[CONTENT]
December 20   2015, Sunday
emedinexus
EDITORIAL

Dr KK AggarwalDr KK Aggarwal Study links pathogenic gut flora to severity of heart failure

The role of gut in chronic heart failure (CHF) has been an emerging focus of research with increasing evidence suggesting a pathophysiological role. Now, findings from a new study published in JACC: Heart Failure have suggested that patients with CHF are likely to have "intestinal overgrowth" of pathogenic gut flora and permeability that is associated with disease severity. Patients with CHF were found to have pathogenic bacteria and candida in huge numbers as compared against healthy controls. The specific types of the increased pathogens found in stool samples included Campylobacter, Shigella, Salmonella, Yersinia enterocolitica, and Candidaspecies. Those with CHF also had significantly increased inflammation, intestinal permeability, and right atrial pressure (RAP), which is a signal of venous blood congestion. And most of these associations were stronger in those with moderate-severe HF (NYHA 3-4) vs those with mild HF (NYHA 1-2).

Lead author, Dr Evasio Pasini (Salvatore Maugeri Foundation, IRCCS, Medical Center of Lumezzane, Brescia, Italy) and co-author suggest that gut microbiota need to be continually investigated as soon as CHF is diagnosed. Using simple, noninvasive, reproducible methods to measure gut-flora development could provide "important clinical information to treat complicated multiorgan syndromes."

Breaking News

Study provides more evidence that coffee may reduce mortality

A new study adds to growing evidence that coffee is good for us, finding that consuming four to five cups daily may reduce the risk of early death – even for those who drink decaf. Published in the American Journal of Epidemiology, the study is the latest in a number of coffee-related studies conducted by Dr. Erikka Loftfield, of the Division of Cancer Epidemiology and Genetics at the National Cancer Institute. Dr. Loftfield and her team analyzed the self–reported coffee drinking habits and health of 90,317 adults who joined the Prostate, Lung, Colorectal and Ovarian Cancer Screening Trial between 1998–2001. During an average 10 years of follow-up, compared with individuals who did not drink coffee, those who consumed four to five cups daily had the lowest risk of death from various causes, including diabetes, heart disease, respiratory diseases, influenza and suicide.
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Specialty Updates
• A new study adds to growing evidence that coffee is good for us, stating that consuming four to five cups daily may reduce the risk of early death, even for those who drink decaf. The findings are published in the American Journal of Epidemiology.

• When combined with repeated binge drinking, chronic alcohol use damages the liver more than previously thought, suggests a new study published in the journal Biomolecules.

• Bariatric surgery and subsequent weight loss leads to marked reductions in cardiac troponin I levels, a marker of subclinical myocardial injury, suggests new research published in the European Journal of Preventive Cardiology.

• Consuming a cocoa product could help patients with kidney failure to improve their blood vessel function, reported new research published in the Clinical Journal of the American Society of Nephrology. Researchers noted that cocoa flavanol was well-tolerated by patients, and it improved blood vessel function and reduced diastolic blood pressure.

• A study, published in the Journal of Pediatric Gastroenterology and Nutrition, confirms freeze-drying as an effective alternative means of storing breast milk to the deep-freezing typically used at milk banks. Researchers found that freeze-drying is a viable storage method for breast milk, leading to no microbiological contamination and no loss of its health benefits for infants.

• Combining palbociclib with fulvestrant is an effective strategy to overcome endocrine resistance in women with hormone receptor positive (HR+), HER2 negative (HER2-) advanced breast cancer, suggested new study presented at the first ESMO Asia 2015.

• New research links reduced action of an inhibitory neurotransmitter, GABA, to behavioral measures in individuals with autism. The findings were published in Current Biology.

• The FDA approved the LifeVest wearable cardioverter defibrillator for certain children at risk for sudden cardiac arrest but not able to get an implantable defibrillator due to medical contraindications or lack of parental consent.
eSPIRITUAL
Who is a Good Teacher?

A good teacher is the one who follows the principles of listening first, teaching in detail till confusion arises and then teaching with reasoning while going into the minutest details and finally summarizing the ‘take–home’ messages.

This is how Lord Krishna discoursed to Arjuna in Bhagavad Gita. In the first chapter, he only listens, in the second, he gives detailed counseling and from chapters 2 to 17, he gives reasoning and in 18th chapter, he revises.
Legal Quote
Samira Kohli vs Dr. Prabha Manchanda and Anr, SCI, Civil Appeal No. 1949 of 2004, 16.01.2008

”When a doctor dealing with a sick man strongly believed that the only hope of cure was submission to a particular therapy, he could not be criticized if, believing the danger involved in the treatment to be minimal, did not stress them to the patient. ”
ISNCON 2015
Dr VN ACHARYA ORATION

Toxic Acute Kidney Injury

Lessons learnt from Hair Dye poisoning: Clinical and Experimental Study

Dr V Sivakumar


• The kidney is the target of numerous xenobiotic toxicants, including environmental chemicals.

• Hair–dye poisoning is observed world over and may be intentional or accidental.

• Systemic injury was demonstrated in clinical and experimental methods.

• Kidney injury is associated with poor prognosis.

• Our study reiterates importance of public awareness, display of toxicity warnings on hair-dye labels and control measures to prevent the over the counter sale.

Other ways in which the prostate irritates

Dr Saubhik Sural,
Kolkata

• Screening should be offered only to men with reasonable life expectancy.

• Additional data may be used to provide risk adjustments to screening interval and biopsy threshold.

• Decision to undergo PSA screening should be made by both the provider and the well-informed patient after a complete discussion of the potentially limited benefit and associated harms of early PCa detection and treatment.

• MRI is a very important tool in diagnosis and screening decisions regarding treatment.

• Take into account patient preferences for various treatment options, with consideration of complications, adverse effects, relative efficacy and QOL issues.

• HRQOL like postoperative incontinence and sexual dysfunction is a particularly important concern for patients with clinically localized prostate cancer.

We need Nephrologist–Urologist Team work to get the most benefit for the patient and more research for better evidence.

Management of BPH: What Nephrologists can do …

Dr Vivek Kute,
Ahmedabad

• Behavior modifications for all patients with symptomatic BPH (grade 2B)

• Mild to moderate symptoms with effect on QOL: treatment with a–adrenergic antagonist alone (grade 2a). Choice of agent may be made on basis of cost and side–effect

• In patients who cannot tolerate a1–adrenergic antagonists and do not have OAB or concomitant ED, 5– a–reductase inhibitor is option. Treatment for 6 to 12 m is generally needed before prostate size is sufficiently reduced to improve symptoms.

• Finasteride and dutasteride: Similar efficacy and adverse effects

• Low PVR urine volumes and irritative symptoms (OAB): Anticholinergics for initial therapy

• Mild to moderate symptoms and ED: PDE–5 inhibitors for initial therapy

• Severe symptoms, those with a large prostate (>40 ml), and/or in those who do not get an adequate response to maximal dose monotherapy with an a–adrenergic antagonist; combination with a-adrenergic antagonist + 5– a–reductase inhibitor (grade 2a).

• Low PVR urine volumes and irritative symptoms that persist with a–1–adrenergic antagonist or anticholinergic agents, combination with a–1–adrenergic antagonists + anticholinergic agents (grade 2c).

Prostate for the Nephrologist

Imaging and Size Assessment: What matters?

Dr Jayant Thomas Mathew,
Thrissur

• Baseline prostate volume is related to BPH progression and negative outcomes related to BPH progression, (such as AUR and the need for surgery), and can predict response to therapy

• A meta–analysis has shown that prostate volume to be a key predictor of outcomes with finasteride therapy: finasteride is most effective in men with large prostate glands. Most clinically significant response was seen in men with larger prostate glands and high baseline PSA levels.

• The combined analyses of 2–year international RCTs showed that men with larger prostate volumes and higher PSA levels experienced a clinically significant response to therapy vs those with smaller prostates and lower PSA levels
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22nd MTNL Perfect Health Mela, the annual flagship event of the Heart Care Foundation of India
The Year in Medicine 2015: News That Made a Difference

Meaningful Use Rule Released; Coalition Takes Issues to Congress

On October 7, the US Department of Health and Human Services released its final rule for stage 3 of the electronic health record (EHR) incentive program, along with changes to stages 1 and 2, and 2015 EHR certification criteria.(9) In early November, a coalition of 111 medical societies called on Congress to refocus stage 3 of the EHR meaningful use incentive program. The coalition, led by the American Medical Association, asked for legislation to prevent the repetition of what it considers the failure of stage 2.(10) According to the coalition, only 12% of physicians had successfully attested in stage 2 by early November. This was partly because of the difficulty of exchanging data between providers, as well as what it called ”excessive documentation requirements.” All eligible professionals must begin stage 3 in 2018 at the latest. Physicians who do not attest face reductions in their Medicare payments.

(Source: Medscape)
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http://module.ima-india.org/ima/jima/2015/September/
Bioethical issues in medical practice
Protecting the privacy and confidentiality of patients

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

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

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

Any suggestions? Do write in!

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

Responses received

Medical discussions of difficult cases are very important from the doctor’s point of view and also from the patient’s point of view. They should definitely be discussed at home, in medical get–togethers, but not in lifts, hotels and public places. Medical science is based on discussions and exploration of the knowledge what one has. Dr BR Bhatnagar
eWELLNESS
Have Leg Artery Blockages? Walk on a Treadmill

A planned program of walking is good for people with blockage of leg blood vessels called peripheral arterial disease (PAD).

Normally when there is pain in the calf muscles in the leg on walking, the usual tendency is to rest and not walk. A study of 156 people with PAD published in JAMA showed that regular 6–minute walks on a treadmill improved their endurance and quality of life. The study examined patients with symptoms and without symptoms. Over the six months of the study, the participants who did their regular 6–minute treadmill walks increased their walking distance by about 69 feet, while those who did not walk regularly saw a decrease of 49 feet.

There is the potential for greater oxygen extraction from the blood under maximum exercise conditions. The muscles can make better use of blood flow and the oxygen release that comes from it.

Such exercise leads to improvement in ”collateral circulation” –– growth in the number of blood vessels supplying the legs. Clinicians should urge all PAD patients, whether or not they have symptoms, to engage in a regular, supervised exercise program.

Walking is a standard recommendation for people with PAD. A recommended regimen is a 40–minute walk three times a week for at least six months.

Persistent leg pain is an indication that help is needed. In the absence of that symptom, physicians can test for PAD by measuring the difference in blood pressure between an ankle and an arm.
WP(C) No.8706/2015 titled “Indian Medical Association Vs. Union of India & Anr (NCERT)” Delhi High Court, New Delhi

Click here to read the proposed changes
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Inspirational Story
The Ant and the Contact Lens

Brenda was a young woman who was invited to go rock climbing. Although she was scared to death, she went with her group to a tremendous granite cliff. In spite of her fear, she put on the gear, took hold of the rope and started up the face of that rock. Well, she got to a ledge where she could take a breather. As she was hanging on there, the safety rope snapped against Brenda’s eye and knocked out her contact lens.

Well, here she is on a rock ledge, with hundreds of feet below her and hundreds of feet above her. Of course, she looked and looked and looked, hoping it had landed on the ledge, but it just wasn’t there. Here she was, far from home, her sight now blurry. She was desperate and began to get upset, so she prayed to the Lord to help her to find it.

When she got to the top, a friend examined her eye and her clothing for the lens, but there was no contact lens to be found. She sat down, despondent, with the rest of the party, waiting for the rest of them to make it up the face of the cliff.

She looked out across range after range of mountains She thought, ”Lord, You can see all these mountains. You know every stone and leaf, and You know exactly where my contact lens is. Please help me.”

Finally, they walked down the trail to the bottom. At the bottom there was a new party of climbers just starting up the face of the cliff. One of them shouted out, ”Hey, you guys! Anybody lose a contact lens?” Well, that would be startling enough, but you know why the climber saw it? An ant was moving slowly across the face of the rock, carrying it.

Brenda told me that her father is a cartoonist. When she told him the incredible story of the ant, the prayer, and the contact lens, he drew a picture of an ant lugging that contact lens with the words, ”Lord, I don’t know why You want me to carry this thing. I can’t eat it, and it’s awfully heavy. But if this is what You want me do, I’ll carry it for You.”

I think it would probably do some of us good to occasionally say, ”God, I don’t know why you want me to carry this load. I can see no good in it and it’s awfully heavy. But, if you want Me to carry it, I will.”
eMEDI QUIZ
isotopic response is seen in scars of which condition

a. orolabial herpes
b.herpes genitalis
c.pyoderma ganagerenosum
d.eosinophilic pustular folliculitis

Yesterday’s Mind Teaser: Formation of antibody against acetyl choline receptor in pemphigus can be explained by

a. desmoglein compensation theory
b. antibody excess prozone phenomenon
c. anti idiptypic
d. epitope spreading phenomenon

Answer for Yesterday’s Mind Teaser: d. epitope spreading phenomenon

Answers received from: Dr Poonam Chablani, Dr Bitaan Sen & Dr Jayashree Sen, jayashree sen, Daivadheenam Jella, VISWANATHA SARMA, Dr Raghvendra Chakurkar, Dr K Raju, Dr AVTAR KRISHAN.

Answer for 15th December Mind Teaser: b. medina ramirez reaction

Answers received from: Dr Poonam Chablani, Dr Bitaan Sen & Dr Jayashree Sen.
Readers column
Dear Sir, Very Informative Editorial. Thanks. Regards: Dr Karan
Humor
Last week I took my children to a restaurant. My six–year–old son asked if he could say grace.

As we bowed our heads he said, ”God is good. God is great. Thank you for the food, and I would even thank you more if Mom gets us ice cream for dessert. And Liberty and justice for all! Amen!”
Press Release
Severe Heart Attacks claim more lives of women as opposed to men in a hospital setting

During the winters the incidence of heart attacks increase drastically. There are several reasons for this including winter depression, Vitamin D deficiency, as well as an excess consumption of a comfort diet comprising of food high in high trans fat, salt and sugar content.

Additionally, cold temperatures cause the heart arteries to condense thereby restricting the blood and oxygen flow to the heart. This often causes a rise in the blood pressure of patients with hypertension or existing cardiovascular disease. The temperature drop also increases the chances of blood clot formation, since blood platelets are more active and stickier in cold temperatures. It is found that there is a 50% increased risk of angina and heart attacks during winters as opposed to other seasons.

Commenting on the topic, Padma Shri Awardee Dr. A Marthanda Pillai – National President and Padma Shri Awardee Dr. KK Aggarwal – Honorary Secretary General IMA in a joint statement said, "It is a known fact that the number of deaths due to heart attacks, cardiac arrests and strokes increase during the winters. However many remain unaware that while men and women have about the same adjusted in–hospital death rate for heart attacks – but women are more likely to die if hospitalized for a more severe type of heart attack."

According to research, Women are twice as likely as men to die if hospitalized for a type of heart attack known as ST–elevation myocardial infarction (STEMI).Women are also less likely to receive appropriate and timely treatment for heart attack.Women with STEMI have a 12 percent higher relative risk for in–hospital death compared to men.

Compared to men, women are 14 percent less likely to receive early aspirin; 10 percent less likely to receive beta blockers; 25 percent less likely to receive reperfusion therapy (to restore blood flow); 22 percent less likely to receive reperfusion therapy within 30 minutes of hospital arrival; and 13 percent less likely to receive angioplasty within 90 minutes of hospital arrival.

Women admitted with an STEMI are about twice as likely to die in the first 24 hours of hospitalization as men.

A few ways in which people can prevent heart attacks this winter include:

• Consume a diet rich in both soluble and insoluble fibres

• Staying well hydrated is key during the winter months since it gives you more energy, mental clarity and an enhanced digestive function.

• Make an effort to include raw foods such as fruits, vegetables, sprouts, nuts, seeds and fresh herbs in your diet.

• Get enough Sunlight.

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