November 22   2015, Sunday
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EDITORIAL
Dr KK AggarwalDr KK Aggarwal Residents make more mistakes when tired

As per JCI, when residents work recurrent 24-hour shifts, there are 36% more adverse events than when they work for only 16 hours at a time. They make five times the number of important diagnostic mistakes.
This is especially true during night shifts.

Residents should not work longer than 16 hours without a sleep break.

Fatigue can have numerous undesirable effects, including lapses in attention and memory, difficulties in communicating and problem solving, and impairments in understanding and judgment.

Residents are supposed to limit work shifts of no more than 30 hours, with a maximum of 80 hours in a given week.

Studies continue to document the problems among residents who repeatedly work 24-hour shifts, such as having twice the incidence of episodes of inattention during the night and performing 1.5 to 2 standard deviations below resting performance on clinical and nonclinical activities.
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
First Enbrel Biosimilar recommended for approval in Europe

The European Medicines Agency (EMA) Committee for Medicinal Products for Human Use has recommended approval of Benepali, a biosimilar of etanercept (Enbrel, Immunex and Amgen), for treatment of rheumatoid arthritis (RA), psoriatic arthritis, axial spondyloarthritis, and plaque psoriasis. Etanercept is a fusion protein that inhibits the activity of tumor necrosis factor alpha. The agency recommended Benepali for use in combination with methotrexate for the treatment of moderate to severe active RA in adults who have an inadequate response to disease-modifying antirheumatic drugs (DMARDs), including methotrexate. Benepali can be used alone in case of intolerance to methotrexate or when continued treatment with methotrexate is inappropriate, the EMA said. Benepali is also indicated for severe, active, and progressive RA in adults not previously treated with methotrexate … (Medscape)

Health Ministry organises national consultation to signal commitment to implementation of IHR

Signaling its strong commitment to the implementation of International Health Regulations (IHR), the Union health ministry in collaboration with the WHO Country Office for India has organised a national consultation on strengthening inter-sectoral coordination for IHR (2005) and Points of Entry, at Goa on November 18-19, 2015. Speaking on the occasion, Dr (Prof) Jagdish Prasad, Director General of Health Services (DGHS) highlighted the critical role various sectors play in IHR and called for greater attention on building capacities at state level, particularly for hospital preparedness, infection control and surge capacity for IHR. In his address, Anshu Prakash, joint secretary, ministry of health and family welfare, emphasized that pathogens do not recognise political boundaries and hence move across countries. Government of India has prioritised the implementation of IHR as it moves towards full compliance by 2016. It is investing in building and sustaining core capacities under IHR (2005), particularly in view of emerging global threats such as Ebola and MERS-CoV… (Healthtechnology)
Dr Good Dr Bad
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Make Sure
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eSpiritual
Win Relationships and Not Arguments

It is a well known saying that when you are arguing with a wrong boss, you may win the argument but you may invariably lose the relationship and not argument. Lord Krishna was born after Lord Rama and Krishna taught us when to say ‘sorry’ even if you are not at fault. Never hurt the ego of a person who is under influence of alcohol or boss when he is angry.
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Specialty Updates
• Melatonin supplements are a safe and effective way to address sleep problems in children with atopic dermatitis, suggests a new clinical trial published online in JAMA Pediatrics.
• In an extended follow-up of participants of COURAGE trial, no late benefit in survival was noted between patients with stable CAD who received PCI as an initial strategy plus optimal medical therapy and those who received optimal medical therapy alone. The findings were published online in the New England Journal of Medicine.
• A new study published in the journal Science revealed how parasitic worms can influence a woman's likelihood of becoming pregnant. The study revealed that hookworm infection was found to reduce the likelihood of pregnancy, while roundworm infection increased it.
• Sildenafil, a drug commonly used to treat erectile dysfunction, improves insulin sensitivity and markers of endothelial function in people with prediabetes, suggested a new study published online November 18 in the Journal of Clinical Endocrinology and Metabolism.
• Findings from an Indian registry study suggest that speaking more than one language might protect against cognitive injury related to stroke. The findings, published online in Stroke, revealed that bilingual stroke patients were more than twice as likely to have normal cognition following their stroke and also performed better on tests measuring post-stroke attention and function, when compared with patients who spoke only one language.
Legal Quote
Sanjeevan Medical Research Centre (Private) Ltd. & Ors vs State of NCT of Delhi & Anr on 11 February, 201

It has been emphasized by Court that mere error of judgment or an accident does not involve criminal liability or mere inadvertence or some degree of want of adequate care would not create criminal liability though it may create civil liability.
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Digital IMA
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Medicofinance
Classification of assets to determine long-term capital gain/loss
In a particular year, an investor may have gains and losses arising out of following accounts:

• Stocks/Stock Mutual funds
• Debt/Liquid funds
• Bonds
• Real estate property
• Gold/Commodities
• Foreign assets

(Source: IJCP)
Media
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eMEDIPICS
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Dr Naresh Trehan, Medanta – The Medicity, Shri ML Khattar, Chief Minister of Haryana, Amitabh Bachchan and Mr Richard Verma US Ambassador to India at a function to launch the campaign ‘Mission TB-Free’ in Haryana
Read ISGCON 2015 updates at www.emedinexus.com
PN Chuttani Oration

Vascular Disease of the Liver: Recent Advances in Understanding and Management

Dr Deepak Amarapurkar,
Mumbai

• Vascular diseases in India up to 90s

o Extrahepatic portal vein thrombosis predominantly disease in children: (No thrombophilia association)

o Budd Chiari Syndrome – predominantly membranous obstruction of inferior vena cava – congenital or acquired: (Thrombophilia association uncommon)

• Local risk factors for venous thrombosis: Liver cirrhosis, hepatobiliary malignancy, cholecystitis, pancreatitis, appendicitis, inflammatory bowel disease, gastrointestinal surgery, splenectomy

• Systemic risk factors for venous thrombosis may be inherited (Factor V Leiden Mutation, deficiency of protein C, S and antithrombin); acquired factors (antiphospholipid syndrome, PNH, OCs, malignancy, pregnancy, or puerperium)

• Risk factors may co-exist in many patients.

• JAK2(V617F) mutation occurs at high frequency in patients with idiopathic IAVT, so they should be screened for latent MPD (Amarapurkar D, et al. Trop Gastroenterol. 2011;32:279-84)

• An extensive workup for prothrombotic causes is probably indicated only in case of primary splanchnic vein thrombosis: Aids decision making,

• Diagnostic tests- to help clinicians to make decisions, impact of an accurate etiologic identification on management and outcome is not established

• IAVT: Low levels of antithrombin, Protein C or S are most likely acquired due to liver damage; but, if defect is single and other coagulation factors synthesized by the liver are normal, then inherited; do family studies in such case to confirm that defects are inherited.

• Factor II gene mutation: Most frequent cause of hereditary thrombophilia, alone or combine with other risk factors (OCs, pregnancy)

• Hyperhomocysteinemia is a weak risk factor for both arterial and venous thrombosis

• High levels of F VIII, IX, and XI have been recently recognized as new markers of prothrombotic risk; not know if inherited or acquired.

• Budd-Chiari syndrome: Extremely varied presentations, high index of suspicion, should be considered for any acute/ chronic liver disease

• To diagnose primary BCS, look at the hepatic veins and terminal IVC

• Good long-term outcome of BCS with a step-wise treatment approach (Hepatology, 2013)

• Cirrhosis, malignancy and MPN: important in etiology of PVT, which is often multifactorial

• GI bleeding: Main complication of chronic PVT, but a rare cause of mortality

• Endoscopic therapy of varices in chronic PVT comparable to cirrhotics

• Anticoagulation should be individualized in chronic PVT

• Prognosis depends on the underlying disorder and is good in patients without cirrhosis or malignancy.

Abdominal Venous Thrombosis: What do we know in 2015

• A blood disease
• Presenting features are protean vary from acute liver failure to mimicking cirrhosis and HCC
• Currently treatable with a strategy of minimal invasiveness
• Issues
o Impact of treatment for underlying disorder?
o Expert centers for management?
o How to decrease bleeding on anticoagulation?

Grading of fundal varices: Practical significance

Mandhir Kumar,
New Delhi

• Gastric varices (GV) are an inhomogenous entity; present in 20% of patients with PHTN

• Large (>10 mm), medium (5-10 mm) and small (< 5 mm)

• High risk for bleeding: Fundal varices, large GV (>5 mm), presence of a red spot, and Child's C liver status.

• Independent predictors of bleeding: Size of GV, fundal location, presence of red signs, degree of liver dysfunction, HCC, treatment of EVs by either EVL or EST

• GOV1: Continuation of EVs - share the same vascular anatomy and are treated as EVs. GOV1 have a much lower risk for bleeding.

• Baveno VI recommendations

o To prevent rebleeding from gastric varices: Additional glue injection (after 2-4 weeks), β-blocker treatment or both combined or TIPS

o Bleeding from GOV1: EVL or tissue adhesive

o Acute bleeding from IGV and GOV2: Endoscopic therapy with tissue adhesive (e.g. N-butyl- cyanoacrylate):

• An early TIPS with PTFE-covered stents within 72 h (ideally <24 h) must be considered in patients bleeding from EV, GOV1 and GOV2 at high risk of treatment failure (e.g. Child-Pugh class C or Child-Pugh class B with active bleeding) after initial pharmacological and endoscopic therapy (changed from Baveno V)

• Prevention of recurrent variceal hemorrhage (changed from Baveno V)

o First line therapy for all patients is the combination of NSBB (propranolol or nadolol) + EVL.

o EVL should not be used as monotherapy unless there is intolerance/ contraindications to NSBB.

o NSBB should be used as monotherapy in patients with cirrhosis who are unable or unwilling to be treated with EVL.

o Covered TIPS is the treatment of choice in patients that fail first line therapy (NSBB + EVL).

o Because carvedilol has not been compared to current standard of care, its use cannot be recommended in the prevention of rebleeding.

Gastric varices classification (Sarin)

• GOV1: Esophageal varices (EVs) extending along the lesser curvature of stomach
• GOV2: Extension of the esophageal varices along the greater curvature
• IGV1: Gastric varices localized to fundus, without any associated esophageal varices
• IGV2: Gastric varices present elsewhere other than the fundus.

Young Investigator Award Session

Patients with mild enteropathy have apoptotic injury of enterocytes, similar to that in advanced enteropathy in Celiac disease: Implications on the treatment

Prasenjit Das, GPS Gahlot, Ritu Mehta, Archita Makharia, Anil K Verma, V Sreenivas, Siddhartha Datta Gupta, Subrat K Panda, Vineet Ahuja, Govind K Makharia

Dept. of Gastroenterology & Human Nutrition, Pathology, Biostatistics, AIIMS, New Delhi

• Immune mediated apoptotic enterocyte loss is as rampant in ‘mild enteropathy’, as that in ‘advanced enteropathy’ celiac disease.

• Maintained crypt regenerative activity in the ‘mild enteropathy’ is responsible for maintenance of villous height.

• If extent of immune mediated enterocyte loss, is as active in ‘mild enteropathy’ as that advanced disease, it raises a question mark on the existing practice of not treating patients with mild enteropathy.

• This is the first objective evidence of marked immune mediated mucosal injury in ‘mild enteropathy’, supporting the need of institution of GFD in them.

• There is a need of large multicenter studies, and randomized controlled trials to resolve this issue.

How to use cyclosporine and tacrolimus in IBD

Haruhiko Ogata,
Japan

• The Endoscopic Activity Index (EAI) is equivalent to other endoscopic indices and relatively more useful in choosing a treatment for patients with severe UC (J Gastroenterol. 2010 Sep;45(9):936-43).

• Rapid endoscopic improvement is important for 1-year avoidance of colectomy but not for the long-term prognosis in cyclosporine A treatment for ulcerative colitis. Both initial remission and long-term maintenance should be considered in treatment of severe UC with cyclosporine (J Gastroenterol. 2010 Nov;45(11):1129-37).

• Cyclosporine A is an effective treatment to avoid immediate surgery (J Gastroenterol. 2010 Nov;45(11):1129-37).

• EAI score post Cyclosporine A therapy is one of good predictive markers for the risk of future total colectomy (J Gastroenterol. 2010 Nov;45(11):936-943).

• Oral tacrolimus therapy in patients with steroid-refractory UC shortened the acute phase and induced rapid mucosal healing (Inflamm Bowel Dis. 2012)

• Mucosal healing with oral tacrolimus is associated with favorable medium- and long-term prognosis in steroid refractory/dependent ulcerative colitis patients (J Crohns Colitis. 2013).

• ACTIVE: Efficacy & safety of tacrolimus vs infliximab; multicenter randomized prospective study; enrollment started May 2013, end of study March 2017; clinical improvement rate at wk 10 (primary endpoint); clinical remission rate, DAI score, endoscopic remission rate at wk 10; partial DAI score at wks 2, 6; Lichtiger score, clinical remission rate, clinical improvement rate at wks 2,6,10 and surgical operation rate at wk10 (secondary endpoints).

Dr Sreekanth Appasani, Hyderabad

• There is a need for grading because GERD is a spectrum of diseases, not a single one: NERD-Mild esophagitis - severe esophagitis

• Grading provides uniformity of reporting

• Grading guides usage of newer gadgets: 24hr pH metry, NBI (narrow band imaging)

• Grading predicts natural course of GERD, guides complications assessment

• Grading predicts response with treatment: Predicts PPI response, guides duration of PPI usage, predicts maintenance PPI therapy and relapse

• GERD newer endoscopic techniques: HD white light endoscopy, NBI, magnification endoscopy, chromoendoscopy, combination (NBI + magnification)

Which classification to use

 S-M classification usage: Discouraged
 Erosions scoring: MUSE comparable to LA
 MUSE system : Endoscopists’ acceptance lacking; relative complexity of this 4-dimensional classification
 LA classification: Easier to use, but complications must be described separately

Symptoms are not sufficient; grading is a must to differentiate; grading plays an important role in predicting natural course.
India has most people waiting for sanitation: WaterAid

WaterAid's report reveals the hardest places in the world to find a toilet, where one can find the most people waiting, and which developed nations are facing their own challenges on sanitation. The world's youngest country, South Sudan, has the worst household access to sanitation in the world, followed closely by Niger, Togo and Madagascar. India now has 60.4 percent of its people without access to safe, private toilets. India, it said, holds the record for the most people waiting for sanitation (774 million) and the most people per sq km (173) practising open defecation… (Business Standard – IANS)
NPPA warns cos of penal action for failing to register under IPDMS by Dec 15

The National Pharmaceutical Pricing Authority (NPPA) has warned the pharma companies of penal action under the provisions of the DPCO, 2013 read with Essential Commodities Act, 1955, for failing to submit requisite and mandatory form under the DPCO 2013, through Integrated Pharmaceutical Database Management System (IPDMS), which was aimed at facilitating on-line submission of mandatory returns/reports under the DPCO, 2013 by manufacturers as defined under 2(1) (n) of the DPCO, 2013… (Pharmabiz – Ramesh Shankar)
eWellness
Wet vs Dry winter

The whole universe is made up of five elements, i.e. Air, Space, Fire, Water and Earth. These five elements are also responsible for formation of the human body as per Vedic principles. In our body, Air and Space components are responsible for different types of movement functions, Fire and Water elements for metabolism and Water and Earth components for formation of secretions and structures. Ayurveda calls them as Vata, Pitta and Kapha humors.

People with Vata humor personality have more of Air and Space elements and, therefore, have more dry and cold extremities. On the other hand people with Kapha humor personality have more of structure and water, therefore have wet and cold extremities. In terms of atmosphere, Vata period will be cold and dry and Kapha period will be cold and wet.

According to the Vedic concept, early winter is cold and wet with more humidity and late winter is dry and cold with less humidity and more of windy movements. The chances of fog and smog are higher in early winter as compared to late winter. The hypothermic deaths are much more in late winter because of cold winds.

As per Ayurveda, in Kapha period, prone persons will experience fluctuations in blood sugar and will have more frequent attacks of bronchitis, expectoration and joints pains with effusion. The lower blood pressure will rise more than upper blood pressure and if a patient ends up with a heart attack there are more chances of heart muscle dysfunction.

Whereas in the cold and dry winter due to Vata aggravation, there will be acceleration of upper blood pressure and more chances of brain hemorrhage, nose bleeding, joints pain and heart attacks presenting with abnormal accelerated rhythm disorders.

In the early Kapha wet winter, there are more chances of water retention, depression, movement disorders, seasonal effective disorder and craving for sweets and salts.
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
The Chinese Farmer

There is a Chinese story of an old farmer who had an old horse for tilling his fields. One day the horse escaped into the hills and, when all the farmer’s neighbors sympathized with the old man over his bad luck, the farmer replied, ‘Bad luck? Good luck? Who knows?’

A week later the horse returned with a herd of wild horses from the hills and this time the neighbors congratulated the farmer on his good luck. His reply was, ‘Good luck? Bad luck? Who knows?’

Then, when the farmer’s son was attempting to tame one of the wild horses, he fell off its back and broke his leg. Everyone thought this very bad luck. Not the farmer, whose only reaction was, ‘Bad luck? Good luck? Who knows?’

Some weeks later the army marched into the village and conscripted every able–bodied youth they found there. When they saw the farmer’s son with his broken leg they let him off.

Now was that good luck? Bad luck? Who knows?
eMedi Quiz
A 60 year old male presented to the emergency with breathlessness, facial swelling and dilated veins on the chest wall. The most common cause is:

1. Thymoma
2. Lung Cancer.
3. Hodgkin's lymphoma.
4. Superior vena caval obstruction.

Yesterday’s Mind Teaser:  Which one of the following is a recognized X-Ray feature of rheumatoid arthritis?

1. Juxta-articular osteosclerosis.
2. Sacroilitis.
3. Bone erosions.
4. Peri-articular calcification.

Answer for Yesterday’s Mind Teaser: 4. Superior vena caval obstruction.

Answers received from: Daivadheenam Jella, Dr Arvind Jain, Dr Kailash Chandra Sharma, Dr Avtar Krishan.

Answer for 21st November Mind Teaser: 3. Bone erosions

Answers received from: Dr K V Sarma, Dr K Raju.
Humor
A group of expectant fathers sat nervously in the hall. A nurse beckoned to one of them and said, "Congratulations, you have a son!"

Another man dropped his magazine, jumped up and said, "Hey, what’s the idea? I got here two hours before he did!"
Readers column
Dear Dr KK Aggarwal, I enjoy reading eMedinewS. With warm regards: Dr.S.Pathak
Press Release
How eating home cooked food decreases the risk of Diabetes?

Food items prepared in restaurants, cafes and eateries are high in sugar, trans fat and sodium content increasing the risk of type-2 diabetes, obesity, and hypertension

A recent Harvard report has proved that people who eat most meals at home appear to carry a lower risk of developing type-2 diabetes. The reason for this is the high level of trans fat, additives, salt and sugar found in food at restaurants and cafes. Home cooked meals, on the other hand, are more nutritious and freshly prepared. Re-heating and frying practices at outside eateries kill all nutritious elements for food and make it a become risk factor for several lifestyle diseases.

According to the Harvard research, consuming 11 to 14 lunches or dinners prepared at home per week -- or about two meals per day -- is associated with a hazard ratio of 0.87 for incident diabetes compared with six or fewer homemade meals a week. During eight years of follow-up, those who ate more meals prepared at home had lower weight gain and risk of obesity (HR 0.87 for obesity), which could have accounted for the lower diabetes risk.

Speaking on the topic, Padma Shri Awardee Dr. A Marthanda Pillai – National President IMA and Padma Shri Awardee Dr. K K Aggarwal, Honorary Secretary General, IMA and President, HCFI said, “Food items that are available outside are not only high in calories but are also highly processed, which is enough to cause obesity, hypertension, and diabetes. They tend to have no or very little vitamins and minerals and are usually low in fiber. This holds particularly true for most Indian snacks and food, like samosas and pakoras that are deep fried, dal makhani which is simmered in ounces of butter, parathas made in ghee and butter and sweet items like laddoos, gulab jamun that are made with liquefied sugar. It is thus recommended that majority of the meals consumed should be prepared at home”.

“For this working high-stress jobs and living alone or in a nuclear family set up, it advised that a home cooked tiffin service is used. Offices and schools providing food for their employees and students must ensure that a healthy and nutritious meal is served. Our diet is directly linked to our future risk of lifestyle diseases, and extra precautions must be taken. The government must also discourage the fast growth of fast food chains in the country", Dr. KK Aggarwal added.

It is believed that people who eat at fast-food restaurants twice a week have a two-fold risk of developing insulin resistance in comparison to those who ate meals one or no meal outside in a week. Not only this, it has been found that having distorted eating habits cause individuals to develop unbalanced and unhealthy cholesterol levels including a high quantity of LDL/bad cholesterol and low quantity of HDL/good cholesterol and high triglycerides. Additionally, records also show that obese and diabetic individuals may also develop insulin resistance associated lipid disorder known as atherogenic dyslipidemia or diabetic dyslipidemia.

Why avoid foods prepared outside?

• High in calorific value
• Poor nutritional value
• Low in fiber
• Contains fats, sugar and salt in excessive quantities
• Some of the foods contain a specific amount of MSG as well
• Processed foods contain saturated and trans fats
• Often have addictive properties

Having a meal outside once in a while is fine, but making it a habit can be extremely harmful to one's health. That’s why we advise that you should revise your eating habits to prevent from being one of the 62 million people suffering from severe to moderate diabetes complexities in the country.
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