December 21   2015, Monday
Dr KK AggarwalDr KK Aggarwal April 25, 2016: “National Switchover Day” from trivalent Oral Polio Vaccine (tOPV) to bivalent Oral Polio Vaccine (bOPV)

In routine immunization babies will get bOPV and not tOPV from 25th April and at third dose of oral polio vaccine (OPV) they will also be administered an injection with inactivated polio vaccine (IPV)

By that date all vaccines having three types of polioviruses will be destroyed. Type 2 virus will also be destroyed in all laboratories ( except Pune Virology Institute ) to eliminate the chances of its spread again.

The efficacy of bOPV will be five times that of tOPV because there will be only two viruses in the vaccine.

Type 3 virus would be removed from the vaccine as next step because not a single case of this virus had been reported from anywhere in the world during the past two years. By 2020 OPV will be completely stopped and only Inactivated Polio Vaccine, which is a dead virus, will be used all over the world.

IPV and OPV together can provide additional protection to a child.

The last polio case was reported in India in 2011. India was certified polio-free on 27 March 2014, but the immunization programme continues since two of its neighbors ( Pakistan and Afghanistan) remain polio-endemic and due to the threat of vaccine-derived polio. Since 2009, India has witnessed 41 cases of Vaccine-derived poliovirus (VDPV), including two such cases in 2014

Switch to bivalent is necessary as in settings with low immunization coverage, live vaccine virus used in Oral polio vaccines (OPV) can multiply for long and undergo mutations to gain neuro-virulence. This VDPV can cause paralysis and circulate in the community to cause outbreaks. Vaccine-associated paralytic polio (VAPP) is a rare but serious adverse event following OPV administration. VAPP tends to occur in both OPV recipients and their unimmunized contacts.

Currently, two types of polio vaccines are mainly used in National health programs in India. The trivalent OPV (tOPV) contains live attenuated polioviruses of all three serotypes ( 1,2,3). Bivalent OPV (bOPV) contains two serotypes of live attenuated poliovirus (type 1 and 3). More than 90% VDPV cases in India are caused by type 2 virus.

OPV was preferred over IPV for public health programs during pre-eradication period, mainly due to its lower costs and ease of implementation. Now, VAPP and VDPV overwhelmingly outnumber polio due to WPVs, and therefore OPV has to be discontinued as early as feasible, for ethical reasons. It is imperative to eliminate the iatrogenic risk of VAPP at any cost, (in line with the principle of first do no harm).

There is an increased risk of emergence of cVDPVs during the withdrawal of trivalent OPV as the immunity level against type 2 poliovirus will decrease. To prevent such an emergence of VDPV, it is recommended that before this switch population immunity against type 2 polio virus be boosted by introduction of at least one dose of Inactivated Polio Vaccine (IPV) in the UIP. Global OPV2 withdrawal requires the absence of ‘persistent’ cVDPV2 for at least 6 months.

If one dose of IPV is used, it should be given from 14 weeks of age (when maternal antibodies have diminished and immunogenicity is significantly higher), and can be co-administered with an OPV dose. New schedule (three OPV doses + one IPV dose)
After months of complaints about a lack of transparency by some physician groups, patients, and patient advocates, the Centers for Disease Control and Prevention (CDC) has published a draft guideline on opioid prescribing, but many are still concerned.
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Binge drinking plus chronic alcohol use damages liver more than expected

During the holiday festivities, our alcohol consumption typically tends to increase. A new study, however, provides a word of caution, as it found that when combined with repeated binge drinking, chronic alcohol use damages the liver more than previously thought. The study, led by Shivendra Shukla, PhD, from the University of Missouri School of Medicine, is published in the journal Biomolecules. Binge drinking is a drinking pattern that brings an individual's blood alcohol concentration (BAC) to 0.08 g percent or above. For men, this typically happens when they consume five or more drinks within about 2 hours; for women, this happens when they consume four drinks or more in the same time. According to Shukla, ’Drinking alcohol excessively can create an inflammatory response to the liver and other organ systems in the body. If those organs work at a lower level of function, then a whole host of physiological processes can be affected. It was important for us to understand the extent of damage caused by alcohol abuse, which also can lead to other health issues such as diabetes, cardiovascular disease and some forms of cancer.’
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Specialty Updates
• The online cognitive training business has grown from about $200 million annually 6 or 7 years ago to an estimated $2 billion a year today.

• Treatment of unipolar depression with selective serotonin reuptake inhibitors (SSRIs) or venlafaxine (multiple brands) is associated with a significantly increased risk for subsequent diagnoses of manic or bipolar disorder BMJ

• The largest trial of ovarian cancer screening – which compared annual screening with no annual screening in more than 200,000 women, who were followed for 14 years – has concluded that screening could reduce mortality from the disease by about 20%. ( Univ College London)

• Almost all doctors doing cardiac ultrasounds report have work–related musculoskeletal pain at some point during their careers. They are 11.6 times more likely to experience occupation–related pain than fellow workers in cardiology and radiology departments. Transthoracic echocardiography is the mainstay of cardiac imaging, but the constrained body positions and repetitive movements that sonographers use to obtain these images can result in musculoskeletal pain. The wrist and back) hurt after a long day of doing echos. You have to hold awkward positions for minutes and then crane your neck over.”
My answer is yes, not tell me your problem

This was the best statement I have ever come across in my life. One of the medical superintendents at Moolchand Hospital when he joined had this statement on the wall above his head. It clearly indicates that he was sitting to solve the problem and not to create problems.

If all the service provider agencies follow this statement, the scenario of the country can change. Our job should be to solve the problems and not find mistakes. None of us is 100% truthful, honest or hardworking. Each one of us will have some positive points and some negative points. Our job should be to remove our negative points and convert them into positive. Remembers SWOT analysis taught in marketing i.e. ”Strength, Weakness, Opportunity and Threat”. Our job should be to convert our weakness into strength and threat into opportunities.
Legal Quote
Sanjeevan Medical Research Centre (Private) Ltd. & Ors vs State of NCT of Delhi ' Anr on 11 February, 2011

”The basic and underlying principle of these three judgments* and other similar judgments is that every careless act of a medical man cannot be termed as ”criminal”. It can be termed ”criminal” only when the medical man exhibits a gross lack of competence or inaction and wanton indifference to his patient’s safety and which is found to have arisen from gross ignorance or gross negligence.”

*Jacob Matthew v. State of Punjab (2005) 6 SCC 1, Martin F. D’Souza v. Mohd. Ishfaq (2009) 3 SCC 1 and Kusum Sharma v. Batra Hospital (2010) 3 SCC 480
The dilemma: Disease activity in lupus nephritis

Dr Manish Rathi, Chandigarh

• Disease activity markers are a good guide to assess the disease activity in the body.
• Measuring lupus disease activity accurately remains a challenging and demanding task given the complex multi–system nature of lupus, its variability between patients and within the same patient over time.

• Measuring disease activity helps to decide when to treat and how to treat, avoid unnecessary immunosuppression, to identify the endpoint of treatment and when to taper or stop.

• Each of the marker used in current clinical practice had its own limitations.

• The markers should be used just a guide. The final decision should be individualized taking entire picture in consideration.

Diagnostic approach to the CKD patient with joint pain

Dr Sanjay D’Cruz, Chandigarh

• Rheumatology mainly involves joints but because of the inflammatory nature of the disease, many organs including kidneys are involved.

• Rheumatology has a lot to do with a proper history taking and clinical examination. Investigations are as a backup.

• The first thing to do is to decide if the disease is acute or chronic. Most acute conditions can fit into infective pathology (but not all); chronic conditions favor inflammatory or degenerative process

• Then look at the number of joints involved followed by the pattern of joint involvement (peripheral/axial/symmetrical/migratory); whether pain is due to joint or periarticular tissue (bursae, synovia, tendons)

• Ask time of onset of disease.

• Tailor the questions to fit the d/d of inflammatory vs non inflammatory

• Joint pains are multifactorial: Dx of joint diseases based upon pattern of involvement

o Acute inflammatory monoarthritis: Sepsis, crystal disease
o Acute inflammatory polyarthritis: Post viral, PsA, RA, SLE, infective endocarditis, Acute rheumatic fever, meningococcal/gonococcal
o Acute noninflammatory monoarthritis: Mechanical or structural derangements

o Acute noninflammatory polyarthritis: Fibromyalgia

o Chronic inflammatory polyarthritis: RA, or RA mimics

o Chronic inflammatory monoarthritis: Spondyloarthritis, infection

o Chronic noninflammatory polyarthritis: OA, amyloidosis, hemophilia

o Chronic noninflammatory monoarthritis: OA, Mechanical or structural derangements

• Look for extra articular manifestations: Skin (oral ulcers, malar rash, psoriasis like lesions, punched out lesions), eyes (episcleritis, scleritis, scleromalacia, retinal bleed), nails (pitting of nails, clubbing, splinter hemorrhages)

• Dialysis related amyloidosis: Risk factors (duration of dialysis, low flux membranes/ bioincompatible membranes, lack of residual renal function), clinical presentation (carpal tunnel syndrome, scapulohumeral periarthritis, destructive spondyloarthropathy, bone cysts, flexor tenosynovitis, deposition in viscera)

• Drug dosing and choice of drugs should be carefully considered.
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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

Medical Response to Paris Terrorist Attacks

French physicians spontaneously responded to the November 13 terrorist attacks that devastated Paris, racing to hospital accident and emergency departments to offer their help. Private practice physicians immediately halted a strike, called Black Friday, to give priority to emergency care. Over a period of just a few hours, the Parisian medical world made the transition from Black Friday to the White Plan, triggered by the Paris hospitals authority. The White Plan has been enshrined in law since 2004 and enables additional means and human resources to be mobilized, nonessential activities to be rescheduled, and additional beds to be opened. At least 132 people died in the attacks and more than 250 were injured.

(Source: Medscape)
Mandrola's Top 10 Cardiology Stories 2015

PCSK9 Inhibitors Released Into the Real World

This year, the FDA approved the injectable monoclonal antibodies evolocumab and alirocumab, which induce dramatic drops in LDL cholesterol. The problem is we do not know whether that translates to fewer heart attacks, strokes, or death. We also don't know whether the drugs are safe over the long term. The longest follow-up in a clinical trial was less than 2 years; LDL-lowering is a lifelong proposal. I'm not saying the drugs are unsafe; I'm merely saying we don't know.

Without outcomes data, we can’t know anything about cost-effectiveness. We have made a big gamble. If the outcomes trial (FOURIER) due out in 2017 shows minimal to no benefit, we will have wasted a lot of money –and waste is something the US healthcare system needs less of. A caveat: patients with familial hypercholesterolemia who have high LDL –C levels uncontrolled with statin drugs might want to take a chance on these drugs.
(Source: Medscape)

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
Why do we regard trees and plants as being sacred?

The upper part of the plants, the leaves, flowers and fruits are worshipped as sacred and offered to God. As per the Bhagwad Gita, these have satvik properties. Roots of any plant are tamsik and not offered in pooja or eaten during pooja days. The same is true for the stems of plants, which have rajsik properties.

1. Fresh and live fruits have the same spirit and life force as in the human beings and are considered sacred the same way as any human being.

2. Human life also depends on plants and trees. They give us the vital factors that make life possible on earth: food, oxygen, clothing, shelter, medicines etc.

3. Ancient scriptures suggest the planting of a minimum of ten trees. We are also urged to apologize to a plant or tree before cutting it to avoid incurring a specific sin named soona.

4. Many trees and plants like tulsi, peepal etc., which also have medicinal value, are worshipped.
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 Three Dolls

A sage presented a prince with a set of three small dolls. The prince was not amused. ”Am I a girl that you give me dolls?” – He asked.

”This is a gift for a future king,” Said the sage. ”If you look carefully, you’ll see a hole in the ear of each doll.”The sage handed him a piece of string. “Pass it through each doll.” – He said.

Intrigued, the prince picked up the first doll and put the string into the ear. It came out from the other ear. ”This is one type of person,” said the sage, ”whatever you tell him, comes out from the other ear. He doesn’t retain anything.”

The prince put the string into the second doll. It came out from the mouth. ”This is the second type of person,”said the sage, ”whatever you tell him, he tells everybody else.”

The prince picked up the third doll and repeated the process. The string did not come out. ”This is the third type of person,” said the sage, ”whatever you tell him is locked up within him. It never comes out.”

”What is the best type of person?”– Asked the prince. The sage handed him a fourth doll, in answer. When the prince put the string into the doll, it came out from the other ear.

”Do it again.” – Said the sage. The prince repeated the process. This time the string came out from the mouth. When he put the string in a third time, it did not come out at all.

”This is the best type of person,” said the sage. “To be trustworthy, a man must know when not to listen, when to remain silent and when to speak out. ”
IRIS commonly occurs after how many weeks of ART initiation

a.1–4 week
b.2–12 weeks
c.12–24 weeks
d.after 6 months

Yesterday’s Mind Teaser: isotopic response is seen in scars of which condition

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

Answer for Yesterday’s Mind Teaser: c.pyoderma ganagerenosum

Answers received from: Raghu Chaks, Dr.K.Raju, Daivadheenam Jella, Dr Avtar Krishan,

Answer for 19th December 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.
Readers column
Dear Sir, emedinews is really very useful newspaper. Regards: Dr Jaya
Funny meanings…

Conference: The confusion of one man multiplied by the number present.
Press Release
Your guide to winter depression and its prevention

New Delhi, Dec 20, 2015: SAD or seasonal affective disorder also known as winter depression is characterized by increased sleep (inability to get up in the morning); increased appetite with carbohydrate craving (craving for sweet, sour and salt); marked increase in weight; irritability; interpersonal difficulties (especially rejection sensitivity) and leaden paralysis (heavy, leaden feelings in arms or legs).

Speaking about winter depression, 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, “SAD or seasonal affective disorder is caused by the imbalance of serotonin to melatonin ratio in the body. These two chemicals are responsible for regulation of mood and sleep patterns. The shorter days and lesser sunlight during the winter season lead to increased melatonin and lowered serotonin levels that lead to depression. But to manage these chemicals or the disorder one must be exposed to sunlight or artificial light. Sunlight is the best remedy as being a natural source it is more effective than any artificial light or drugs. Winter sun exposure is something that everyone should adopt.”

Artificial light exposure is effective but may take 4 to 6 weeks to see a response, although some patients improve within days. Therapy is continued until sufficient daily natural sunlight exposure is available. Therapeutic light therapy is also one option.

In most cases, seasonal affective disorder symptoms appear during late fall or early winter and go away during the sunnier days of spring and summer. However, some people with the opposite pattern have symptoms that begin in spring or summer. In either case, symptoms may start out mild and become more severe as the season progresses.

A few ways in which people can prevent winter depression include:
Consume a healthy and balanced diet
Staying well hydrated is key during the winter months since it gives you more energy, mental clarity and an enhanced digestive function.
Get enough Sunlight. Vitamin D deficiency is directly linked to winter depression
Get regular outdoor physical exercise
Meet people – People have the tendency to isolate themselves from everyone during the winter months. It is extremely important to maintain one’s activity level to avoid depression
Do not indulge in evils such as smoking and drinking as it can only put a person at danger of other diseases