and down to earth person. A man of a tall stature literally and academically, Dr Robert wears many hats-Reproductive and Endocrinologist specialist at NIH and Walter Reed National medical and Military Center, President American Medical Association and Council Member of WMA - the World Medical Association.

According to Dr Robert, the biggest challenge in healthcare is to decide the best way of delivering medical care to people - to clear the necessary from the unimportant and make this ongoing process more meaningful and useful to the patients at large.

Social determinants of health like poverty and environment cannot be controlled but how to deliver the best health care taking these hurdles into cognisance is what turns around the tables in health care delivery.

We talk of increasing life expectancy by giving better health care but at the same time we need to recognize that this is resulting in an increase in the number of the elderly population, which has its own set of medical needs and challenges and these need to be addressed.

WMA gives a very good platform for all these deliberations and many more such issues like child abuse, alcohol restrictions, transgender issues, corporal punishment and many other ethical issues. AMA is as such a spokesperson for the medical community of the world as it is a representative of all the leading minds in healthcare of countries around the globe. It is an open platform where Nations from across the world come together to deliberate and collaborate to strengthen health policies on various issues.
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213th Meeting of the Central Working Committee of Indian Medical Association at Hotel Radisson Blu, New Delhi.
News
  • New research has suggested that patients with optic neuritis (often the first symptom of multiple sclerosis) who were given the monoclonal antibody BIIB033 had improved conduction of electrical impulses along the optic nerve between the retina and the brain. The findings will be presented at the American Association of Neurology (AAN) 67th Annual Meeting.
  • Losing weight in middle age may be associated with losing precious bone density, at least for women, suggests a new study published online in The Journal of Clinical Endocrinology and Metabolism.
  • An aerosolized measles vaccine appeared to provide significantly less protection than a traditional shot in a noninferiority trial from India. Ninety one days after vaccination, 85.4% in the aerosol group and 94.6% in the subcutaneous injection group were seropositive, reported the study published April 16 in the New England Journal of Medicine.
  • Limited use of radioactive iodine (RAI) should be the strategy of choice in the treatment of low–risk differentiated thyroid cancer (DTC), as survival outcomes are excellent even without use of RAI, suggests new research published in the April issue of Thyroid.
  • Patients over 70 years of age with end–stage ankle arthritis experience improvements in gait parameters after total ankle arthroplasty that are comparable with those seen in patients in their 50s, suggests new research presented at the 2015 Annual Meeting of the American Academy of Orthopedic Surgeons.
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Dr KK Spiritual Blog
Doctors are God Later and Human Beings First

Doctors are regarded as God because their primary job is to save the life of a patient. In fact, they are the messengers of God to look after the health of the sick person. But, Doctors are God later and human beings first.

To err is human and every doctor is likely to make mistakes. The very fact that a doctor gets himself/herself insured under Indemnity insurance means that medical errors are recognized as a part and parcel of Government policies.

For any error, the Court has decided a financial compensation to the patient and that compensation is paid by the insurance company as the doctor is covered under the Indemnity insurance. Medical negligence on the other hand, if proved, is not covered under the insurance. Therefore, medical negligence has to be differentiated from medical errors.

The error of judgment and difference of opinion are accepted in the law as not negligence and there are ample Supreme Court judgments to support this. Medical accidents are also exempted from being termed negligence by various Supreme Court clarifications/judgments. For a doctor to be punished under medical negligence, there has to be a proof that he willfully did some omission or commission which led to the death or caused harm to a person.

A doctor is also not required to possess the maximum degree of skill and knowledge but is required to possess only an average degree of skill and knowledge. Therefore, when an expert is called for an opinion, he should never give an opinion from his level of perception and knowledge but should take into consideration the knowledge of an average doctor of that specialty.

Recently, one of my friends forwarded a report to me, which showed that in US when the doctors went on a strike, the number of deaths in the city during the strike period reduced.

I totally agree with this observation and I am of the firm opinion that if allopathic medical profession ceases to exit, the number of deaths per day will be reduced. But at what cost?

It will invariably be at the cost of increased morbidity, impaired quality of life and more sufferings. In that scenario people with sexual dysfunction will live without enjoying sexual life; people with heart failure will be bedridden, patients with TB will be back in sanitariums, patients with fractures will remain on the bed for months together and patients requiring orthopedic surgeries will remain with life–long deformations. To have a better quality of life, one has to pay the price as any intervention or surgery done to improve the quality of life invariably will carry some risk and mortality. Even a simple bypass surgery of the heart carries a mortality of up to 0.5–1%. But for the family whose patient dies that 1%, the mortality is 100%.

In a follow up program on Aaj Tak, the film actor, Aamir Khan, said that every household in India has a negative story to tell about medical doctors. He probably misunderstood or could not differentiate medical errors, medical accidents from medical negligence. People equate money with medical success. Most medical disputes occur in private sector when the patient’s relatives have to pay money for an unsuccessful surgery or treatment. Attempts have been made to compare the results of medical treatment in India with the results of similar treatment abroad. They are totally incomparable as the amount of fee charged by doctors in India is practically a fraction of what is charged in the west. The patients load in India per doctor is also responsible for potential medical errors. One should also remember that the Drug Controller Government of India does not inform doctors about banned drugs, introduction of new drugs or introduction of new equipments. Most doctors depend on learning latest technology through the manufacturers of respective machines. The manufacturers either bring the training persons from abroad or support the training of Indian doctors abroad. Their interest is ultimately covered as the doctors once trained ultimately end up in purchasing their technology.

When a new drug is launched, as there is no information from Drug Controller of India to individual doctors, they are forced to attend symposia by drug companies, which have now come under the purview of unethical doctor–pharma relationship.

Most doctors will write pharmaceutical drugs of a company, which people think is in lieu of a commission they are getting. The reality is that a doctor will invariably write a drug of a company who is constantly engaged in efforts in educating doctors about new technologies and innovations as both Medical Council of India and the Government of India Health Ministry have no such provisions for the doctors. On the other hand, not attending medical educational programs is considered a professional misconduct by MCI and many state councils.
Cardiology eMedinewS
  • Individuals who are exposed to multiple adverse experiences in childhood, such as abuse, neglect, or growing up in dysfunctional household, have significantly higher systolic blood pressures in young adulthood compared with individuals who grew up without such traumatic experiences, suggests a new study published online in Circulation.
  • A new study published in the American Journal of Hypertension has linked eating meals away from home and high blood pressure. Researchers noted that participants with hypertension or pre–hypertension were more likely than participants without hypertension or pre–hypertension to eat out more often, have a higher BMI, have lower levels of physical activity and be current smokers.
Pediatrics eMedinewS
  • The age of the medium used to culture fertilized embryos may affect eventual birth weight, suggests a new study. Researchers noted that birth weight of a singleton newborn drops by 3.6 g for every day the culture medium ages. The findings are published online in Human Reproduction.
  • A new review suggested that children who take part in school–based programs designed to prevent sexual abuse are more likely to report it to an adult than children who have received no such education. The report is published in the Cochrane Database of Systematic Reviews.
Make Sure
Situation: A patient with suspected meningitis developed brain damage.
Reaction: Oh my God! Why was the antibiotic not started when the diagnosis was suspected?
Lesson: Make sure that the first dose of antibiotic is given at the very time meningitis is suspected.
Dr Good Dr Bad
Situation: A pregnant lady developed hypotension with respiratory distress immediately after delivery.
Dr Bad: This is an internal bleed.
Dr Good: It looks like AFES.
Lesson: Amniotic fluid embolism syndrome (AFES) is a catastrophic condition that occurs during pregnancy or shortly after delivery. It is characterized by the abrupt and fulminant onset of hypotension due to cardiogenic shock, hypoxemia, respiratory failure and disseminated intravascular coagulation (DIC). AFES should be suspected whenever shock or respiratory compromise develops during labor and delivery, or immediately postpartum. Other causes of sudden intrapartum or postpartum cardiorespiratory failure must be excluded.

(Copyright IJCP)
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Reader Response
Dear Sir, very informative news. Regards: Dr Karan
eMedi Quiz
Which of the following factors can increase your risk of having a stroke?

A. Hypertension and aging.
B. Being female and Caucasian.
C. Being female and African–American.
D. Menopause.
E. B and C.

Yesterday’s Mind Teaser: Do women have more headaches than men?

A. No, they get equal numbers.
B. Yes, but not that many more.
C. Yes, and the headaches are more severe.
D. Yes, but men tend to get more painful kinds that last longer.
E. None of the above.

Answer for yesterday’s Mind Teaser: C. Yes, and the headaches are more severe.

Correct Answers received from: Dr Avtar Krishan, Dr K Raju, Dr Poonam Chablani, Tukaram Pagad.

Answer for 14th April Mind Teaser: 4. Dessication of a dead body.

Correct Answers receives: Dr K Raju, Tukaram Pagad, Dr KV Sarma, Dr Shangarpawar, Daivadheenam Jella, Dr Avtar Krishan, Dr G Madhusudhan.
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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
IMA News
WMA Resolution on Unproven Therapy and the Ebola Virus
Adopted by the 65th WMA General Assembly, Durban, South Africa, October 2014

In the case of Ebola virus, the WMA strongly supports the intention of Paragraph 37 of the 2013 revision of the Declaration of Helsinki, which reads:

In the treatment of an individual patient, where proven interventions do not exist or other known interventions have been ineffective, the physician, after seeking expert advice, with informed consent from the patient or a legally authorized representative, may use an unproven intervention if in the physician’s judgement it offers hope of saving life, re–establishing health or alleviating suffering. This intervention should subsequently be made the object of research, designed to evaluate its safety and efficacy. In all cases, new information must be recorded and, where appropriate, made publicly available.
Growing Violence Against Doctors Alarms Medical Profession
(17.04.2015) Grave concern about the growing incidence of violence against doctors across the globe has been expressed by the World Medical Association.

At their Council meeting in Oslo, delegates from almost 40 national medical associations heard a report about violence in every part of the world.

Dr. Xavier Deau, President of the WMA, said: ‘We are hearing about increasing violence against doctors, ranging from verbal to physical attacks and even kidnapping and murder.

‘Everyone has the right to work in a safe environment. Violence against doctors is particularly mindless as it impacts on the entire healthcare system including the care of patients.

‘Three years ago the WMA called on national medical associations to encourage healthcare institutions to develop a zero tolerance policy towards workplace violence. That call has become even more urgent today.’

Dr. Bayazit Ilhan, President of the Turkish Medical Association, said: ‘Today is the third anniversary of the tragic murder of the young Turkish surgeon Dr. Ersin Arslan who was stabbed by a relative of his patient while on duty in his hospital. Regrettably violence against doctors in Turkey has increased since then as it has in other parts of the world. We now need to take collaborative steps to eliminate violence against all health professionals.’
A message from Secy Gen WMA
Dr Otmar Kloiber

Very concerned about the growing violence in the world especially against the medical professionals. It's a global phenomenon in both rich and the poor countries. Very bad in areas like Mexico but is a general and rising trend. Recently a doctor was killed in Istanbul, a third such incident. We need more emphasis on addressing this issue as health professionals need to be safe in order to discharge their duties effectively.
Sonal Namaste
Antibiotics are not indicated for most children with acute watery diarrhea; suspected cholera is an important exception in which antibiotic therapy is warranted
Facts about Tuberculosis (TB)
What has been the impact of RNTCP in reducing this burden?

RNTCP has been successful in bringing down the death rate from 29% (in 1990) to <5% presently resulting in saving of over 2.2 million additional lives.
Malaria Keypoints
Malaria is one of the most widespread parasitic disease in the world. In India it is mainly caused by Plasmodium vivax and P. falciparum
Conference Update - Diabetes India 2015
HbA1c alone is sufficient as a marker of good diabetes control

Dr Ashish S Dengra,
Jabalpur
  • Chronic hyperglycemia is captured by A1c but not by FPG (even when repeated twice).
  • Microangiopathic complications (retinopathy) are associated with A1c as strongly as with FPG.
  • A1c is better related to cardiovascular disease than FPG.
  • Fasting is not needed for A1c assessment.
  • No acute perturbations (e.g., stress, diet, exercise, smoking) affect A1c.
  • A1c has a greater pre–analytical stability than blood glucose.
  • A1c has an analytical variability not inferior to blood glucose.
  • Standardization of A1c assay is not inferior to blood glucose assay.
  • Biological variability of A1C is lower than FPG and 2–h OGTT PG.
  • Individual susceptibility to protein glycation might be caught by A1c.
  • A1c can be used concomitantly for diagnosing and initiating diabetes monitoring
Therapeutic inertia & targets achievement

Dr Michael P Hermans, Belgium
  • Clinical inertia: Failure to initiate or intensify therapy according to evidence-based recommendations, when indicated or failure to act despite recognition of the problem.
  • Leads to poor management of diabetes, and other conditions like HT, dyslipidemia
  • Studies on clinical inertia are most relevant in the context of asymptomatic chronic diseases. Its identification requires 3 dimensions: Recognized clinical outcomes (goals or targets), recommended therapy that can be measured and an appropriate window of time for appropriate initiation or intensification of available therapies.
  • Therapeutic inertia is linked to factors related to providers, patients and system.
  • It is particularly relevant in the frame of asymptomatic or paucisymptomatic chronic conditions like T2DM, with a potential for worsening over time, and where therapeutic decisions are influenced by assessment of consensual clinical outcomes or validated surrogate markers (such as HbA1c) rather than by evaluating symptoms or complaints.
  • Therapeutic inertia suboptimal control of modifiable risk factors known to lead to long–term complications. Clinical inertia in T2DM increases risk of developing incident micro– and macrovascular disease, or worsening of existing complications in due course of time.
  • True clinical inertia needs to be addressed; it exists only if recommendation exists, provider knows the recommendations and the provider believes that the recommendation is applicable to the patient, he/she has the necessary resources to apply the recommendation or the provider does not apply the recommendation to the patient
  • There can be many barriers to management of diabetes; patient– and provider–related factors may lead to clinical apathy and target non attainment.
  • Rule out the following causes before labeling as clinical inertia: baseline level is far away from the target value, recommended target values < normal value in reference population, target value lies in a range where side-effects become more common, achieving the recommended target requires several steps, such as dose uptitration, or escalating the number of drugs or the patient is a poor responder.
Keep your Kidneys Healthy to stay healthy: Indian Medical Association
http://newssuperfast.com: Healthy and well-functioning kidneys are vital to good health. Many disease conditions such as hypertension, diabetes, kidney stones, infections, can adversely affect function of the kidneys, leading to kidney failure in due course of time. Hence, it is important that we follow a healthy lifestyle to protect our kidneys, said Padma Shri Awardee Dr A Marthanda Pillai National President Indian Medical Association and Padma Shri, Dr B C Roy & DST National Science Communication Awardee, Dr KK Aggarwal, President Heart Care Foundation of India and Honorary Secretary General Indian Medical Association.

Tips to keep kidneys healthy
  1. Keep your blood pressure at the recommended target levels.
  2. Control your blood glucose level.
  3. Keep blood cholesterol level in the target range
  4. Control body weight.
  5. Avoid overuse of over-the-counter painkillers.
  6. If you have a family history of diabetes, heart disease, or chronic kidney disease (CKD), you are at risk of developing kidney disease.
  7. Do not smoke.
  8. Be physically active.
  9. Eat a healthy diet, with more of fruits and vegetables.
  10. Get an annual physical exam.
  11. Take your medications as directed by your doctor.
  12. Get yourself tested for CKD, if you’re at risk. Early diagnosis can delay or prevent kidney failure.
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Inspirational Story
Hide and Seek

One summer day a mother looked out the window of her house. There in the garden she saw her little daughter rolling around the grass in laughter. Intrigued she went outside to investigate. Approaching her daughter the mother asked, "My child, what do you find so amusing?"

"I understand, I understand," replied the child among bursts of giggles. "What do you mean?" questioned the mother.

"Well," answered the child, "I was playing outside on the grass when I started thinking about God, and how I have heard people say that God is everywhere. But I looked around and couldn't see God anywhere. So I thought: of course! God must be playing a game of hide and seek. So I decided to try find God. I looked amongst the roses for I have heard that God is beautiful. But God was not there. I lay on my back and searched the skies for I have heard that God is up in the Heavens. But God was not there. I dug in the ground for I have heard that God supports us all. But God was not there. And I became very frustrated and I called out: Where are you God? Why have you left me? And then, all of a sudden, a sense of peace came over me and I realized the Truth!"

Spellbound, the mother gently inquired, "What truth?" "That," giggled the little child, "It was not God who was hiding, it was me". So much of our lives we stumble around lost trying to seek God, never realizing we are already Found. All we merely need to do is to stop hiding from God and to embrace Him fully.
Wellness Blog
Can diabetes be warded off?

Adhering to Mediterranean diet, rich in fruits and vegetables and low in animal products may protect from type 2 diabetes. The Mediterranean diet gives emphasis to olive oil, vegetables, fruits, nuts, cereals, legumes and fish and de–emphasizes meat and dairy products. It is a healthy eating plan that prevents heart disease.

In a study published in the British Medical Journal, researchers tracked the diets of 13,380 Spanish university graduates with no history of diabetes. The study participants filled out a 136–item food questionnaire, which measured their entire diet (including their intake of fats), their cooking methods and their use of dietary supplements. During an average of 4.4 years of follow–up, the researchers found that people who adhered to a Mediterranean diet were at a lower risk of developing type 2 diabetes. In fact, those who very closely adhered to the diet reduced their risk by 83 percent.

Moreover, the people who tended to stick closest to the diet were those with factors that put them at the highest risk for developing diabetes, such as being older, having a family history of diabetes and being an ex–smoker. These people were expected to have a higher rate of diabetes, but when they adhered to the Mediterranean diet this was not the case.

Type 2 diabetes is typically brought on by poor eating habits, too much body weight and too little exercise. One key factor that might be responsible for the protective effect of the Mediterranean diet is its emphasis on olive oil for cooking, frying, putting on bread and mixing in salad dressings.

Tips to prevent diabetes
  • Eat less
  • Omit refined carbohydrates (white sugar, white rice and white maida)
  • Use olive oil, vegetables, fruits, nuts, cereals, legumes and fish, and reduce meat and dairy products.
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Talent works, genius creates. Robert A. Schumann
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Wo Man

An English teacher wrote this phrase on the board and asked her students to properly punctuate it:

"Woman without her man is nothing."

MEN WROTE: Woman, without her man, is nothing.

WOMEN WROTE: Woman! Without her, man is nothing.
Celiac disease patients can substitute ‘besan’ or gram flour for wheat flour
If you think that the food you eat may be at the root of your illness, you should try to substitute one food each day, said Padma Shri Awardee Dr A Marthanda Pillai National President Indian Medical Association and Padma Shri, Dr B C Roy & DST National Science Communication Awardee, Dr K K Aggarwal, President Heart Care Foundation of India and Honorary Secretary General Indian Medical Association. You can start by substituting wheat flour with besan or gram flour. This is especially applicable to patients who have celiac disease, they further added.

Patients of celiac disease cannot digest gluten, a protein. If they eat food that contains gluten, their immune system damages the tiny, finger-like protrusions, called villi, which line the small intestine. These villi help to absorb nutrients from food. If villi are damaged, nutrient absorption is impaired and patient becomes malnourished, leading to weight loss, fatigue and anemia.

A gluten-free diet is also recommended for patients who have wheat allergy, autoimmune disorders, dermatitis herpetiformis, multiple sclerosis, autism spectrum disorders, attention-deficit hyperactivity disorder (ADHD) and some behavioral problems.

These patients should switch to gluten-free foods. Shifting from wheat flour to gram flour (besan) is the best alternative.

Gluten is found in cereals like wheat, barley and rye including wheat products like broken wheat (Dalia), semolina (sooji), vermicelli (siwain), noodles, pastas, and macaroni. Gluten is also present as a food additive in the form of a flavoring, stabilizing or thickening agent.
Rabies News (Dr A K Gupta)
Is it essential to perform skin sensitivity test prior to the administration of ERIG?

Majority of reactions to ERIG result from complement activation and are not IgE mediated and will not be predicted by skin testing.

The recent WHO recommendation states that there are no scientific grounds for performing a skin test prior to the administration of ERIG, because testing does not predict reactions and ERIG should be given whatever the result of the test.

However, skin test is mandatory to avoid any possible litigation under Consumer Protection Act in India.