June 22  2015, Monday
The cost of drugs may vary
Dr KK Aggarwal Quite often doctors are blamed of prescribing costly drugs to their patients. Every patient must know that convenience comes for a cost. The same drug molecule with same efficacy may cost more if it gives you convenience. Why should the cost of drugs vary? The cost of a drug may increase:
  • If it does not give a bitter taste
  • If it does not emit an odd smell
  • If it's aftertaste is better
  • If it looks soothing to the eyes due to specific shape or color
  • If the size of a tablet is small
  • If it is in a capsule form
  • If it provides instant relief
  • If it is to be used only once in day or it is a slow-, continuous- or delayed-release formulation
  • If the packing is better
  • If the preservative used is not sodium
  • If it does not contain any non vegetarian ingredients
  • If it is in liquid formulation
  • If it uses nanotechnology
  • If it is a scored tablet
  • If it does not interfere with food
  • If it does not interfere with juices (grape)
  • If it is a combination of two or three drugs (as a single drug)
  • If the drug is numbered in the strip (day-wise)
  • If the drug contains multiple drugs in the same strip so that the patient does not miss the dose
  • If it is not dispensed as loose tablets.
To commemorate World Asthma Day, a CME program on Bronchial Asthma was organized at IMA Hall on 8th May 2015, Curchorem, Goa Dr. Uday Kakodkar, Director Professor, Dept. of Pulmonary Medicine at GMC was the guest speaker.
Individualized preventive topical corticosteroid (TCS) regimens are best for the long-term management of adult vulvar lichen sclerosus (VLS), suggests a new study published online in JAMA Dermatology.
Higher rates of adenoma detection may cut the lifetime risk for colorectal cancer incidence and death in half, reported to a new study published in the June 16 issue of JAMA.
Sedentary activities like watching TV, playing video games, and surfing the web could be associated with an increased risk of anxiety, suggests a new study published in BMC Public Health.
A new study published in the Journal of Obesity suggests that frequently weighing oneself and looking at the progress on a chart every day is an effective way to lose a modest amount of weight and keep it off.
Regardless of chronological age, people who live in neighborhoods with high crime, noise and vandalism are biologically more than a decade older than those who do not, suggested a study published online in PLOS One.
Cardiology eMedinewS
  • For young to middle-aged adult patients with mildly elevated office blood pressure (BP) but no cardiovascular risk factors, it is probably best to watch and wait before initiating antihypertensive treatment, according to new research based on the Hypertension and Ambulatory Recording Venetia Study (HARVEST). Young patients with normal ambulatory blood-pressure readings and those whose BP readings that dropped after 1 year are more likely to have normal BP a decade later. According to the researchers, the findings can help spot which young patients are likely to have white-coat hypertension who do not need to be started on antihypertensive therapy.
  • Results of a one-year study of 19,000 adults from more than 150 countries, who used a pedometer and smartphone-based blood-pressure monitor, suggest that walking an additional 1000 steps a month was associated with significant improvements in systolic BP (European Society of Hypertension (ESH) 2015 Scientific Sessions).
Pediatrics eMedinewS
  • Children as young as 3 years old possess a keen sense of restorative justice and a surprising level of concern for others, suggests a new study published in the journal Current Biology.
  • The academic performance of children conceived by assisted reproduction techniques (ART) is no better or worse than that of spontaneously conceived children when assessed at the ninth grade of their school education, suggests new research presented at the Annual Meeting of European Society of Human Reproduction and Embryology.
Dr KK Spiritual Blog
Spiritual Prescriptions – Controlling the Inner Noise

Yoga Sutras of Patanjali define yoga as restraint of the mental states (Chapter 1.2). In the state of total restraint, the mind is devoid of any external object and is in its true self or the consciousness. Many Vedic scholars have given their own formulae to control the mind. Being in touch with one’s own consciousness requires restraining of the mind, intellect and ego on one hand and the triad of rajas, tamas and satwa on the other hand. Every action leads to a memory, which in turn leads to a desire and with this a vicious cycle starts.

The mental turmoil of thoughts can be equated to the internal noise and the external desires and objects to an external noise.

The process of withdrawing from the external noise with an aim to start a journey inwards the silent field of awareness bypassing the internal noise is called pratihara by Yoga Sutras of Patanjali. It involves living in a satwik atmosphere based on the dos and don’ts learnt over a period of time or as told by the scriptures. To control inner noise-based thoughts, we either need to neutralize negative thoughts by cultivating opposite thoughts or kill the origin of negative thoughts.

Not allowing thoughts to occur has been one of the strategies mentioned by the scholars. One of them has been neti–neti by Yagnayakya.

The other method is to pass through these inner thoughts and not get disturbed by it and that is what the process of meditation is. This can be equated to a situation where two people are talking in an atmosphere of loud external noise. For proper communication one will have to concentrate on each other’s voice for long till the external noise ceases to disturb. In meditation, one concentrates on the object of concentration to such an extent that the noisy thoughts cease to bother or exist.

One of the ways mentioned by Adi Shankaracharya in Bhaja Govindam and by Yoga Sutras of Patanjali (Chapter 2.35) is that whenever one is surrounded by evil or negative thoughts, one should meditate open the contrary thoughts. For example, if one is feeling greedy, one can think of donating something to somebody. Deepak Chopra in his book Seven Laws of Spiritual Success talks in detail about the importance of giving and sharing. He says you should never visit friends or relations empty handed. You should always carry some gift of nature, which if nothing is available can be a simple smile, compliment or a flower. By repeatedly indulging into positive behavior and thoughts, you can reduce the internal noise, which helps in making the process of meditation or conscious living a simpler one.

Washing out negative thoughts is another way mentioned by many Vedic scholars. Writing for 3 min is one such exercise which anybody can do. Just before sleeping, take 3 min and write down all your emotions and then discard the paper. Another exercise is to reward or punish oneself at bed time for the activities done during the day by either patting or slapping yourself.
Make Sure
Situation: A dengue patient with BP 100/90 developed shock.
Reaction: Oh my God! Why was rapid fluid challenge not given?
Lesson: Make sure that pulse pressure (upper minus lower blood pressure) is maintained above 40 in all patients with dengue
Dr Good Dr Bad
Situation: A patient came with tubercular pericarditis
Dr Bad: No steroids are needed
Dr Good: Start steroids
Lesson: The current recommendation is to use corticosteroids for patients with constrictive tuberculous pericarditis and for those felt to be at high risk of developing the condition (ie, large effusion, high level of pericardial fluid inflammatory cells, or early signs of constriction)

(Copyright IJCP)
eMedi Quiz
Elements of primary health care include all of the following except:

1. Adequate supply of safe water and basic sanitation.
2. Providing essential drugs.
3. Sound referral system.
4. Health Education.

Yesterday’s Mind Teaser: A case of Gestational Trophoblastic Neoplasia belongs to high risk group if disease develop after:

1. Hydatidiform mole.
2.Full term pregancy.
3. Spontaneous abortion.
4. Ectopic Pregancy

Answer for yesterday’s Mind Teaser: 3. Down's syndrome.
Correct Answers received from: Dr Poonam Chablani, Dr Shangarpawar, Dr.K.V.Sarma, Dr.K.Raju, Dr Avtar Krishan, Daivadheenam Jella
Answer for 20th June Mind Teaser: Teaser4. Glycosylation.
Correct Answers received: Dr Jainendra Upadhyay, Dr Poonam Chablani, Dr K Raju, Dr K V Sarma, Dr G Madhusudhan, Daivadheenam Jella, Dr Avtar Krishan.
IJCP Book of Medical Records
IJCP’s ejournals
CPR 10
Total CPR since 1st November 2012 – 101090 trained
Video of the Day
Sameer Malik Heart Care Foundation Fund
The Sameer Malik Heart Care Foundation Fund is a one of its kind initiative by the Heart Care Foundation of India instituted in memory of Sameer Malik to ensure that no person dies of a heart disease because they cannot afford treatment. Any person can apply for the financial and technical assistance provided by the fund by calling on its helpline number or by filling the online form.
Madan Singh, SM Heart Care Foundation Fund, Post CAG
Kishan, SM Heart Care Foundation Fund, Post CHD Repair
Deepak, SM Heart Care Foundation Fund, CHD TOF
Reader Response
Dear Sir, Very informative news. Regards: Dr Kala
Rabies News (Dr A K Gupta)
Can the vaccine be injected in gluteal region?

Rabies vaccine must not be administered in gluteal region as the gluteal fat may retard vaccine absorption resulting in delayed and lower seroconversion.
Press Release
Diabetes is a progressive disease

Diabetes is a progressive disease, said Padma Shri, Dr B C Roy & DST National Science Communication Awardee, Dr K K Aggarwal, President Heart Care Foundation of India and Honorary Secretary General Indian Medical Association (IMA).

Dr Aggarwal said that an analysis from the United Kingdom Prospective Diabetes Study (UKPDS) found that 50 percent of patients originally controlled with a single drug required the addition of a second drug after three years; by nine years 75 percent of patients need multiple therapies to achieve the target hemoglobin A1c (HbA1c) value, which is the average blood sugar of the last three months.

After a successful initial response to oral therapy, patients fail to maintain target A1c levels (<7 percent) at a rate of 5 to 10 percent per year.

This means that all diabetic patients will start with one drug and will invariably end up with three with or without the addition of insulin within 10 years.

A1c should be done every three months until <7 percent and then at least every 6 months and should be preferred over the fasting sugar levels. It represents the average blood sugar of the last three months and the value should be kept lower than 7%.

Regardless of the initial response to therapy, the natural history of most patients with type 2 diabetes for blood glucose concentrations is to rise gradually with time.

Initial treatment of patients with type 2 diabetes mellitus includes education, with emphasis on lifestyle changes including diet, exercise and weight reduction when appropriate. Monotherapy with metformin is indicated for most patients and insulin may be indicated for initial treatment for some.

In the absence of contraindications, metformin is usually the initial therapy for most patients with type 2 diabetes.
eIMA News
IMA Ponda Branch, Goa
Community activities under Aao Gaon Chalen

1.03/05/15: Netradeep camp, an initiative of the IMA Goa State, under the auspices of Aao Gaon Chalen Abhiyan was held on 03/05/15 at V D & S V Wagle High School, in association with The Golden Jubilee Celebration Committee of Wagle High School, as a part of celebration of 50th year of inception of the school. The Master of Ceremonies for the Inaugural function was Dr Madhu Ghodkirekar. Dr Ajay Pednekar, chairman of the Health committee of the Golden Jubilee committee, as also a member of IMA Ponda, and the third Vice President of IMA, Goa state, welcomed the dignitaries on the dais and the people gathered for the camp. The dignitaries on the dais were welcomed with rose buds. This was followed by the lighting of the traditional lamp by the dignitaries. Dr Kaushik Dhume, the chief coordinator for Netradeep campaign for 2015, then addressed the gathering. The sarpanch of VPK panchayat, Mr. Damodar Naik stressed about the need for such camps and appreciated the efforts of IMA and especially of Dr Ajay Pednekar for making it possible to be held in Mangueshi at a short notice. Dr Purnima Usgaonkar, coordinator of Aao Gaon Chalen Abhiyan and Dr Dattaram Desai, President, IMA, Ponda, and Dr Prasad Netravalkar, President IMA, Goa state too addressed the gathering. Mementos were then presented to the dignitaries on and off the dais.
Dr Ajay Pednekar then proposed the vote of thanks.

Other members of IMA present were Dr Ashadevi Netravalkar, Treasurer, IMA, Goa state, Dr Francisco Couto, Secretary, IMA, Goa state, Dr Sandeep Naik, Secretary, IMA Ponda, Dr Amey Kamat, Treasurer, IMA Ponda and Dr Shweta Khandeparkar, Consultant ophthalmologist, IMA Ponda. Mr Kishor Sasolkar of Mukta Opticians too was felicitated. Breakfast/snacks for patients were sponsored by Sarpanch and the Panchayat, who had also earlier helped in fixing the banners for the camp and carried out pre-camp publicity. The camp then commenced and carried on for around 4 hours. The camp was being held in collaboration with Mukta Opticians, which had arranged for technical manpower and diagnostic instruments for the camp, with financial assistance from Cipla Pharmaceuticals Pvt. Ltd. A total of 328 patients were seen;18 cataracts and 2 glaucoma cases were detected who will further receive free medical treatment and surgery at GMC with prior appointments. 240 spectacles too will be distributed, free of cost to deserving patients. After the camp, lunch for the organisers and doctors involved in the camp was sponsored by Mrs. Sanjeeta Pednekar and Mr. Sanjay Nadkarni.
PUDUCHERRY: The Indian Medical Association (IMA),

PUDUCHERRY: The Indian Medical Association (IMA), Puducherry has mounted pressure on the Puducherry government for enacting a legislation, Medicare Service Personnel and Medicare Service Institutions (Prevention of Violence and Damage to Property) Act, through an ordinance for according immediate protection to healthcare workers and hospital properties. This is against the backdrop of growing attacks on hospitals and hospital staff. he IMA would take out a rally on June 27 from JIPMER to Indira Gandhi Government General Hospital and Post Graduate Institute (IGGGH & PGI) in which doctors, nurses, paramedical staff, technicians and healthcare workers in government as well as private hospitals and medical colleges would participate. At the end of the rally a memorandum would be submitted to the Chief Minister and Chief Secretary urging the government to bring in the ordinance....[NEW INDIAN EXPRESS]

Tribune News Service, Hisar, June 20:

The Hisar unit of the Indian Medical Association (IMA) started a two-day yoga workshop for doctors today. Inspector General of Police (IGP) Anil Kumar Rao inaugurated the workshop, which is meant exclusively for the medical fraternity.
Ethanol for methyl alcohol poisoning
  • Ethanol has been used as a competitive inhibitor of alcohol dehydrogenase (ADH), as ADH has greater affinity for ethanol than for methanol or ethylene glycol.
  • It is best to give IV ethanol. But ethanol is difficult to dose, and appropriate levels are difficult to maintain; as a result, frequent testing and infusion adjustments are often required. It also irritates veins when infused, and can complicate fluid balance in oliguric patients.
  • When IV ethanol therapy must be used, the appropriate target for therapy is a serum ethanol concentration of at least one-third of the serum methanol or ethylene glycol concentration expressed as mg/dL, since inhibition is competitive.
  • An IV loading dose of 10 mL/kg of a 10% ethanol (volume/volume) solution in D5W (i.e., 800 mg/kg of ethanol) will raise serum ethanol concentrations by about 100 mg/dL. The loading dose should be given over 60 min to avoid excessive side effects (e.g., hypotension, respiratory depression, and somnolence). A maintenance infusion of the 10% ethanol solution, starting at 1 mL/kg/hour should be titrated according to serial ethanol concentrations (measured every one to two hours initially and following any change in dose or infusion rate), and increased by about 50% during hemodialysis.
  • When unavailable, ethanol can also be administered orally, both to load and to maintain serum ethanol concentrations as described above. Distilled spirits (40-50% vol/vol) intended for human consumption can be diluted to a 20% solution, and administered per os or via nasogastric tube at half the volumes recommended (5 mL/kg of a 20% solution to raise serum concentrations by 100 mg/dL, and 0.5 mL/kg/hour for the initial maintenance dose). (Source: Uptodate)
Physician Got $439K in Kickbacks for $5K 'Investment,' Feds Say
Robert Lowes, Medscape

June 18, 2015

Aria Sabit, MD, was a newly minted spinal surgeon in Southern California who got very busy following a business proposition in April 2010. During the prior 8 months, Dr Sabit had performed 64 instrumented spinal fusion surgeries — installing various screws, plates, rods, and other pieces of hardware — at Community Memorial Hospital, in Ventura, according to the US Department of Justice (DOJ). In the 8 months that followed, he doubled his pace, performing 130 of these procedures at the hospital.

What happened in between, the DOJ said, was a lucrative offer from Apex Medical Technologies, which distributes spinal surgery instrumentation. Invest $5000 in the company, use its hardware, and share in the revenue. They'd be fat enough, potential investors were told, "to put their kids through college."

Dr Sabit, a refugee from Afghanistan, performed his end of the bargain, according to the DOJ. He used Apex products in more than 90% of his subsequent spinal fusion surgeries after having used none before the investment offer.

In turn, Apex made good on its profit sharing promise. From May 2010 to December 2010, when Dr Sabit resigned from the hospital staff under a cloud, the company paid him $264,957, the DOJ said. The payments continued through June 2012, while he was practicing in Michigan. In all, Dr Sabit made $438,570 on his $5000 investment.

What some might call profit sharing, however, amounts to illegal kickbacks in the eyes of the DOJ.

Last month, the 41-year-old Dr Sabit pleaded guilty in a federal district court in Detroit, Michigan, to conspiring to receive kickbacks from Apex. The payments "incentivized" him to operate when he didn't have to, according to the plea agreement that he signed (and initialed on every page). Dr Sabit also pleaded guilty to billing Medicare, Medicaid, and private insurers for spinal fusion surgeries that omitted the documented hardware and to illegally prescribing a painkiller.....
Inspirational Story
Depend on Miracles

One Sunday morning I heard my minister say if you want result from prayer, pray for thirty days without ceasing. I didn't know why it was 30 days, but I was willing to give it a try. The following became my daily prayer:

I am available, Lord, to be used by You each day. Guide me, precious Lord, and lead me in what I say and do. May my words and actions be a witness that You are living in me. To the one that is lonely, may I be a friend. To those with heavy burdens, help me to meet their needs. Lord, I do not want fame or fortune. My prayer is that You will use me to glorify your name. I know I don't have much to offer, but I will give You my all. Guide me to be what You want me to be. Amen

On the twenty–first day of this prayer, CPR took on a new meaning for me. I was working an extremely busy twelve–hour night shift in Labor and Delivery. I had just sat down for my first break when a phone call came from my friend working in the Emergency Room. I barely recognized her urgent voice. An eighteen–year–old boy had been brought to the ER for alcohol and drug overdose. The young man was very close to death and they had done all they could do to help him. The father of this boy was requesting a priest or minister and they were having difficulty locating one that could come to the ER quickly. My friend stated, "We know you’re a Christian and we need you to come and try to comfort this father. Please help."

Reluctantly, I said I would come down. As I waited for the elevator my thoughts became very judgmental and frustration welled up inside me. Then I remembered the prayer I'd been praying. I walked into the ER and approached the father. Taking his hand, I silently led him to the chapel. Before I could even say, "I am not a minister," this six–foot, two–hundred–twenty–pound man sank into the chair and became a broken hearted child.

Through his non–stop sobbing he spoke, "Christian, pray for Raymond. I remember the first time I held my boy. I felt so proud and I just kept saying, ‘I have a son.’ As the years passed those tiny feet became bigger and walked away from his family’s love and entered a strange, hardened, and destructive world. Tonight, too much alcohol and an overdose of drugs are taking his life.

It’s as though he wants to rebel against everything his family stood for. He knew what he was doing was wrong. Sometimes he seemed so afraid, but he wouldn’t stop. Now it is too late. Christian, you have to pray for Raymond." Those large hands trembled in mine and as I looked into his eyes, I mourned with him. Silence fell between us, as I searched for the words that would comfort this crumbling tower of a man. I felt so inadequate. I wanted to scream, "Lord it has only been twenty–one days since I began that prayer! I am not ready for this!"

Time was running out and I knew I couldn’t stall any longer. I clutched his hands, now wet with tears, and began to pray. The words came easy, much to my surprise. I finished praying with him and went to Raymond’s bedside. I took his cold, lifeless hand and once again began to pray. "Lord I am asking for a miracle and I know you can do it."

I stayed with them both until Raymond was taken to Intensive Care. I visited Raymond on a daily basis and continued to pray for him. Eight days passed with little improvement. On the ninth day I entered the ICU and a miracle had taken place. Raymond was awake and talking with his father. CPR had taken on a new meaning for me: "Christian Pray for Raymond". As I left the ICU with tears falling down my face, I realized, today is the 30th day of my prayer.

Now I not only believe in miracles, I depend on them.
Wellness Blog
Diet and Aging: Gaining a Nutritional Edge

Choose fruits and vegetables wisely
  • Eat at least five servings of fruits and vegetables a day.
  • When filling your plate with fruits and vegetables, choose from a full color palette.
  • For even more health benefits, aim for nine servings a day. To get there, choose vegetable soups and vegetable or fruit salads. Sprinkle fruit on breakfast cereal, and select it for snacks or as a sweet end note after meals.
Choose fats wisely
  • Whenever possible, use monounsaturated and polyunsaturated oils. Avoid trans fats entirely. Limit saturated fats to less than 7% of daily calories and total fat to 20% to 30% of daily calories.
  • If you don’t have coronary artery disease, the American Heart Association recommends eating foods rich in omega–3 fatty acids, such as salmon, trout, or mackerel, twice weekly. If you have documented coronary artery disease, consume roughly 1 gram a day of EPA or DHA from oily fish and supplements if your doctor advises this.
Choose carbohydrates wisely
  • Choose whole–grain foods over those made with refined grains, such as white bread. Look beyond popular choices like whole oats and brown rice to lesser–known whole grains like barley, bulgur, kasha and quinoa. Limit your intake of white potatoes.
Choosing protein wisely
  • Emphasize plant sources of protein, such as beans, nuts, and grains, to help you bypass unhealthy fats predominant in animal sources. Enjoying a wide variety of vegetables and eating beans and grains helps you get a full complement of amino acids over the course of a week. Shy away from protein sources high in saturated fat. Favor fish and well–trimmed poultry. If you do eat beef, pick lean cuts.
  • Don’t char or overcook meat, poultry, or fish, it causes a buildup of carcinogens. Cutting off fat, which causes flames to flare on the grill, can help avoid charring; try gently sautéing, steaming, or braising these foods in liquid instead. Grilling vegetables is safe, however.
Quote of the Day
Whatever you do in life, surround yourself with smart people who’ll argue with you. John Wooden
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