November 23   2015, Monday
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EDITORIAL
Dr KK AggarwalDr KK Aggarwal Ivabradine in heart failure with reduced ejection fraction

In patients with chronic stable heart failure with LVEF ≤ 35 percent, in sinus rhythm with a resting heart rate ≥70 bpm, and who are either on a maximum tolerated dose of a beta blocker or who have a contraindication to beta blocker use one can start ivabradine. The drug slows the sinus rate. In such patients, ivabradine has been shown to reduce the risk of hospitalization for worsening heart failure
(http://www.accessdata.fda.gov/drugsatfda_docs
/label/2015/206143Orig1s000lbl.pdf)
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
Norms for medical device prices soon

The contentious issue of introducing price caps on exorbitantly priced medical devices is nearing a solution with the department of pharmaceuticals now directing all stakeholders, including medical device manufacturers and health ministry officials, to thrash out the matter and arrive at a final decision soon. The department will meet medical device manufacturers, health ministry officials and stakeholders on November 23 to come up with a model to regulate and cap prices. Earlier efforts to bring down prices of medical devices have failed as the government has not been able to reach a consensus, with some departments having opposed the move saying it may impede potential foreign investment, as well as weaken the 'Make in India' pitch… (ET Healthworld)

Characteristics of exceptional or super responders to cancer drugs

Some super-responders to specific cancer treatments likely have slow-growing tumors or cancers that are broadly sensitive to oncologic therapy, according to a first-of-its kind study. "So-called N-of-one stories of exceptional and super-responders have really fueled the enthusiasm for precision and personalized medicine," said lead author Vinay Prasad, MD, a medical oncologist at the Oregon Health and Sciences University in Portland. The study has been published online November 3 in the Mayo Clinic Proceedings. According to Dr Prasad and Dr Vandross, this review is the first to systematically document the characteristics of published super-responder… (Medscape)
Dr Good Dr Bad
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eSpiritual
Try to get what you like and try to like what you get

Most people get frustrated when they do not get what they desire. The frustration can manifest as anger, jealousy or irritation, which can ultimately cause much more damage to the person. The law of nature is that you get what you deserve and not what you desire. Each action has a karmic expression, which ultimately leads to a result, which can be desirable or undesirable. Each action, therefore, invariably ends into either a feeling of pleasure or pain. And the one which ends with pleasure creates more desire and attachment further leading to frustration. What you are depends on your past karmic expression and what you will be in future will depend on your present karmic actions. For every action there is an opposite and equal reaction which is the natural law of karma. According to Vedanta scriptures, every karmic debt has to be paid sooner or later.

Every result should be accepted as a gift of the nature or the gift of God. One should not get excited nor tainted with results. According to Bhagavad Gita, one should be attached to the actions but detached from their results. Once you have controlled your mind and won over the duality of pleasure and pain, you attain internal happiness and the realization of your true Self.

Every karmic expression should be accepted as a message from the God, the results of which may be evident later. Any bad experiences with your present karma need not necessarily mean that it is a result of your bad past karma or is a repayment of the past debt. It may also be taken as an experience to prevent occurrence of the same in future and also an opportunity to teach others through your own experience, so that they can prevent themselves from getting into such a bad experience. ‘The more you give, the more you get’ is another law of nature. If you want others to love you, you will also have to learn to love others. The bad karmic actions done today can only give you a momentary pleasure, but in long run you will be a loser.

One should be content with what one gets, both in terms of one’s profession as well as day-to-day life. Contentment is the key to self-happiness. However, this does not means that one should not have any desire and one should leave everything to destiny. With continuous effort and repeated attempts, one can change one’s destiny.

Fulfillment of desires should also obey the laws of nature. Substantial fulfillment of desires is a supernatural power. People, who are committed or self-realized, attain these powers happenings and experience substantial effortless fulfillment of any desire. But even if one achieves that, one should not get attached to it. Fulfillment of desires should be seen as any ordinary karmic action and one should learn to detach oneself from the result of such an action.
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Specialty Updates
• Topical application of imiquimod at the injection site improves the immunogenicity of intradermal trivalent influenza vaccine, suggests new research published online in The Lancet Infectious Diseases.
• Collagen crosslinking (CXL) treatment may curb the progression of keratoconus in young patients, but nerve disorientation persists, suggests new research published online in JAMA Ophthalmology.
• A new study published in the November 18 issue of the Journal of Bone & Joint Surgery revealed a link between obesity and a higher risk for surgery in orthopedic trauma patients. Obesity was associated with increased surgery risk, longer hospital stays, higher charges, and increased odds of discharge to care facility rather than home.
• Giving tenofovir to pregnant women with high levels of hepatitis B virus can reduce transmission to children, suggests new research presented at the American Association for the Study of Liver Diseases meeting.
• Light therapy may treat more than just seasonal affective disorder, and when used alone or in conjunction with antidepressants, it seems to be effective and well-tolerated for those with major depressive disorder, suggested a study published online in JAMA Psychiatry.
Legal Quote
Poonam Verma vs Ashwin Patel & Ors on 10 May, 1996 1996 AIR 2111, 1996 SCC (4) 332

“…a person who is registered under the Bombay Homoeopathic Practitioners Act, 1959 can practice Homoeopathy only. He cannot be registered under the Indian Medical Council Act, 1956 or under the State Act, namely, the Maharashtra Medical Council Act, 1965 because of the restriction on registration of persons not possessing the requisite qualification.”
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Digital IMA
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Medicofinance
Computation of Gains

For every capital asset item, get buy date and sale date; compute holding period. If that item is eligible for long-term taxation benefits as per the above table, one can include other costs incurred at the time of purchase and costs incurred at the time of disposal of the assets. This may include taxes, brokerages, statutory, and other costs. By inclusion of these costs, the taxable gain reduces.

(Source: IJCP)
Media
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22nd MTNL Perfect Health Mela, the annual flagship event of the Heart Care Foundation of India
Read ISGCON 2015 updates at www.emedinexus.com
Presidential Oration

Dr Ajay C Anand

In a brilliant Presidential address, Dr Ajay Anand gave his view from both sides of the fence-as a committed army man serving his country as he pursued his vocation to the commercial business-oriented practice that is prevalent today and which unfortunately most people in private practice have perforce become a part of.

Dr Anand reflected on the glorious 40 years serving in the army where there was life beyond medicine while working for the deserving in conditions incomprehensible by most doctors in the civilian arena. The most valuable lesson learnt was that we must focus on the problems you face in your practice and find the best solution in solving them with the available recourses. Needless to say Dr Anand did a lot of research and opened up a liver transplant center of excellence. He also initiated a very successful organ donation movement in the army with a high rate of success.

Dr Anand then shifted his talk to perspectives gained during his Presidential year in ISG. He was instrumental in initiating a number of reforms including e-voting and enhancing engagement of doctors across specialties as also setting up various committees to look into the affairs of ISG. According to him gastroenterology in India is like a wild stallion "raring to go" but needs proper handling and taming.

Giving a real life story about a poor boy who through various ups and downs ultimately became a top business tycoon, Dr Anand brought out a few very disturbing facets of healthcare in India. That Doctors are willing to give more than 25% of their fees as well as that of a procedure/ operation fees to get more patients is a very alarming trend but more alarming is the perception that ethics is a matter for the medical professionals to think about while the business men go about commercializing healthcare.

"For the triumph of evil, it is only necessary for good men to do nothing" Edmund Burke. This is very apt in our scenario, said Dr Anand. There is public distrust towards doctors. The corporate environment is nudging doctors to over investigate and overtreat. He said, “I come from a background where commercialization and corruption had no place. I have seen life from both sides of the fence and I think it is all about ‘us’. We should sit together and find a solution to this very serious problem which threatens our very core value system- that of service to mankind. As an organization, isn’t it our duty to see that we as well as our patients are not unnecessarily victimized?”

Dr Anand received a much deserved standing ovation!

Diabetes, obesity, NAFLD and HCC: The link unfolds

Dr Deepak Amarapurkar, Mumbai

• Incidence and prevalence of NAFLD is increasing worldwide.
• Natural history of NAFLD is expanding from simple steatosis to HCC.
• Obesity, T2DM and insulin resistance are strongly associated with NAFLD and increased incidence of HCC.
• Follow up of patients with diabetes including screening for liver disease should be recommended.
• T2DM is an independent risk factor for disease severity/progression in NAFLD.
• HCC incidence is increasing as NAFLD becomes the most common cause of liver disease.
• HCC can develop in NAFLD patients without cirrhosis so cancers may be missed given the high prevalence of NAFLD and the limitations of current screening strategies.
• Activation of pathways that promote inflammation, insulin resistance, angiogenesis, and cellular proliferation seen in these diseases promote the development of HCC.
• Clinical studies to prevent the development of HCC in patients with obesity, T2DM or NAFLD are critically needed.
CDC reports rising trends in syphilis, gonorrhea, chlamydia rates

The number of cases of three key sexually transmitted diseases increased last year for the first time since 2006, concerned U.S. health officials reported Tuesday. In 2014, 1.4 million cases of chlamydia were reported to the US Centers for Disease Control and Prevention -- a 2.8% increase since 2013. This is the highest number of cases of any STD ever reported to the CDC, the government researchers said in the annual report. Substantial increases were also reported in rates of syphilis (15%) and gonorrhea (5%). And the syphilis rates were highest among gay and bisexual men, according to the CDC's Sexually Transmitted Disease Surveillance, 2014 report…. (CDC)
Mobile app that helps one manage epilepsy on the go launched in Mumbai

The Epilepsy Foundation India has launched an interactive app, HELP, which can be downloaded for free from Google play store. This will send an alert to the doctor and caretaker once the patient suffers a seizure. The patient, in turn, will immediately receive details on his/her medical history, first aid information, do's and don'ts, list of sensitive drugs etc. Launched on Tuesday at a function organised at Bombay Hospital to mark the National Epilepsy Week (Nov 11-17), the app is also aimed at addressing myths associated with the disease. "We wanted to try out something unique that will help dispel misconceptions among general public," said Dr Nirmal Surya, founder of Epilepsy Foundation adding the app will help monitor the patient's overall health and help them lead a balanced life… (Daily News & Analysis- Santosh Andhale)
World’s online population to double to 5bn by 2020

The world’s online population will double to five billion by 2020 presenting “huge” business opportunities for tech start-ups on the cutting edge of the unprecedented expansion, the head of Google Europe said. (Indian Express)
National Research Development Corporation (NRDC) and DIPP Launch Pan India Intellectual Property Rights (IPR) Awareness Programmes

National Research Development Corporation, (NRDC), an Enterprise of the Department of Scientific & Industrial Research, Ministry of Science & Technology in association with the office of the Controller General of Patents, Designs and Trademarks (CGPDTM), under Department of Industrial Policy & Promotion (DIPP), Ministry of Commerce & Industry, Govt of India is launching series of IPR awareness and capacity building workshops in 25 Universities/Institutions in 21 States of the country, starting from 24th November 2015. The objective of this IPRs campaign is to create awareness about IP in the academia in the wake of new IPR policy being launched by government of India and connecting IPRs to the Make in India and Start up India programs of Government of India… (PIB)
eWellness
Sitting over 3 hours a day may reduce life expectancy

Sitting for three hours per day or longer may reduce an individual’s life expectancy. A study calculated that limiting the time people spend sitting to 3 hours or fewer each day would increase the life expectancy of the population by two years. Cutting down TV watching to fewer than two hours each day would bump life expectancy up by another 1.4 years.

When you are sitting, your leg muscles (the largest in the body) are completely inactive, which causes problems with how you handle your blood sugar and how you handle cholesterol.
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
Have lunch with God – bring chips!

A little boy wanted to meet God. He knew it was a long trip to where God lived, so he packed his suitcase with a bag of potato chips and a six-pack of cola and started his journey. When he had gone about three blocks, he met an old woman. She was sitting in the park, staring at some pigeons. The boy sat down next to her and opened his suitcase.

He was about to take a drink from his cola when he noticed that the old lady looked hungry, so he offered her some chips. She gratefully accepted it and smiled at him.
Her smile was so pretty that the boy wanted to see it again, so he offered her a cola. Again, she smiled at him. The boy was delighted! They sat there all afternoon eating and smiling, but they never said a word.

As twilight approached, the boy realized how tired he was and he got up to leave… but before he had gone more than a few steps, he turned around, ran back to the old woman, and gave her a hug. She gave him her biggest smile ever. When the boy opened the door to his own house a short time later, his mother was surprised by the look of joy on his face.

She asked him, "What did you do today that made you so happy?"

He replied, "I had lunch with God." But before his mother could respond, he added, "You know what? She's got the most beautiful smile I've ever seen!"

Meanwhile, the old woman, also radiant with joy, returned to her home.

Her son was stunned by the look of peace on her face and he asked, "Mother, what did you do today that made you so happy?"

She replied, "I ate potato chips in the park with God." However, before her son responded, she added, "You know, he's much younger than I expected."

Too often we underestimate the power of a touch, a smile, a kind word, a listening ear, an honest compliment, or the smallest act of caring, all of which have the potential to turn a life around. People come into our lives for a reason, a season, or a lifetime. Embrace all equally!
eMedi Quiz
A vitreous aspirate has been collected in an emergency at 9 pm what advice you like to give to the staff on duty regarding the overnight storage of the sample.

1. The sample should be kept at 4°C.
2. The sample should be incubated at 37°C.
3. The sample should be refrigerated deep freezer.
4. The sample should be refrigerated for the initial 3 hours and then incubated at 37°C.

Yesterday’s Mind Teaser:  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.

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

Answers received from: Kapil Roy, Jayashree sen, Dr poonam chablani

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

Answers received from: Dr K V Sarma, Dr K Raju.
Humor

A man was complaining to a railroad engineer. What’s the use of having a train schedule if the trains are always late?

The railroad engineer replied, "How would we know they were late, if we didn’t have a schedule?"

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I appreciate your eMedinewS. Dr Tara.
Press Release
How the use of antibiotic drugs in animals can prove to be harmful to humans?

Citing the potential threat to children’s health, and the whole public at large, the IMA has taken a stand against the use of nontherapeutic antibiotic drugs in animals

New Delhi, 22nd November 2015: Medical experts from across the globe have stressed on how the excessive usage of antibiotics in humans and animals has led to an array of consequences. Thespread of resistant bacteria is the most paramount of them all.According to a recent report by the American Academy of Paediatrics, the use of antibiotics in livestock as growth stimulants, and not for treating illnesses, contributes to the threat of antimicrobial resistance and potential infection through the food supply -- especially among young children who are most vulnerable to infection.

Children under 5 have the highest incidence of most food-related infections. Children can become infected through food, contact with animals, and environmental exposures such as when animal runoff contaminates surface waters used for drinking and recreation.Antibiotic-resistant bacteria are easily transmitted from animals to humans through the food we eat, making them vulnerable to several health ailments in the future.

Speaking about the issue, Padma Shri Awardee Dr. A MarthandaPillai – National President IMA and Padma Shri Awardee Dr. KK Aggarwal, Honorary Secretary General, IMA and President, HCFI said, “Children under 5 are considered to be at the highest risk of developing resistance to antibiotics and contacting food-related infections. Medical experts from all across the globe have argued that restricting the non-therapeutic use of antibiotics is essential both for animal and human health. Stricter regulations are needed to keep a check on the over-the-counter sale of antibiotics. It is essential that chemists only hand over these medicines upon a valid doctor's prescription. It is also recommended that families opt for antibiotic free or organic meat. In addition to this, it is also recommended that food must be washed and cooked properly to kill the bacterial infection.”

According to the CDC's Foodborne Diseases Active Surveillance Network, three leading causes of pediatric food-related illness are from exposure to:
• Non-typhoid Salmonella (which can infect fetuses via maternal exposure)
• Campylobacter species
• Staphylococcus aureus

Morealarmingly, growing proportions of Salmonella and Campylobacter infections are drug-resistant. In 2013, almost 25% of Campylobacter species were resistant to at least one antibiotic -- a dramatic increase from 13% in 1997. Of the 310,000 drug-resistant infections, 23% were resistant to ciprofloxacin and 2% resistant to erythromycin (which, with azithromycin, is considered the preferred antibiotic to treat children withCampylobacter).

Of the 100,000 Salmonella infections, 3% were resistant to ceftriaxone, the first-line pediatric therapy for these organisms. Some Salmonella strains have been found to be resistant to five or more classes of antibiotics.

It is thus essential that awareness is raised about antibiotic resistance, and the diet of children, in particular, is monitored to eliminate any future risk. Eating a healthy diet is key to a healthy life.
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