August 22   2015, Saturday
eMedinewS
editorial
Tackling obesity in children
Dr KK AggarwalMore than 30% people of the society including children have potbelly abdominal obesity. The incidence of metabolic syndrome, characterized by abdominal obesity, high triglyceride, low good cholesterol, high blood pressure and high blood sugar is rising in India.

Abdominal girth of more than 90 cm in men and 80 cm in women indicates that the person is vulnerable to future heart attack.

Normal weight obesity is the new epidemic. A person could be obese even if his body weight was within the normal range. An extra inch of fat around the abdomen increases the chances of heart disease by 1.5 times.

Normally once the height stops growing, most of the organs will also stop growing. The weight of the heart, liver of kidney cannot increase after that. Only muscles can build up to some extent. The only thing, after that stage, which can increase the weight of the body, is deposition of fat. Therefore any weight gain after puberty is invariably due to fat. Though the overall weight can be in the acceptable normal range but any weight gain within that range will be abnormal for that person. One should not gain weight of more than 5 kg after the age of 20 years in males and 18 years in females. After the age of 50, the weight should reduce and not increase.

Potbelly obesity is linked to eating refined carbohydrates and not animal fats. General obesity is linked to eating animal fats.

Refined carbohydrate includes white rice, white maida and white sugar. Brown sugar is better than white sugar. Refined carbohydrates are called bad carbohydrates and animal fat is called bad fat.

Trans fat or vanaspati is bad for health. It increases the levels of bad cholesterol and reduces good cholesterol in the body.

Losing weight can reduce snoring, pain of arthritis, blood pressure and also check uncontrolled diabetes.

Some tips
  1. Skip carbohydrates once in a week.
  2. Combine a sweet food with bitter food (prefer aloo methi over aloo matar).
  3. Walk, walk and walk…
  4. Consume green bitter items in foods such as karela, methi, palak, bhindi etc.
  5. Do not eat trans fats (vanaspati).
  6. Do not consume more than 80 ml of soft drink in a day.
  7. Do not consume sweets with more than 30% sugar.
  8. Avoid maida, rice and white sugar.
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eMedipics
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Heart Care Foundation of India’s (HCFI) trains over 200 school children on the importance of healthy eating, hygiene and sanitation
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News
Oncology
Genetics

Preliminary findings from a "basket study" show that BRAF V600 may be a targetable oncogene for some cancers other than melanoma. The findings were published in the August 20 issue of the New England Journal of Medicine. Vemurafenib, a selective oral inhibitor of BRAF V600 kinase, approved in 2011 for use in melanoma was evaluated in the study for clinical efficacy in cancers other than melanoma.

Obstetrics and Gynecology
The American College of Obstetricians and Gynecologists review the evidence on diagnosing and managing nausea and vomiting during pregnancy in guidelines published online August 19 and in the September issue of Obstetrics & Gynecology. The new guidelines replace those from 2004.

Neurology
Geriatrics

Measuring cortisol in saliva may help identify healthy older people with cognitive impairment, suggests a new study published online August 19 in Neurology. Researchers noted that higher evening saliva cortisol levels were associated with lower total brain volume and poorer global cognitive function in older dementia-free elderly individuals, while higher morning saliva cortisol levels correlated with greater white matter volume and some aspects of cognitive function.

Obesity
Genetics

Scientists analyzed the cell-level circuits surrounding the activity of the FTO gene - the one most strongly associated with obesity - and discovered a metabolic pathway that appears to exert overall control over whether our fat cells store or burn calories. The findings are published in The New England Journal of Medicine.

Diabetes
Nephrology

A new study, published in the journal Diabetes Care, shows that the glucose-lowering effect of metformin takes place in the gut and not in the bloodstream. Thus, a delayed-release form of metformin could suit 40% of type 2 diabetes patients who cannot use the current formulation (those with impaired kidneys).
Cardiology eMedinewS
For patients with atrial fibrillation (AF) treated with surgical ablation, nearly 80% were free from the arrhythmia and two out of every three were free from AF without the use of antiarrhythmic medications at 5 years, suggested the results of a new analysis published online in the Journal of Thoracic and Cardiovascular Surgery.

Working 55 or more hours a week is associated with an increased risk for stroke, and the more hours put in at the workplace the greater the increase in risk, suggested a new meta-analysis published online August 20 in The Lancet. Additionally, long working hours were also associated with an increased risk for coronary heart disease (CHD).
Pediatrics eMedinewS
Pediatrics/Addiction
Teens may be less likely to drink and smoke if their friends participate in substance abuse prevention programs, suggests a U.S. study published in the Journal of Adolescent Health.

Pediatrics/Neurology/Cardiology
Continuous EEG monitoring finds seizures not uncommon, not apparent clinically, and linked to higher mortality in neonates who had undergone cardiac surgery, according to a report published in The Journal of Thoracic and Cardiovascular Surgery.
Dr KK Spiritual Blog
Definition of Health

Health is not mere absence of disease; it is a state of physical, mental, social, spiritual, environmental and financial well being. All aspects of health are not defined in allopathy.

During MBBS, medical students are taught more about physical health. Social and mental healthcare is covered only in few lectures. Community health is a separate subject but is never given its due importance. Spiritual health is not defined at all and financial health is hardly covered.

Yet, in day–to–day practice, it is the social, financial, spiritual and community health which is the most important during patient–doctor communication. It is incorporated in the four basic purposes: dharma, artha, kama and moksha.

Dharma and artha together form the basis of karma, which is righteous earning. You are what your deep rooted desires are. Most of the diseases today can be traced to a particular emotion, positive or negative. Anger and jealousy are related with heart attack, fear with blood pressure, greed and possessiveness with heart failure. Unless the mind is healthy, one cannot be free of diseases.

The best description of health comes from Ayurveda. In Sanskrit, health means swasthya, which means establishment in the self. One is established in the self when there is a union of mind, body and soul. Most symbols of health are established around a shaft with two snakes and two wings. The shaft represents the body, two snakes represent the duality of mind and the two wings represent the freedom of soul.

Sushrut Samhita in Chapter 15 shloka 10 defines the Ayurvedic person as under:

Samadosha, samagnischa,
Samadhatumalkriyah,
Prasannatmendriyamanah,
Swastha iti abhidhiyate.

From Ayurvedic point of view, for a person to be healthy, he/she must have balanced doshas, balanced agni, balanced dhatus, normal functioning of mal kriyas and mind, body, spirit and indriyas full of bliss and happiness.

Human body is made up of structures (Kapha, which have two basic functions to perform; firstly, metabolism (pitta) and movement (vata). Vata, pitta and kapha are called doshas in Ayurveda. Samana dosha means balance of structures, metabolism and movement functions in the body. Agni in Ayurveda is said to be in balance when a person has normal tejas and a good appetite.

Ayurveda describes seven dhatus: rasa, rakta, mamsa, medha, asthi, majja, shukra and they are required to be in balance. They are equivalent to various tissues in the human body.

Ayurveda necessitates proper functioning of natural urges like urination, stool, sweating and breathing and that is what balance in mal kriya means.

Ayurveda says for a person to be healthy he/she has to be mentally and spiritually healthy, which will only be possible when his or her indriyas are cheerful, full of bliss and devoid of any negativities. For indriyas to be in balance, one has to learn to control over lust and desires, greed and ego. This can be done by learning regular pranayama, learning the dos and don’ts in life, living in a disciplined atmosphere and learn to live in the present.

Regular pranayama shifts one from sympathetic to parasympathetic mode, balances the mind and thoughts and helps in removing negative thoughts from the mind. For living a disabled life one can follow the yama and niyama of yoga sutras of Patanjali or dos and don’ts taught by various religious gurus, leaders and principles of naturopathy.

Living in the present means conscious or meditative living. This involves either learning meditation 20 minutes twice a day or learning subtle mental exercises like mind-body relaxation, yogic shavasana, self–hypnotic exercises, etc.

According to Yoga Sutras of Patanjali, a person who eats thrice a day is a rogi, twice a day is a bhogi and once a day is yogi. The take home message is: to live more, one has to eat less.

Swar yoga defines the importance of respiration and longevity. According to this yoga shastra, everybody has a fixed number of breaths to be taken during the life span. Lesser the number a person takes in a minute more is the life. It also forms the basis of pranayama, which is nothing but longer and deeper breathing with reduced respiratory rate.

To be healthy one should follow the principle of moderation and variety in diet and exercise, regular pranayama and meditation and positive thinking.
Scientific awareness on personal hygiene and prevention from obesity among school going children, Maharaja Aggarsain Adarsh Public School on 21st August 2015
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Make Sure
Situation: A patient with cough of more than 4 weeks duration came with blood in his sputum
Reaction: Oh my God! Why was TB not suspected earlier?
Lesson: that all patients with cough of more than 3 weeks duration are investigated for TB.
Dr Good Dr Bad
Situation: A female with rheumatoid arthritis became pregnant while taking leflunomide.
Dr. Bad: Continue it.
Dr. Good: Stop it immediately.
Lesson: In women with rheumatoid arthritis who become pregnant while taking leflunomide, healthy pregnancy outcomes usually occur, if the drug is discontinued at the earliest and a cholestyramine drug elimination procedure is done. (Arthritis Rheum 2010;62:1494)

(Copyright IJCP)
eIMA Quiz
Which of the following is not true for malignancy of familial adenomatous polyposis?
a) Adrenals
b) Thyroid
c) Astrocytomas
d) Hepatoblastomas

Yesterday’s Mind Teaser: In ulcerative colitis with toxic megacolon, the lowest rate of recurrence is seen in
a) Complete proctocolectomy and Brook's ileostomy
b) Ileorectal anastomoses
c) Kock's pouch
d) Ileo anal pull-through procedure

Answer for Yesterday’s Mind Teaser: a) Complete proctocolectomy and Brook's ileostomy
Answers received from: Dr Jainendra Upadhyay, Dr Poonam Chablani, Dr KV Sarma, Dr B R Bhatnagar, Dr G Madhusudhan, Dr Avtar Krishan.
Answer for 20th August Mind Teaser: c) It is related to duration of ulcerative colitis
Correct Answers received from: Raghu Chaks, Dr Avtar Krishan, Daivadheenam Jella, Dr B R Bhatnagar, Dr G Madhusudhan, Dr Poonam Chablani, Dr SUSHMA CHAWLA, Dr Jainendra Upadhyay.
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Rabies News (Dr A K Gupta)
What should be done with a patient who has had exposure but goes for treatment after considerable delay (weeks to months)?

An early and correct administration of modern anti–rabies vaccine is lifesaving. The vaccination must be started immediately irrespective of the status of the biting animal. Patients who seek treatment after a delay of 48 hours or even months after having been bitten should be dealt in the same manner as if the exposure occurred recently.
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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
eIMA News
News
  • In the ODYSSEY LONG TERM trial, a strategy of not exploiting the maximum potential of statins in high-risk patients may have overestimated the benefit of PCSK9 inhibition, write Johann Auer, MD, of Austria's St. Josef Hospital Braunau, and colleagues in a letter to the editors of the New England Journal of Medicine. (Medpage)
  • If a pregnant woman with high blood pressure and no history of headache suddenly develops a headache that quickly gets worse, she could be at risk for pregnancy complications, including pre-eclampsia (Neurology).
  • Memory-boosting tips: Dr. Fabiny suggests the following tips and tricks:
    • Follow routines, such as leaving your car keys, glasses, and cell phone in the same place every day so that finding them becomes a "no-brainer."
    • Slow down and pay attention to what you are doing to give your brain's memory systems enough time to create an enduring memory.
    • Avoid distracting or noisy environments and multitasking — the major memory busters in today's fast-paced society.
    • Get enough sleep, reduce stress, and check with your doctor to see if any of your medications affect memory — all three are potential memory spoilers.(Harvard)
Viral Syndromes Take Longer Than We Think
A systematic review(1) of 23 randomized controlled trials and 25 observational studies analyzed duration of symptoms of common respiratory infections in children birth to age 18 years. With no antibiotics, in 90% of the children, croup resolved in 2 days; sore throat resolved in 2-7 days, earaches resolved in 7-8 days, common upper respiratory tract infection resolved within 15 days, nonspecific upper respiratory tract infection symptoms resolved within 16 days, bronchiolitis resolved within 21 days and acute cough resolved within 25 days. Main treatment was patience and symptom control.

Parental concerns
  1. Explain about possible antibiotic-associated diarrhea resulting in watery stools
  2. Paracetamol (15 mg/kg every 6 hours) plus ibuprofen 10 mg/kg every 6 hours) to treat fever and discomfort: Evidence does not indicate that administration of these agents on an alternate schedule is more effective.(2) In fact, co-administration may be more effective,(3) can lead to less parental confusion,(4) and may reduce the risk for overdose(5)
  3. Consider provision of safety-net antibiotic prescriptions—a prescription given with instructions for the family to fill it only if the child is not better by a specified time point. In the case of children who meet criteria for observation and symptomatic treatment rather than antibiotic therapy for otitis media, this method was shown to avoid use of antibiotics in two thirds of children.(6)
  4. Limit use of cough suppressants and decongestants (especially in children younger than 6 years)
  5. Consider the use of honey in children over the age of 12 months, which is a more effective cough suppressant than such agents as diphenhydramine.(7)
When to give antibiotics
  • Otitis media in children aged 6-23 months, meeting strict criteria(8); and
  • Streptococcal pharyngitis confirmed by rapid testing, a positive culture, or a Centor score of 4 or higher.(9)
Antivirals are of no benefit in the treatment of non influenza respiratory infections.

References
  1. Thompson M, et al; TARGET Programme Team. Duration of symptoms of respiratory tract infections in children: systematic review. BMJ. 2013;347:f7027.
  2. Section on Clinical Pharmacology and Therapeutics; Committee on Drugs, Sullivan JE, Farrar HC. Fever and antipyretic use in children. Pediatrics. 2011;127:580-587.
  3. Wright AD, et al. Alternating antipyretics for fever reduction in children: an unfounded practice passed down to parents from pediatricians. Clin Pediatr (Phila). 2007;46:146-150.
  4. Mayoral CE, et al. Alternating antipyretics: is this an alternative? Pediatrics. 2000;105:1009-1012.
  5. Saphyakhajon P, et al. Alternating acetaminophen and ibuprofen in children may cause parental confusion and is dangerous. Arch Pediatr Adolesc Med. 2006;160:757.
  6. Siegel RM, et al. Treatment of otitis media with observation and a safety-net antibiotic prescription. Pediatrics. 2003;112(3 Pt 1):527-531.
  7. Oduwole O, et al. Honey for acute cough in children. Cochrane Database Syst Rev. 2012;3:CD007094.
  8. Lieberthal AS, et al. The diagnosis and management of acute otitis media. Pediatrics. 2013;131:e964-e999.
  9. Choby BA. Diagnosis and treatment of streptococcal pharyngitis. Am Fam Physician. 2009;79:383-390.
(Source: Medscape)
New model of care (Pre-emptive care model)
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Dr Marthanda Pillai,                        Dr KK Aggarwal
IMA Digital TV – Webcast Done So far
23rd July 2015 – TB Notification

6th August 2015 - Breastfeeding and Neonatal Skin Care

13th August 2015 - All About Vitamin D - IMA USV Initiative
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ICON 2015
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Inspirational Story
Attitude is Everything

Jerry was the kind of guy you love to hate. He was always in a good mood and always had something positive to say. When someone would ask him how he was doing, he would reply, "If I were any better, I would be twins!"

He was a unique manager because he had several waiters who had followed him around from restaurant to restaurant. The reason the waiters followed Jerry was because of his attitude. He was a natural motivator. If an employee was having a bad day, Jerry was there telling the employee how to look on the positive side of the situation. Seeing this style really made me curious, so one day I went up to Jerry and asked him, "I don’t get it! You can’t be a positive person all of the time.

How do you do it?" Jerry replied, "Each morning I wake up and say to myself, ‘Jerry, you have two choices today. You can choose to be in a good mood or you can choose to be in a bad mood.’ I choose to be in a good mood. Each time something bad happens, I can choose to be a victim or I can choose to learn from it. I choose to learn from it. Every time someone comes to me complaining, I can choose to accept their complaining or I can point out the positive side of life. I choose the positive side of life." "Yeah, right, it’s not that easy," I protested.

"Yes, it is," Jerry said. "Life is all about choices. When you cut away all the junk, every situation is a choice. You choose how you react to situations. You choose how people will affect your mood. You choose to be in a good mood or bad mood. The bottom line: It’s your choice how you live life."

I reflected on what Jerry said. Soon thereafter, I left the restaurant industry to start my own business. We lost touch, but I often thought about him when I made a choice about life instead of reacting to it.

Several years later, I heard that Jerry did something you are never supposed to do in a restaurant business: he left the back door open one morning and was held up at gunpoint by three armed robbers. While trying to open the safe, his hand, shaking from nervousness, slipped off the combination. The robbers panicked and shot him. Luckily, Jerry was found relatively quickly and rushed to the local trauma center. After 18 hours of surgery and weeks of intensive care, Jerry was released from the hospital with fragments of the bullets still in his body.

I saw Jerry about six months after the accident. When I asked him how he was, he replied, "If I were any better, I’d be twins. Want to see my scars?" I declined to see his wounds, but did ask him what had gone through his mind as the robbery took place. "The first thing that went through my mind was that I should have locked the back door," Jerry replied. "Then, as I lay on the floor, I remembered that I had two choices: I could choose to live, or I could choose to die. I chose to live."

"Weren’t you scared? Did you lose consciousness?" I asked. Jerry continued, "The paramedics were great. They kept telling me I was going to be fine. But when they wheeled me into the emergency room and I saw the expressions on the faces of the doctors and nurses, I got really scared. In their eyes, I read, ‘He’s a dead man.’ "I knew I needed to take action."

"What did you do?" I asked. "Well, there was a big, burly nurse shouting questions at me," said Jerry. "She asked if I was allergic to anything. ‘Yes,’ I replied. The doctors and nurses stopped working as they waited for my reply. I took a deep breath and yelled, ‘Bullets!’ Over their laughter, I told them. ‘I am choosing to live. Operate on me as if I am alive, not dead."

Jerry lived thanks to the skill of his doctors, but also because of his amazing attitude. I learned from him that every day we have the choice to live fully. Attitude, after all, is everything.
Quote of the Day
No matter how much you plan, it is tenacity, unyielding desire to succeed, and the ability to cope with change that will eventually prevail. Perry Payne
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Reader Response
Dear Dr KK, Extremely useful webcast, very practical in day to day practice. Hats off to you for carrying out such innovative ideas. Regards: Dr Kanan
Wellness Blog
Smell check, scratch and sniff, a new test for Parkinson’s disease

Olfactory dysfunction presenting as odor detection, discrimination, and identification is a common finding in patients with early non vascular Parkinson’s disease.

As per a study of 2,267 men published in the Annals of Neurology, an impaired sense of smell could be an early indicator of Parkinson’s disease, occurring up to four years before motor skill problems appear.

In the study, decreased odor identification was associated with older age, smoking, more coffee consumption, less frequent bowel movements, lower cognitive function and excessive daytime sleepiness, but even after adjusting for these factors, those with the lowest odor identification scores had a five time greater risk of developing Parkinson's disease than those with the highest scores.

Nerve loss and the formation of Lewy bodies –– abnormal clumps of proteins inside nerve cells that are thought to be a marker of the disease –– are known to take place in the olfactory structures of patients with the disease.

An impaired sense of smell could also be caused by impaired sniffing, which may be another motor symptom of Parkinson’s.

Early indicators of Parkinson’s disease are olfactory abnormality, constipation and sleep disturbances.

Besides Parkinson’s disease, obesity, diabetes, hypertension, malnutrition, Alzheimer’s disease, multiple sclerosis and Korsakoff’s psychosis are all accompanied or signaled by smell disorders.
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Missing Homework

After teaching high school for nearly 20 years, I thought I’d heard every possible excuse for missing homework until one parent sent me this note: "Please excuse Lori for not having her algebra homework. The cat had kittens on it last night."
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Press Release
Platelet deficiency is not the cause of death in people suffering from Dengue

According to International guidelines, unless a patient’s platelet count is below 10,000, and there is spontaneous, active bleeding, no platelet transfusion is required. The outbreak of dengue in the Capital has given rise to extreme panic. Hospital beds are full and families are seen running around in search of platelets for transfusion. However what most people do not realize is that the first line of treatment for dengue is not platelet transfusion. It, in fact, does more harm than good if used in a patient whose counts are over 10,000.

The primary cause of death in patients suffering from dengue is capillary leakage, which causes blood deficiency in the intravascular compartment, leading to multi-organ failure. At the first instance of plasma leakage from the intravascular compartment to the extravascular compartment, fluid replacement amounting to 20 ml per kg body weight per hour must be administered. This must be continued till the difference between the upper and lower blood pressure is over 40 mmHg, or the patient passes adequate urine. This is all that is required to treat the patient. Giving unnecessary platelet transfusion can make the patient more unwell.

Speaking about the issue, Padma Shri Awardee, Dr KK Aggarwal, President HCFI & Honorary Secretary General IMA said, “While treating dengue patients, physicians should remember the ‘Formula of 20' i.e. rise in pulse by more than 20; fall of BP by more than 20; difference between lower and upper BP of less than 20 and presence of more than 20 hemorrhagic spots on the arm after a tourniquet test suggest a high-risk situation and the person needs immediate medical attention.”

Dengue fever is a painful mosquito-borne disease. It is caused by any one of four types of dengue virus, which is transmitted by the bite of an infected female Aedes aegypti mosquito. Common symptoms of dengue include high fever, runny nose, a mild skin rash, cough, and pain behind the eyes and in the joints. However, some people may develop a red and white patchy skin rash followed by loss of appetite, nausea, vomiting, etc. Patients suffering from dengue should seek medical advice, rest and drink plenty of fluids. Paracetamol can be taken to bring down fever and reduce joint pains. However, aspirin or ibuprofen should not be taken since they can increase the risk of bleeding.

The risk of complications is in less than 1% of dengue cases and, if warning signals are known to the public, all deaths from dengue can be avoided.