December 1   2015, Tueseday
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Dr KK AggarwalDr KK Aggarwal HIV Update

• Over 200 diseases can be transmitted from exposure to blood.

• The most deadly diseases transmitted by blood are hepatitis B, hepatitis C and HIV.

• Co infection with HIV and hepatitis C or HIV with hepatitis B is common. They share similar routes of transmission. Thirty percent HIV-positive patients are also co infected with HCV and 10% with chronic hepatitis B infection.

• In HIV-positive cases, hepatitis C seroprevalence is up to 73% in injection drug users compared to 4% in patients at low risk.

• Injection drug users acquire hepatitis C virus before HIV infection while MSM typically acquire HIV before they acquire hepatitis C virus infection.

• Hepatitis C virus is transmitted efficiently via percutaneous routes, so seroprevalence rates are highest in intravenous drug users.

• Injection drug use is the leading route of HCV transmission.

• Hepatitis B virus is the most infectious virus that can be transmitted through the blood or bodily fluids.

• A healthcare worker stuck with a needle containing blood infected with hepatitis B virus has 6-30% chance of developing hepatitis B. The risk of hepatitis C virus and HIV in the same situation is 1.8 and 0.3% respectively.

• The hepatitis B virus can survive on counter tops for 7 days and remain capable of causing infection.

• Hepatitis C virus can survive on environmental surfaces for at least 16 hours.

• Transmission of hepatitis C virus from blood splashes to the conjunctiva has been described.

• Alcohol kills HIV, hepatitis B virus and hepatitis C virus.

• The risk of becoming infected with hepatitis B is greater than the risk of becoming infected with other viruses.

• For HIV, treatments are available to reduce the risk of becoming infected with HIV after exposure.

• The risk of becoming infected with HIV as a result of exposure to rape is even lower than the risk of infection after a needle stick. All rape victims should be given anti-HIV drugs.

• The CDC recommends a combination of 2 or 3 medications to prevent developing HIV after exposure. Four weeks of treatment is generally recommended.

• Condoms reduce, but do not completely eliminate, the chances of transmitting hepatitis B, hepatitis C, or HIV infection to others.

• New weapons of war are HIV kanya, HIV blood transfusions after kidnapping, HIV positive syringes for extraction of money and infected hepatitis C, hepatitis B and HIV combined blood (most deadly weapon ever possible).

• The average risk of seroconversion after a needle stick injury is about 3 per 1000 with no prophylaxis. This risk is reduced at least 80% when post exposure prophylaxis (started within 3 hours) is administered in a timely fashion.

• Infection is high with hollow needle, high bore needle and if the needle is inserted in the artery or the vein.

• Start antiretroviral therapy (ART) in nearly all HIV-infected individuals regardless of their CD4 count. Previous recommendations for delayed ART (unless CD4 count < 350) were heavily influenced by drug toxicities, the potential risk for drug resistance if virologic suppression was not achieved, and limited treatment options for patients who failed therapy. Therapeutic options have expanded, and the available agents are more potent, better tolerated, and associated with less toxicity compared with earlier agents. In addition, simplified regimens have led to improved adherence

• HIV, Hepatitis B and Hepatitis C, mixed infection: If a patient has a mixed infection, always treat all of them together; do not treat one particular infection.

• If a person is diagnosed to have HIV and an opportunistic infection: Treat opportunistic infection first. For example, if the patient has TB, give ATT for two weeks and then start ART.
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
Drugs for all HIV patients not feasible

The National Aids Control Organisation (NACO) has made it clear that India is not ready to adhere to WHO's recent recommendation of providing antiretroviral therapy (ART) for all HIV patients regardless of their disease stage. Till now, in India, only those with a CD4 cell count of less than 350 are started under the ART programme. The NACO, for the first time in over a decade, has decided that the lifesaving antiretroviral drugs will now be offered to even those with a slightly higher CD4 count of 500. So now more than 2-3lakh HIV patients, who earlier did not qualify for the free ART therapy, are likely to be brought under its ambit. Currently, only 8 lakh people in the country are on the ART programme, even though the total number of people living with HIV in India is estimated to be 21 lakh. Dr BB Rewari, national programme officer (ART), NACO said, “We have to look into the evidence of starting ART for all. More than evidence, it is operational feasibility, finances, human resource and how the ART centres will cope with the increased load of more patients." The WHO recommendations are never meant to be adopted immediately, it might take a year or two, he further added… (ET Healthworld - Sumitra Deb Roy& Malathy Iyer)

India introduces injectable polio vaccine in routine immunization

Babies getting their third dose of oral polio vaccine (OPV) will now also be administered an injection with inactivated polio vaccine (IPV), as part of India’s efforts to boost its polio immunization program. The two vaccines given together can provide additional protection to a child. India was certified polio-free on March 27, 2014, but the immunization program continues in the country since two of its neighbors remain polio-endemic and due to the threat of vaccine-derived polio. The injection will be introduced in six states - Assam, Bihar, Uttar Pradesh, Gujarat, Madhya Pradesh and Punjab - in the first phase ……(LiveMint)
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Specialty Updates
• A pet dog may protect children from childhood anxiety, suggested new research published by the Centers for Disease Control and Prevention. Researchers noted that among the 58% of children with a dog in the home, 12% tested positive on a screening test for anxiety, compared with 21% of children who did not have a pet dog.

• A new study from the National Institutes of Health suggests that, while men still drink more than women, the gap is closing. The findings are published in the journal Alcoholism: Clinical and Experimental Research.

• Reductions in radiation dose may be achieved by using patient-specific, weight-based protocols during whole-body FDG PET/CT imaging, suggested new research presented at the Radiological Society of North America (RSNA) meeting. Researchers stated that the radiation dose can be reduced by 43%.

• A new study, published in the journal Brain, Behavior and Immunity, suggests that a high-fat diet destroys synapses in the hippocampus of the brain, which may impair learning and memory. Additionally, switching to a low-fat diet for 2 months can counteract the brain-damaging effects of a high-fat diet.

• Denosumab inhibited the progression of bone erosion and increased bone mineral density in Japanese patients with rheumatoid arthritis (RA) who were on methotrexate, suggested a new study published in the Annals of the Rheumatic Diseases.

• People with diabetes may be harboring advanced vascular disease that could increase their risk of stroke, and arterial imaging with 3-D MRI could be useful in helping determine stroke risk among diabetics, suggested new research presented at the annual meeting of the Radiological Society of North America (RSNA).

• Among patients with suspected acute coronary syndrome (ACS) seen in emergency rooms, coronary CT angiography (CCTA) did not lead to better detection of significant CAD compared with standard optimal care that included high sensitivity (hs) troponin tests, reported a new study from the Netherlands, presented at the American Heart Association (AHA) 2015 Scientific Sessions.

• Scientists seeking a cure for the AIDS virus have discovered that disulfiram, a drug designed to combat alcoholism could be a critical part of a strategy to "wake up" and then kill latent HIV. As per the study in Lancet HIV 2015, short-term administration of disulfiram resulted in increases in cell-associated unspliced HIV RNA at all doses, consistent with activating HIV latency.
Soul does not leave the body immediately after the death

According to Prashna Upanishad, at the time of death, the Prana Vayu (life force and respiration) merges with Udana Vayu (brain stem reflexes) and leaves the body. But this does not happen immediately after clinical death, which is defined as stoppage of heart and respiration. Medically the term used for clinically dead patients is sudden cardiac arrest.

As per the modern medicine, in cardiac arrest, the brain does not die for the next 10 minutes and during this period, if the heart can be revived, life can be brought back.

The revival of patient during this period can be remembered by the ‘Formula of 10’: Within 10 minutes of the stoppage of heart (cardiac arrest), if effective chest compressions are given for the next ten minutes with a speed of 100 per minutes (10X10), 80% of the cardiac arrest victims can be revived.

This period can be much longer in hypothermia state. If the temperature of the body is low, the soul does not leave the body till the temperature is brought back to normal. Today, this property of soul is also used as therapeutic measure where patients who cannot be revived in the first 10 minutes of clinical death are put in a freezing chamber and artificial hypothermia is produced and these patients can then be transported to an advance cardiac centre where even after 24 hours, resuscitation measures can be applied after re-warming the body. Many people have been revived even after 24 hours of cardiac arrest with such a technology.

There are instances in literature where a newborn with hypothermia was declared dead but revived in the cremation ground when the environment heat brought the body temperature to normal and the pressure of the wood worked like cardiac massage.

This aspect of “life after death” is a contribution of the modern science to the Vedic science. Though in Vedic literature, it was well known phenomenon as Savitri brought life back into Satyavan even after his clinical death.

Take home message is that one should not declare a patient dead in the first 10 minutes; give cardiac massage and try reviving him with chest compression cardiopulmonary resuscitation (CPR).
Legal Quote
Jacob Mathew vs State of Punjab and Anr: 5th day of August 2005: 334/2005/SCI/ 144-145 of 2004

”A doctor accused of rashness or negligence, may not be arrested in a routine manner (simply because a charge has been levelled against him). Unless his arrest is necessary for furthering the investigation or for collecting evidence or unless the investigation officer feels satisfied that the doctor proceeded against would not make himself available to face the prosecution unless arrested, the arrest may be withheld. ”
Digital IMA
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Retirement Tax Suggestions

Once having decided how you want to live and having determined roughly how much it will cost, compare that with a projected income:

• Company and other pension payments
• Insurance or mutual funds to annuitize for income
• Calculate after-tax profit from home sale
• If you plan to sell your home, the proceeds could generate additional income. But, you should consider the rent required for the type of home that would meet your post-retirement needs as well as the location. Remember, however, that there are no ceilings on rent increase.
• Other liquid assets to produce additional cash.

(Source: IJCP)
HCFI and IMA participate in a five-day health camp organized by the Health Ministry for its Members of Parliament at the Parliament Annexe from 30th November to 4th December 2015

Overtreatment of acute pharyngitis is a major cause of inappropriate antibiotic use, which can be avoided by a systematic approach to evaluation and treatment.
HIV on the wane but high risk groups still cause for concern

On December 1, India will enter the third and perhaps the most perplexing decade of its HIV/AIDS epidemic. The first 29 years were marked with victory as the human immunodeficiency virus (HIV) metamorphosed from being the deadliest word in public health to just another chronic disease such as diabetes or hypertension that can be managed well with medicines. But experts warn that complacency accompanied by a sharp drop in funding could prove to be costly for India. While the incidence of new infection among the general population and pregnant women has shown a significant decline every year, that among risk groups continue to be a cause for concern. As per the HIV sentinel surveillance data of 2010-11, HIV among female sex workers in Mumbai was around 6%, much higher than the national prevalence of 2.7%……… (ET Healthworld - Malathy Iyer & Sumitra Deb Roy)
Hepatitis C drugs may soon cost 90 times less

The apex committee of the Central Drugs Standard Control Organisation (CDSCO) has granted a waiver of local trials for crucial new direct-acting antiviral drugs treating chronic Hepatitis C. The waiver for sofosbuvir and ledipasvir co-formulation and for daclatasvir is expected to bring the generic version of these drugs, which cost a fraction of the branded versions, into the Indian market within weeks. Some patients facing a threat to life currently import these drugs at a huge cost. India is now one of the few countries where generics are available for interferon-free treatment. Pegylated interferon is an old, expensive, injectable chemotherapy drug with serious side effects used to treat Hep C in combination with sofosbuvir and ribavirin. The interferon-free treatment, which costs over $90,000 in the US and over 50,000 euros in the EU will be available to Indian patients for about Rs 55,000 or about $1,000 or even less thanks to competition between generic manufacturers … … (ET Healthworld - Rema Nagarajan)
Burnout rates vary by specialty

Rates of burnout vary markedly by specialty, but generally the highest rates are found among front-line physicians: family medicine, general internal medicine, neurology, and emergency medicine, and the lowest rates were found among pathology, dermatology, general pediatrics, and preventive medicine, according to a survey of burnout among US physicians. The mean average of those reporting burnout was 45.8%, but the emergency physicians had the dubious distinction of being the specialty with the highest burnout rate: more than 60%... (Medpage Today)
Gujarat IMA to identify lifestyle diseases

Vadodara: Doctors in the Gujarat branch of Indian Medical Association (G-IMA) have taken up the cause to reach every citizen to identify cases of tuberculosis and lifestyle diseases. Doctors claim that the late detection and casual attitude of many patients have led to aggravated cases which could have been cured at primary stages. An attempt to revive the failing national tuberculosis programme will also form the principal aim of G-IMA…… (ET Healthworld)
India's first tracheal transplantation surgery carried out successfully

Surgeons at Amrita Institute of Medical Sciences and Research Centre at Kochi have successfully carried out the first phase of trachea transplant in Asia for a female patient who had cancer of the whole length of trachea The highly complex procedure known as tracheal homograft has been carried out only once earlier in Belgium, though surgeons in Spain and the USA have tried different procedures like tissue engineering or synthetic trachea. The transplantation has been planned in two stages. In the first stage, done on Thursday, the soft tissue and mucosa of the donor trachea was denuded off before it was placed into the recipient forearm by a complicated and lengthy surgery, which took 12 hours. In the second stage, two months after the initial surgery and once it is sure that it has taken new blood vessels and become viable, the new trachea in the forearm will be harvested along with its blood vessels to replace the diseased trachea… …… (Hans India)
Scientists record real-time dopamine release in Parkinson's patients

Scientists have reported first-ever measurements of dopamine, a key neurotransmitter involved in learning with unprecedented precision in the brains of people with Parkinson's disease. The measurements, collected during brain surgery as the conscious patients played an investment game, demonstrate how rapid dopamine release encodes information crucial for human choice. The researchers detected changes in the levels of dopamine a thousand times faster than had previously been recorded in humans. These rapid measurements, combined with enhanced chemical specificity, led the scientists to discover that dopamine has a far more complex role than formerly thought. The findings are published in the journal Proceedings of the National Academy of Sciences…… (ET Healthworld)
India's first diabetes app launched to ease diabetic lives

Created by the Indian start-up of the same name, Diabeto, launched on World Diabetes Day, is claimed to be the only app that facilitates the patients to track their blood glucose data and upload and store securely the diabetes data on to the cloud. This app also allows the patients to choose a doctor of their choice and schedule a tele-consultation from a pool of diabetes doctors available on the app. A selected doctor can easily access the patient's records and information from the app and give valuable feedback on diabetes management from the comfort of their homes for as low as Rs. 650 per consultation…… (Times of India)
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
IMA Live Webcast

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Central India Unit of the UNESCO Chair in Bioethics,
Haifa and IMA UNESCO Chair in Bioethics,

December 11, 2015, 9:00A.M
PGIMER - RML Hospital, New Delhi

For Registration for 16 IMA Nominee
Phone: 9811841351
Dr. R.P Beniwal
Bioethical issues in medical practice
Duty as a parent

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

Rina is mother to Chini, an 11 year old girl with mental retardation. Chini can barely look after herself. Her mother is constantly worried as to how she will look after herself when her periods start. At present Chini has barely learnt to bather herself, speak intelligible sentences and move around by herself. However Chini has no idea about her own disability and loves watching romantic scenes on TV. Rina is worried that in these insecure times, Chini may end up being abused or taken advantage of due to her lack of understating. They approach you as a doctor to provide a certificate so that the parents can ask for a hysterectomy. You tell them that this is against human rights and in fact, there is a court judgment against this practice but they keep insisting, because they see you both as a doctor as well as a friend. What should you do?

a) Go all out to help them for the operation because you feel that times are actually bad and chances of (possible) rape and pregnancy are high?
b) Go by the book and say there is nothing you can do?
c) Suggest alternative treatments?

Any other suggestions and solutions? Do write in!

Responses received

It is the responsibility of the mother to protect her from sexual abuses and subsequent pregnancy as she cannot take care of herself. The best course would be to get a certificate from psychologist that she is mentally unfit and cannot take care of herself. Then she should get her operated for tubectomy to save her from subsequent pregnancy and then get her treated by some psychologist for her mental illness. If she recovers and becomes mentally fit she may get her operated for reversal of procedure, reuniting the tubes. This will give her a chance of getting pregnant which is very important factor for any lady. Hysterectomy will be a permanent failure to get the child of her own, which becomes unethical. Dr BR Bhatnagar
IMA Digital TV
Inspirational Story
Our Time in History

The paradox of our time in history is that we have taller buildings, but shorter tempers; wider freeways, but narrower viewpoints. We spend more, but have less; we buy more, but enjoy it less. We have bigger houses and smaller families; more conveniences, but less time.

We have more degrees, but less sense; more knowledge, but less judgment; more experts, but less solutions; more medicine, but less wellness. We have multiplied our possessions, but reduced our values. We talk too much, love too seldom, and hate too often.

We've learned how to make a living, but not a life. We've added years to life, not life to years. We've been all the way to the moon and back, but have trouble crossing the street to meet the new neighbor. We've conquered outer space, but not inner space.

We've cleaned up the air, but polluted the soul. We've split the atom, but not our prejudice. We have higher incomes, but lower morals. We've become long on quantity, but short on quality.

These are the times of tall men, and short character; steep profits, and shallow relationships. These are the times of world peace, but domestic warfare; more leisure, but less fun; more kinds of food, but less nutrition.

These are days of two incomes, but more divorce; of fancier houses, but broken homes. It is a time when there is much in the show window and nothing in the stockroom
eMedi Quiz
The signs and symptoms of H1N1 flu and seasonal human flu are same although gastrointestinal manifestations are more common with H1N1 flu. True or false?

Yesterday’s Mind Teaser: Flu will have:

1. Fever (temperature of 100ºF (37.8ºC) or greater)
2. Cough or sore throat
3. Absence of a known cause other than influenza.
4. All of the above

Answer for Yesterday’s Mind Teaser: 4. All of the above

Answers received from: Dr Rajesh S Joshi,  Dr Jainendra Upadhyay, Dr.B.R.Bhatnagar.

Answer for 29th November Mind Teaser: Celiac disease is a large bowel disorder

Answers received from: Dr. P. C. Das, Dr.K.Raju, DR ARPAN GANDHI,  Dr Chandresh Jardosh,  Dr Jainendra Upadhyay, DR AVTAR KRISHAN, Dr B K Agarwal.
A civilized fight between husband & wife

Wife: Twinkle Twinkle little star, you should know what YOU are and once YOU know what YOU are, then the Mental hospital is’nt so far.

Husband: The rain makes all things beautiful the grass & flowers too, if rain makes all things beautiful, why doesn’t it rain on YOU?

Wife: Roses are red, Violets are blue and monkeys like YOU should be kept in zoo.

Husband: Don’t feel so angry, YOU will find me there too, not in the cage but laughing at YOU!
Readers column
Dear Sir Thanks for the updation.Regards: Dr KP Sharma
Press Release
HCFI and IMA participate in a five-day health camp organized by the Health Ministryfor its members of parliament

On-going at parliament NXE from 30th November - 4th December 2015

Stressing on the importance of living a healthy life,the Health Ministrytoday inaugurateda five-day healthcampfor members of parliament from November 30th to December 4th in the capital. The main motive being, to educate them about important life-saving techniques and preventive health measures. IMA and HCFI are key participants in the event in charge of training all participants in the life-saving technique of Hands Only CPR 10 and sharing important tips and tricks to live a long and healthy life. Inaugurating the event were none other than, Dr. JagatPrakashNadda - Union Minister of Health and Family Welfare and Mrs. S. Mahajan – LokSabhi Speaker.

Other participants included AYUSH, Central Health Education Bureau, and Hindustan Latex Limited.

Speaking on the occasion, Padma Shri Awardee Dr A Marthanda Pillai – National President and Dr KK Aggarwal, Honorary Secretary General, IMA and President, HCFI said, “It an honor to be a part of this unique initiative by the Health Ministry to encourage its MP’s to live a healthier and disease free lifestyle. Over the next five days, both IMA and HCFI together will be training all the participants in the life-saving technique of Hands-only CPR 10 for revival after sudden cardiac arrest. The majority of the people remain unaware that a person can be brought back to life within 10 minutes of their death through a simple and easy to learn technique. In addition to this, we will also be sharing our formula of 80 with the MPs, which include tips to live a disease free life till the age of 80 years.”

Given that medical emergencies can occur anywhere and at anytime and several times it is not possible for a hospital or doctor to be close by, it is extremely important that each one of us knows the technique of Hands-only CPR 10. 50% of all sudden cardiac arrest victims can be brought back to life within the first ten minutes of their death is CPR is administered in a timely and effective fashion.

"We at HCFI have derived a simple, easy formula for the technique. Within 10 minutes of death (earlier the better), for a minimum of 10 minutes (adults 25 minutes and children 35 minutes), compress the center of the chest of the deceased person continuously and effectively with a speed of 10×10 = 100 per minute” Dr. K K Aggarwal added

All the participants on Day 1 took a commendable interest in the exhibition prepared by HCFI in which the formula of 80 was also displayed in the form of messages and placards. The formula of 80 is a guide to live up to the age of 80 without developing any lifestyle diseases and disorders. It is a simple and easy to follow guide, which includes some basic lifestyle changes like the following:

• Women must keep their abdominal circumference lower than 80 cm and men 90 cm
• Keep your fasting sugar lower than 80 mg%.
• Keep your blood pressure lower than 80 mm Hg.
• Keep your heart rate lower than 80 per minute.
• Keep your bad LDL cholesterol lower than 80 mg%.
• Do not consume more than 80 grams of caloric solid or liquid food at once.
• Observe a carbohydrate fast 80 days a year.
• Do not consume alcohol and if you do, restrict it to not more than 80 ml in a day or 80 grams in a week.
• Restrict your soft drink consumption to 80ml in one go. The tip is to add soda and dilute it to make it 200 ml
• Do not consume more than 80 eggs in a month.
• Consume atleast 80 fruits and vegetables servings in a week.
• Do not consume tobacco otherwise you will end up with a surgery bill of Rs.80, 000
• Do not consume more than 80 ml/gram of ghee, oil and butter in a week.