November 19   2015, Thursday
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EDITORIAL
Dr KK AggarwalDr KK Aggarwal Updates in Medicine

• Salt sensitivity is defined as more than 5–10% change in blood pressure in response to a change in NaCl intake and is associated with increased cardiovascular risk, even if the blood pressure does not reach hypertensive levels.

• The Centre has accorded high priority to address maternal and child under-nutrition through multi-sectoral interventions and has recognised nutrition as critical for ensuring child survival and development (Union Health Minister J P Nadda).

• An ozone injection into the knee can soothe pain and improve quality of life for people with knee osteoarthritis, a randomized controlled trial suggests. (American College of Rheumatology (ACR) 2015 Annual Meeting: Abstract 311. Presented November 8, 2015.)

• A low dose of liquid atropine drops (0.01% concentration) helped stall myopic progression nearly as well as higher doses in 5-year follow-up measures in children, ages 6-12 years, but without the side effects and the myopic rebound seen with higher doses (Donald Tan, MD, of the Singapore National Eye Centre, and colleagues at American Academy of Ophthalmology meeting).

• Individuals with seasonal affective disorder (SAD) who participated in 6 weeks of daily cognitive-behavioral therapy (CBT) saw more improvement than those who used light therapy, with the advantage for CBT becoming apparent two winters post-intervention (AJP In Advance).
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Amit Sharma and Nilesh Aggarwal

We are extremely happy to have been part of IMA Satyagraha campaign and would like to congratulate the Indian doctor community as a whole. We are aiming to be a digital voice of all Indian doctors and will continue to work towards raising such important issues. Currently, we are in our Beta phase and we will soon be introducing features such as interesting cases, online CME's, conference updates etc. Please do register and read eMediNews, eIMANews as well as other engaging content on the website/app. You can also add other doctors to your network, find long lost alumni, chat and discuss cases, post questions for the medical fraternity, create your detailed medical resume and lots more.
Breaking News
Health ministry launches 'Nurse Practitioner in Critical Care' course

The Union health ministry has launched a postgraduate programme for nurses titled 'Nurse Practitioner in Critical Care' which will prepare registered BSc nurses for advanced practice roles as clinical experts, managers, educators and consultants leading to MSc degree in Critical Care. The ministry has now issued the draft curriculum for the course under public domain for public opinion.

After the completion of the course, the 'Nurse Practitioners' (NPs) will be able to provide cost effective, competent, safe and quality driven specialized nursing care to patients in a variety of settings in tertiary care centres. The special feature of this 2-year programme is that it is a clinical residency programme emphasizing a strong clinical component with 20% of theoretical instruction including skill lab and 80% of clinical experience. Competency based training is the major approach and NP education is based on competencies adapted from International Council of Nurses (ICN, 2005), and NONPF competencies (2012). The programme is intended to prepare registered BSc nurses to provide advanced nursing care to adults who are critically ill. The nursing care is focused on stabilising patients’ condition, minimising acute complications and maximising restoration of health. … (Pharmabiz - Ramesh Shankar)

Diagnosing stroke in acute dizziness

In patients presenting with acute dizziness and nystagmus or imbalance, a combination of readily available clinical information can help risk-stratify acute stroke. Patients with dizziness from stroke are challenging because they often lack typical stroke warning signs or symptoms. “In acute dizziness presentations, the combination of ABCD2 [age, blood pressure, clinical features, duration, and diabetes] score, general neurologic examination, and a specialized OM [ocular motor] examination has the capacity to risk-stratify acute stroke on MRI." (Kevin A. Kerber, MD, University of Michigan Health System, Ann Arbor, and colleagues in Neurology).
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Specialty Updates
• All iron intravenous (IV) products are associated with anaphylaxis risk, but the risk with iron dextran is significantly higher than with other formulations, and the risk is lowest with iron sucrose, reported a study of nearly 700,000 Medicare nondialysis patients, published in the November 17 issue of JAMA.

• Children, who develop severe wheezing and difficulty breathing after a common cold, with a risk of severe lower respiratory tract illness, could benefit from taking a common antibiotic at the first sign of cold symptoms, suggested a study published in JAMA.

• People who drink up to five cups of coffee per day are less likely to die from heart disease, neurological disease, type 2 diabetes, or suicide, suggested a new study published online November 16 in Circulation.

• A study conducted among overweight and obese patients in Brazil who had intragastric-balloon procedures suggested that though this is a valid endoscopic therapeutic option for weight loss, the weight loss wasn't maintained long-term in most of the people. The findings were presented at the Obesity Week 2015.

• The selective BRAF inhibitors vemurafenib and dabrafenib have significantly improved survival in patients with BRAF V600–mutant metastatic melanoma, when compared with standard therapy. However, both the drugs appear to be associated with an increased risk for acute kidney injury, suggested a new report published in the November issue of JAMA Oncology.

• The phase III open-label ASTRAL-4 study revealed that daily sofosbuvir and velpatasvir, alone or in combination with ribavirin, for 12 weeks yielded similar rates of sustained virologic response (83% and 94%) for the treatment of hepatitis C in patients with liver cirrhosis. The findings were published online in the New England Journal of Medicine.

• The sustained and tapered release of dexamethasone to the ocular surface of the eye after cataract surgery significantly reduces pain and inflammation, reported an analysis of data from two phase 3 trials presented at the American Academy of Ophthalmology 2015 Annual Meeting.

• Adolescent boys with an anterior cruciate ligament (ACL) repair may be at risk for lower bone mineral density (BMD) of the calcanei and associated fracture, suggested a new study published online in Arthroscopy.
eSpiritual
Why do we do Pradakshina?

We cannot draw a circle without a center point. The Lord is the centre, source and essence of our lives. We go about doing our daily chores, recognizing Him as the focal point in our lives. This is the significance of pradakshina, which is a Sanskrit word meaning circumambulation or walking in a circle around the deity. Pradakshina is done only in a clockwise manner. The right side symbolizes auspiciousness. During pradakshina, we remind ourselves to lead an auspicious life of righteousness, with the Lord on our right side. Also every point on the circumference of a circle is equidistant from the center. This means that wherever or whoever we may be, we are equally close to the Lord. His grace flows towards us without partiality.

Indian scriptures enjoin us – “Matru devo Bhava, Pitru devo Bhava, Acharya devo Bhava” - May you consider your parents and teachers as you would the Lord. With this in mind we also do pradakshina around our parents and divine personages.

After the completion of the traditional worship (pooja), we customarily do pradakshina around ourselves. In this way we recognize and remember the supreme divinity within us, which alone is idolized in the form of the Lord that we worship outside.
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Legal Quote
Nizam Institute of Medical Sciences Vs. Prasanth S. Dhananka and Ors, SC/4119 of 1999 and 3126 of 2000, 14.05.2009

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

• Establish an office procedure for inputting data
• Understand the reports
• Coordinate the portfolio with other software to project tax, cash flow and financial statement growth.

(Source: IJCP)
Media
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eMEDIPICS
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22nd MTNL Perfect Health Mela, the annual flagship event of the Heart Care Foundation of India
No.Z.17025/19/2015-Cdn-l
Government of India
Ministry of Health and Family Welfare
Department of Health & Family Welfare
(Coordination-1 Section)
Nirman Bhawan, New Delhi-110011
Dated:13th November,2015

ORDER

Subject: Constitution of a Committee to examine the issues raised by Indian Medical Association-reg. It has been decided to constitute a committee under the Chairmanship of Additional Secretary(Health) to examine the issues raised by Indian Medical Association and submit its report within six weeks from the date of issue of this order. The composition of this Committee is as under:-

I. Joint Secretary (dealing with the subject), Ministry of Health & Family Welfare:
II. Joint Secretary, Ministry of Law & Justice;
III. Joint Secretary, Department of Consumer Affairs;
IV. Joint Secretary, Ministry of Home Affairs;
V. A representative from MCI;
VI. A maximum of three representative from IMA.

2. The Terms of Reference of the committee are as under:-

a) Frequent instances of assault on doctors and clinical establishments across the country and the need for a central Legislation for providing protection to the same.

b) Urgent amendments in the PC & PNDT Act to ensure that strict penalties are imposed only on actual act of sex determination or female feticide and not for clerical errors in the maintenance of registers etc. The IMA is also of the view that registration should be of ultrasound machine and not of doctors not doing pelvic ultrasound.

c) Single doctors establishments should be exempted from the purview pf the Clinical Establishments Act and the need for pre-registration inspection may not be there for those clinical establishments which already have entry level NABH accreditation and above.

d) Suitable amendments should be made in the Consumer Protection Act for capping the compensation amount as the current compensation practice, apart from being very high at times, was also tilted in favour of the persons with higher income.

e) The non-MBBS and non-BDS doctors should not be allowed to prescribe medicines under modern system and the other stream practitioners like AYUSH doctors etc. should not be allowed to practice through bridge courses and through government orders.

3. The committee will examine the issues in depth and any other point which Indian Medical Association (IMA) may have impinging on the above issues and to suggest a time bound plan for implementation of the feasible points.

4. This has the approval of the Secretary(HFW)

                                                                                                                                                           (Rajeev Kumar)
                                                                                                                                                Director (Coordination)
                                                                                                                                                            Tel:-23062495

To

1. Secretary, Ministry of Law & Justice,
2. Secretary, Department of Consumer Affairs,
3. Secretary, Ministry of Home Affairs,
4. Secretary, Medical Council of India,
5. National President, Indian Medical Association

Copy to:

1. Secretary(HFW), Ministry of Health & Family Welfare
2. PS to Hon’ble HFM
IDMA urges DTAB to amend Sch V of D&C Act

The Indian Drug Manufacturers Association (IDMA) has urged the Drugs Technical Advisory Board (DTAB) to delete Schedule V of Drug and Cosmetics Act (D&C Act), 1945 or to amend the schedule in such a manner that it does not overlap with Recommended Daily Allowance (RDA) as it would refrain the nutraceutical manufacturers from including vitamins in their health supplements and would also affect the over the counter (OTC) sale of health supplements. As per the DTAB endorsed recommendations ingredients which are within RDA level, but fall under the range as prescribed under Schedule V of D&C Rules shall be classified as drug… (Health Technology)
Health ministry plans to revamp regulatory rules for biosimilar drugs
Mumbai: The health ministry plans to revamp guidelines for approving biosimilar drugs to make the regulatory pathway more robust and sync it with the rapidly evolving global landscape. Biosimilars are copies of complex drugs, which are based on living cells and 'similar' to an original biologic manufactured by the innovator. These drugs stand distinct from the chemical-based generic drugs that are 'identical' to the originator's compound. The new rules are intended to drill specifically on areas like comparability tests with the reference drug and also address issues such as pharmacovigilance and post-marketing surveillance to report any adverse events. The existing proposals, called Guidelines on Similar Biologics, were released by the department of biotechnology in 2012. They offer a broad roadmap for lab tests, clinical trials and manufacturing processes. The new norms may set the threshold for the minimum number of patients needed for clinical trials and depending on the drug, the number may be increased… (ET Healthworld - Vikas Dandekar)
Short versus long suture width in the closure of abdominal incisions

When abdominal incisions are closed with a running suture, the needle is typically inserted at a distance of 10 mm from the fascia edge (suture width). A reduction of that distance to 5 mm has been proposed. Patients whose incisions are closed with a suture width of 5 mm develop fewer incisional hernias at one year compared with patients whose incisions were closed with a 10 mm suture width (13 versus 21 percent) (Lancet 2015;386:1254).
Accreditation of ethics committees vital for high quality research & trials for new drugs
Certification and accreditation of institutional ethics committees who approve clinical trials, clinical investigators and trial sites are vital for high quality clinical research and clinical trials of new drugs, medical equipments and procedures, according to Dr Y K Gupta, national scientific coordinator for Pharmacovigilance Programme of India (PvPI)… (Pharmabiz - Peethaambaran Kunnathoor)
Don’t advise doctors on reproductive medicine, say infertility specialists
MUMBAI: Don't tell doctors how to practise reproductive medicine. Using this dramatic line, the country's infertility specialists have written a 10-point rejoinder to the central government's Assisted Reproductive Technology (Regulation) Bill 2014. "The bill should not include technical details telling the physician how to practice reproductive medicines. Even the MTP (Medical Termination of Pregnancy) Act & the PCPNDT (Pre-Conception & Prenatal Diagnostic Techniques Act) do not advise physicians on how to perform MTP, ultrasonography, amniocentesis, etc," said a letter by the Indian Society for Assisted Reproduction (ISAR) last week. ISAR, an umbrella organisation of infertility specialists in the country, wrote the letter in response to the Centre's call for suggestions to its draft bill. "The law should act as a guideline and not get into specifics," said ISAR past president Dr Manish Banker from Ahmedabad. ISAR members have said the government should rework certain provisions that duplicate functions laid down by other Acts and hold another meeting with doctors before approving the draft bill. They want "graded punishment" for offences such as clerical errors, lack of proper permission, harm caused by wrong medical treatment and exploitation of surrogate. … (Times of India – Malathy Iyer)
Tracking diagnostic errors will be the key to their reduction, Elizabeth A. McGlynn, PhD, and colleagues write in JAMA in a report titled ‘Measurement Is Essential for Improving Diagnosis and Reducing Diagnostic Error: A Report from the Institute of Medicine’. (Medpage Today)
eWellness
Role of Folate or Folic Acid in Cancer Prevention

Several large observational studies have shown a decrease in risk of colorectal and other cancers with dietary folate, while other randomized trials of folic acid supplementation have raised the possibility of increased cancer risk from folic acid supplementation.

In the largest meta-analysis of individual patient data from randomized trials of folic acid for the prevention of cardiovascular disease (10 trials, n = 49,969) and colorectal adenoma (3 trials, n = 2652), during an average of 5.2 years of treatment, there was no significant difference in overall cancer incidence for patients assigned to folic acid or placebo.

There was also no significant effect on the incidence of specific cancers, including cancers of the large intestine, prostate, lung, or breast. (Lancet 2013;381:1029)
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
Happiness is NOW, Don't Wait

We convince ourselves that life will be better after we get married, have a baby, then another. Then we are frustrated that the kids aren't old enough and we'll be more content when they are. After that, we're frustrated that we have teenagers to deal with. We will certainly be happy when they are out of that stage.
We tell ourselves that our life will be complete when our spouse gets his or her act together, when we get a nicer car, are we able to go on a nice vacation, or when we retire. The truth is, there's no better time to be happy than right now. If not now, when? Your life will always be filled with challenges. It's best to admit this to yourself and decide to be happy anyway.

Happiness is the way. So, treasure every moment that you have and treasure it more because you shared it with someone special, special enough to spend your time with...and remember that time waits for no one. So, stop waiting....

--until your car or home is paid off
--until you get a new car or home
--until your kids leave the house
--until you go back to school
--until you finish school
--until you lose 10 lbs.
--until you gain 10 lbs.
--until you get married
--until you get a divorce
--until you have kids
--until you retire
--until summer
--until spring
--until winter
--until fall
--until you die

There is no better time than right now to be happy. Happiness is a journey, not a destination. So -- work like you don't need money, Love like you've never been hurt, And dance like no one's watching.
eMedi Quiz
A patient using contact lens develops corneal infection. Laboratory diagnosis of acanthamoeba keratitis was established. The following is the best drug for treatment:

1. Propamidine.
2. Neosporine.
3. Ketocanazole
4. Polyhexamethylene biguanide.

Yesterday’s Mind Teaser:  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.

Answer for Yesterday’s Mind Teaser: 2. Sympathetic ophthalmia.

Answers received from: Dr Jainendra Upadhyay, Raghavendra Chakurkar, Dr Poonam Chablani, Dr K V Sarma, Dr K Raju, Dr B R Bhatnagar, Dr Avtar Krishan.

Answer for 17th November 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.
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 Dr. KK Aggarwal, eMedinews has become a cup of morning tea for me. Thoroughly enjoy reading it. My compliments and big thanks, Dr. Chandra
Press Release
A World COPD Day Initiative

What is Chronic Obstructive Pulmonary Disease and how does it affect your lungs?

As per the WHO reports, more than 65 million people are suffering from moderate to severe COPD in India
India’s population accounts for a significant percentage of COPD mortality, which is estimated to be amongst the highest in the world, coming down to about 556,000 in case of India (>20%) out of a world total of 2,748,000 annually


COPD or chronic obstructive pulmonary disease has been characterized as one of the most common lung disorders. Individuals suffering from COPD develop chronic bronchitis, which causes them to develop a persisting cough with mucus. Additionally they may suffer from emphysema, which stimulates lung issues in an individual over time. In this disease, a person suffers from a restricted flow of air to the lungs causing them to develop one or both the diseases.

Coming to the causes, smoking has been talked about as one of the most prominent causes for the development of COPD among the population. It is because more than a third of the population in India consumes tobacco products and other variety of alternatives.

While cigarettes and chewable tobacco products are common in urban areas, the rural population smokes conventional tobacco alternatives like bidi, hookah, and chillum. COPD is prevalent among individuals who don’t smoke or consume tobacco products as well. In such cases, the lack of a protein called alpha-1 antitrypsin can stimulate emphysema. Apart from this, factors like excessive exposure to gasses that harm the lungs, air pollution affecting the quality of breath and lack of proper ventilation can worsen the health of lungs.

People with existing COPD disease are considered to be at an increased risk of developing morbidities like cardiovascular issues, lung cancer and a variety of other medical anomalies.

Stressing on the issue, Padma Shri Awardee Dr. A Marthanda Pillai – National President IMA & Padma Shri Awardee Dr. KK Aggarwal, Honorary Secretary General, IMA and President, HCFI said, “There is little awareness about the fact COPD is treatable, and an individual can be relieved of the disease once the disease has been identified and the necessary precautionary measures have been taken. We recommend individuals to start up an alternative regime that entails fixing lifestyle irregularities. The first and most important way to slow lung damage is to quit smoking. In addition to this it is also recommended that a regular exercise routine is put in motion to help build one’s strength and stamina. It is essential to keep your surroundings clean and ensure proper ventilation. Fireplaces and areas where there is excessive pollution should be avoided since they can aggravate respiratory issues. And lastly, eat healthy so that you can live disease free,”

Individuals suffering from the disease are prescribed inhalers to open the airways so that the air can thoroughly pass; oral medicines are prescribed to decrease lung inflammation reduce swelling and control infection in the lungs. In severe circumstances, injective medicines, using a nebulizer, oxygen therapy, and breathing assistance through a mask or endotracheal tube is preferred. Medical assistance is available to decrease the severity of the disease, but nothing can compare to the precautions and individual takes like saying no to smoking.

A person suffering from COPD might notice symptoms like:

• Short of breath or complete breathlessness
• Chest congestion
• Wheezing
• Coughing Mucus
• Excessively scratchy throat
• Presence of sputum
• Recurring moderate to severe respiratory infection
• Blue tinge in the fingernails and lips
• Feeling lethargy
• Abrupt weight loss

Prevention is always better than cure and this COPD Day IMA will be educating all its 2.5 lakh members on the proper patient counseling techniques in this regard.
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