November 20   2015, Friday
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EDITORIAL
Dr KK AggarwalDr KK Aggarwal Weekend 'Social Jetlag' can be heart unfriendly

Switching to late nights and late mornings on the weekend is associated with cardiometabolic risk. Termed "social jetlag", it is associated with poorer lipid profiles, worse glycemic control, and increased adiposity in healthy adults, as per a report published in Journal of Clinical Endocrinology & Metabolism. These metabolic changes can contribute to the development of obesity, diabetes and cardiovascular disease.

A total of 111 study participants had a social jetlag of more than 60 minutes. Compared to the other study participants, these individuals had:

• Higher mean triglycerides: 107 mg/dL versus 91 mg/dL (P=0.009)
• Lower mean HDL-cholesterol: 54 mg/dL versus 57 mg/dL (P=0.014)
• Higher mean fasting insulin levels: 13.5 µU/mL versus 12 µU/mL (P=0.03)
• More insulin resistance as measured by homeostatic model assessment: 4.0 versus 3.7 (P=0.028)
• Greater mean waist circumference: 94 cm versus 89 cm (P=0.001)
• Higher mean BMI: 28 versus 26 (P=0.004)

It has been shown that regulating sleep times can help treat insomnia, and this emerging evidence along with others suggest that perhaps doing so will have benefits in treatment and prevention of other diseases.
EMEDINEXUS STATEMENT
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
Drug cos get a final chance to register with pharma data bank

The government has given a final chance to pharmaceutical companies to register themselves with pharma data bank by December 15 and said failure to do so will invite penal action. "The companies are hereby given a final opportunity to register themselves in IPDMS and fill all forms as required... on or before December 15, 2015," National Pharmaceutical Pricing Authority (NPPA) said in a notice on its website. Failure to submit mandatory data in IPDMS -- also known as pharma data bank -- or returns prescribed under Drugs (Prices Control) Order, 2013, through the IPDMS "will attract penal action under the provisions of the DPCO 2013 read with EC Act 1955," it added…(ET Healthworld)

Ban Direct-to-Consumer Drug Ads, AMA Says

The American Medical Association (AMA) took a stand in the national debate on affordable drug prices when the group's House of Delegates called for a ban of direct-to-consumer (DTC) advertising of prescription drugs and medical devices. Delegates said that DTC ads boost demand for costly treatments as opposed to less expensive, but clinically effective alternatives, according to an AMA news release on the House of Delegates meeting in Atlanta, Georgia. In addition, patients may ask their physician to prescribe advertised drugs "even when these drugs may not be appropriate," said Patrice Harris, MD, chair-elect of the AMA board of directors… (Medscape)
Dr Good Dr Bad
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Specialty Updates
• Adjunctive use of an antidiabetic agent that increases insulin sensitivity may improve symptoms of chronic depression in nondiabetic patients, suggests new research published online in Psychiatry Research. Pioglitazone was found to have an antidepressant effect in patients who had some degree of insulin resistance at baseline, and the effect was most prominent in younger patients.

• A new study suggests that the overall benefits of thrombolytic therapy may outweigh the risks in stroke patients taking antiplatelet therapy. The findings are published online in JAMA Neurology.

• A new study suggests that results vary significantly from drop to drop in fingerprick blood tests, and thus to achieve consistent test results, as many as six to nine drops of blood should be combined. The study is published in the American Journal of Clinical Pathology.

• The effectiveness of HIV treatment in adults may be hampered by low levels of vitamin D, suggests a new study published in the journal Clinical Nutrition.

• Vitamin E was associated with improvement in liver histology in non-alcoholic steatohepatitis (NASH) patients whether or not they had diabetes, suggested an analysis of pooled data from two trials presented at the American Association for the Study of Liver Diseases meeting.

• Gestational age and type 1 diabetes appear to be linked, independent of familial factors, suggest the results from an extensive study on nearly all births in Sweden over 4 decades, published online in Diabetes Care. Researchers noted that late preterm birth and early-term birth babies were at increased risk of type 1 diabetes.

• Patients with colonic diverticula have no greater risk for colorectal adenomas, suggested a new prospective study published online in the American Journal of Gastroenterology.

• The phase IIIb REALISTIC study demonstrated rapid and sustained clinical improvements among a diverse group of patients with rheumatoid arthritis (RA) treated with certolizumab pegol, including patients who had already been treated with a tumor necrosis factor (TNF) inhibitor. The findings were published online in Arthritis Research & Therapy.
eSpiritual
What is the difference between smile, hug and laugh?

Smile is a sign of joy, while hug is a sign of love. Laughter on the other hand is a sign of inner happiness. None of them are at the level of mind or intellect. All come from within the heart. They are only the gradations of your expressions of your happiness. It is said you are incomplete in your dress if you are not wearing smile on your face. Hug comes next and laughter the last. Laughter is like an internal jogging and has benefits like that of doing meditation. But be careful we must know when not to laugh. The most difficult is to laugh on oneself
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Legal Quote
Samira Kohli vs Dr. Prabha Manchanda and Anr, SCI Civil Appeal No. 1949 of 2004, 16.01.2008

“To establish liability by a doctor where deviation from normal practice is alleged, three facts require to be established. First of all it must be proved that there is a usual and normal practice; secondly it must be proved that the defender has not adopted that practice; and thirdly (and this is of crucial importance) it must be established that the course the doctor adopted is one which no professional man of ordinary skill would have taken if he had been acting with ordinary care.”
Medicofinance
Investments: Monitor the effects of ongoing results

• Compare performance to original expectations.
• Compare performance to standard indices.
• Evaluate the portfolio in light of client’s current needs and objectives.
• Evaluate investments in light of the future outlook for the economy and the investment.

(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
Health ministry issues draft guidelines on 'establishment of new medical colleges by upgrading district/referral hospitals'

The Union health ministry has issued draft guidelines for centrally sponsored scheme of 'establishment of new medical colleges by upgrading district/referral hospitals' preferably in under-served districts of the country. The government is implementing this scheme to mitigate the shortage of doctors by increasing the number of undergraduate seats in the country for equitable healthcare accessibility across the states. The scheme aims to establish 58 medical colleges with intake capacity of 100 in each to increase 5,800 seats at the undergraduate level in government sector and to bridge the gap in number of seats available in government and private sector to ensure availability of more MBBS seats for students who cannot afford costly medical education in private sector… (Pharmabiz – Ramesh Shankar)
Govt to sell 425 generic medicines at Jan Aushadhi stores

Government plans to sell more than 400 generic medicines at cheaper price through Jan Aushadhi stores by end of this year. At present, there are 225 generic medicines available at Jan Aushadhi store. The rates of medicine on these stores are as low as one-third to one-tenth of the market price depending on the type of medicine. The government is also planning to increase the number Jan Aushadhi stores to 3,000 that will be opened in two years across the country by involving B Pharma and M Pharma qualified unemployed populace… (ET Healthworld)
Cabinet approves setting up of National Resource Facility for Bio-medical Research
The Union Cabinet, chaired by Prime Minister Narendra Modi has approved the proposal of the Department of Health Research in the Ministry of Health and Family Welfare for setting up of a National Resource Facility for Bio-medical Research (NARF) at Genome Valley in Hyderabad by the Indian Council for Medical Research (ICMR). The estimated project cost is Rs. 338.58 crores and the resource center is expected to be functional by 2018-19. The institution will be the first of its kind for quality laboratory animals for basic and applied biomedical research in the country… (PIB)
India adds 100M internet users in 2015

The number of internet users in India grew by 49% over last year and is expected to reach 402 million by December 2015, according to a report by industry body Internet and Mobile Association of India (IAMAI). About 306 million of these will access Internet from their mobile devices, up from 276 million in October this year. The report also said that while Internet in India took more than a decade to move from 10 million to 100 million and 3 years from 100 to 200 million, it took only a year to move from 300 to 400 million users. Clearly, Internet is mainstream in India today… (Techcircle.in-PTI)
New approach to fibromyalgia tackles poor-quality sleep
For patients with fibromyalgia, directing treatment toward nonrestorative sleep, a key feature of the syndrome, leads to improvements in other symptoms of the disease, including pain, according to two analyses of data from the phase 2b placebo-controlled BESTFIT study. "We recognized that sleep wasn't only a symptom; poor sleep exacerbates the pain of fibromyalgia. It's probably a vicious cycle of poor sleep, more pain, more pain, and worse sleep," said Seth Lederman, MD. (American College of Rheumatology (ACR) 2015 Annual Meeting)
Eliminating delays can curb infant mortality
Eliminating three types of delays in mother and child healthcare services can greatly reduce the infant mortality rate (IMR) in the state. A recent sample registration system report shows that IMR was 50 in 2013. The fact came to the fore at the UP Health Summit organised by the state commission for protection of child rights on Wednesday. Listing the delays, Dr JV Singh, head of the department of community medicine at King George's Medical University said, "Delay in taking decision that the patient needs medical attention, delay in transporting mother or baby to health facility and delay in providing medical service are extremely crucial for survival." Chief of Unicef's UP office, Niloufer Pourzand, said delays were responsible for at least 40% of neonatal, infant and mother deaths in the state and the problem could be corrected. (ET Healthworld)
Read ISGCON 2015 updates at www.emedinexus.com
Immune tolerant HBV Infection in children – Do they need treatment?
Ujjal Poddar

There is a controversy about the root of transmission of hepatitis B in India. Largely people believe that it is horizontal based on some old studies in pregnant women. However, recent data and clinical experience suggest that a significant proportion of chronic hepatitis B is perinatally transmitted and to substantiate that we from SGPGI, Lucknow have done genotyping of a mother-baby pair and have shown that they are identical in genotype and in their sequence homogeny suggesting that the predominant mode of transmission, especially in children, is vertical. These groups of patients (immune tolerant) have been usually following a benign course in the past 2 decades and 2/3rd of them become inactive in their career by 30 years of age and 1/3rd develop chronic liver disease. The age of seroconversion determines the outcomes of chronic hepatitis B. Studies have shown early seroconversion in childhood days prevents development of chronic liver disease in adulthood precludes having as an adult. Hence, the target of therapy in children with immunotolerant Hep B should be to achieve seroconversion. The trial of sequential combo therapy of lamivudine followed by lamivudine+ interferon showed a promising response in the treatment of immunotolerant Hep B in children. In our study of 28 children, HbsAg seroconversion was seen in 21% of cases. A similar study from King’s College also shows HbsAg seroconversion in 18% of cases. Hence there is some hope of cure with sequential combo therapy in immune tolerant hepatitis B.

Are we ready to take up the challenge of changing the scenario?
Prof VI Mathan

Chennai

Is the gastroenterologist just a man at the end of a tube? So started Dr Mathan speaking at the inauguration of the CME session on day one of ISGCON 2015. Not so, he continued to day, on the contrary, a gastroenterologist should primarily be a physician with the 3 key qualities of Care, Compassion and excellent Care. These are the 3 legs on which we are perched when treating a patient.

When you train to be a gastroenterologist remember you are treating not the investigations but a human being. Health care has unfortunately become an industry rather than a vocation of the earlier days. These days most people seem to be perched on a bar stool with a single leg of cash! As we go forward are we going to change? Contribute to the solution of a problem or be a part of commercialization? Are we ready to take up the challenge of changing the scenario back once again of healthcare being a vocation? This is food for thought for the upcoming GE in the making.

I wish you all the best in this endeavor…

Refractory GERD: An Approach to Management
C Prakash Gyawali


• pH-impedance monitoring is performed off PPI therapy in ‘unproven GERD’, and on maximal therapy in ‘proven GERD’ with persisting symptoms.

• Abnormal acid exposure time and symptom association with impedance detected reflux events predict symptom improvement in GERD.

• Structural disruption at the gastroesophageal junction predicts poor response to PPI and better response to antireflux surgery.

• Overlap of functional disorders (IBS, functional dyspepsia) predicts suboptimal response to PPI therapy.

• Neuromodulators (low dose antidepressants) are of value when perceptive symptoms persist despite optimal GERD management.
eWellness
Extreme exercise may not pose danger to heart: The Wall Street Journal reported that a study of Tour de France cyclists found that they had longer lives than the general population and were less likely to die from heart troubles.

Faster heart attack care has not led to better in–hospital survival: USA Today reported that research published in the New England Journal of Medicine indicates that while hospitals have "shaved 16 minutes off the time it takes to get heart attack patients into treatment from 2005–2006 to 2008–2009, reducing that time from 83 minutes to 67 minutes," investigators “found that the percentage of heart attack patients who die while in the hospital, about 5%, hasn’t changed."

Gut bacteria may play role in determining weight: The investigators found that mice who received bacteria from the obese twin became fat, while the mice who received bacteria from lean individuals remained lean.

CDC: One in four deaths from cardiovascular disease preventable: USA Today reported currently, there are approximately 800,000 deaths annually in the US from cardiovascular disease, but about 200,000 of these deaths "could be prevented if people made healthy changes including stopping smoking, maintaining a healthy weight, doing more physical activity, eating less salt and managing their high blood pressure, high cholesterol and diabetes.
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
Promise Yourself

To be so strong that nothing can disturb your peace of mind;
To talk health, happiness, and prosperity to every person you meet;
To make all your friends feel that there is something in them;
To look at the sunny side of everything and make your optimism come true;
To think only the best, to work only for the best, and to expect only the best;
To be just as enthusiastic about the success of others as you are about your own;
To forget the mistakes of the past and press on to the greater achievements of the future;
To wear a cheerful countenance at all times and give every living creature you meet a smile;
To give so much time to the improvement of yourself that you have no time to criticize others;
To be too large for worry, too noble for anger, too strong for fear; and too happy to permit the presence of trouble;
To think well of yourself and to proclaim this fact to the world, not in loud words, but in great deeds;
To live in the faith that the whole world is on your side so long as you are true to the best that is in you.
eMedi Quiz
All of the following conditions may predispose to pulmonary embolism except:

1. Protein S deficiency.
2. Malignancy.
3. Obesity.
4. Progesterone therapy.

Yesterday’s Mind Teaser:  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. Ketoconazole
4. Polyhexamethylene biguanide.

Answer for Yesterday’s Mind Teaser: 1. Protein S deficiency.

Answers received from: Dr Jainendra Upadhyay, Dr K V Sarma, Dr K Raju, Dr Rajesh S Joshi, Dr B R Bhatnagar, Dr Avtar Krishan, Dr Bitaan Sen & DrJayashree Sen.

Answer for 18th November 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.
Humor
Flustered

As an instructor in driver education at the local area High School, I’ve learned that even the brightest students can become flustered behind the wheel. One day I had three beginners in the car, each scheduled to drive for 30 minutes. When the first student had completed his time, I asked him to change places with one of the others. Gripping the wheel tightly and staring straight ahead, he asked in a shaky voice, "Should I stop the car first?"
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Press Release
Asthma and winter care: What can you do to protect yourself?

In case of patients who are suffering from asthma, the lungs become irritable and more reactive than before during winter months

While the sudden change in weather comes as a sign of relief for many, it also brings with it health implications especially for those suffering from pre-existing lifestyle diseases like asthma. It is essential that special care be taken during this time to be able to properly enjoy the winter season.

According to the World Health Organization, India is home to an estimated 20 million asthma patients. All of them suffer from moderate to severe cases of asthma and hence, it really becomes important for these patients to understand how a common virus can trigger a major asthma attack in the winter months.

Stressing on the topic, Padma Shri Awardee Dr. A Marthanda Pillai – National President IMA & Padma Shri Awardee
Dr. KK Aggarwal, Honorary Secretary General, IMA and President, HCFI said, “To eradicate the dangers, one must understand what triggers asthma. We recommend that people must stay away from smoke filled rooms, highly polluted areas and spend more time in parks and amongst nature. Given that mites also trigger asthma, patients should use mite-proof covers on the mattresses and pillows. Special attention should also be paid to keeping ones house dry and cool so as to prevent mites and molds’ from growing. In addition to this, consuming a healthy diet and getting adequate exercise and Vitamin D through sunlight is key to mainlining necessary immunity levels”.

What can you do?

Wash your hands regularly: The importance of maintaining hand hygiene has been stressed too often because it is one of the best and simplest ways to avoid catching and spreading common cold and flu viruses. Medical experts advise that an individual uses alcohol-based moist hand sanitizers; this trick will definitely shield you against the danger of catching germs as well.

Avoid sitting by the fireplace: Lighting up a bonfire in chilly winters might sound as a great idea for a cozy day, but sitting really close to a fireplace or just near the heater might not be good for asthmatic patients. Smoke coming from the burning wood can harm your lungs and give you breathing issues aggravating an asthma attack.

Get a flu shot: Although having asthma won’t make you susceptible to flu viruses, but these viruses can make asthma severe or more worse in some patients. Getting a vaccine will keep your symptoms under control by protecting you from the harmful attacks of the virus.

Clean the heater and replace the filters: A season off can cause a lot of germs to deposit inside the packed heaters and their filters. And once you start them without cleaning them, it can cause dust to blow through your nose and as well your house causing an asthma patient to develop an allergy. And hence, it is always advised that heaters should be cleaned and filters should be replaced before prepping up for a new season.

Exercise indoor and warm up before starting up: Chilly waves can impact your lungs and might make it problematic to breathe and that’s why medical experts advise that patients should instead opt for a gym or exercise outdoors when the weather is a little warm. Innumerable studies have shown that the lungs of asthmatic patients work more efficiently when they warm up before starting up their exercise routine.