December 24   2015, Thursday
Dr KK AggarwalDr KK AggarwalCVP–guided volume expansion may reduce risk of contrast nephropathy

Central venous pressure (CVP)–guided fluid administration before, during, and after coronary angiography can significantly reduce the risk of contrast-induced nephropathy (CIN) and major adverse clinical events compared with standard protocols, finds a new study published online December 9, 2015 in JACC: Cardiovascular interventions.

In the study, aggressive volume expansion guided by CVP led to 46% reduction in CIN incidence vs standard treatment in high-risk patients undergoing coronary angiography. CIN–defined as an absolute increase in serum creatinine (SCr) >0.5 mg/dL (44.2 µmol/L) or a relative increase =25% compared with baseline SCr levels during the first 72 hours following the procedure–occurred in 15.9% of the CVP–guided hydration group compared with 29.5% in the control group. The proportion of patients who had their SCr levels increase >0.3 mg/dL from baseline was also significantly lower in the CVP–guided hydration group. The same CVP-guided approach also reduced major adverse clinical events by 59% vs standard treatment protocol. In patients with chronic kidney disease [CKD], hydration is usually performed at a low rate because of the fear of overhydration and pulmonary edema, particularly in patients with impaired left ventricular function.

According to initial CVP levels, the CVP-guided group were divided into three groups: group 1 with a CVP <6 cmH2O; group 2 with a CVP 6–12 cmH2O and group 3 with a CVP >12 cmH2O.
The rate at which fluid was administered was adjusted based on which group patients were in, with those in group 1 receiving 3 mL/kg/h, those in group 2 receiving 1.5 mL/kg/h, and those in group 3 receiving 1 mL/kg/h. The total mean volume of saline administered to patients in the CVP–guided group was significantly higher at 1827 mL vs 1202 mL for controls. On the other hand, CVP–guided hydration patients had greater volume of urine output at 1461 mL than controls at 806 mL. Looking at the volume of fluid each group received, investigators note that group 1 received 500 to 1000 mL, group 2 received 1000 to 1500 mL, while group 3 received >1500 mL. Corresponding CIN rates were 37.9% for group 1, 31.3% for group 2, and 7.7% for group three. (Medscape)
Breaking News

Zurampic gets FDA nod for patients with gout

The US Food and Drug Administration (FDA) has approved lesinurad (Zurampic, AstraZeneca) 200 mg once daily to treat gout-associated hyperuricemia, in combination with a xanthine oxidase inhibitor (XOI). Lesinurad acts by increasing uric acid excretion and decreasing its production…(Medscape)

AIIMS to lead the first air quality study

The All India Institute of Medical Sciences (AIIMS) is set to lead the first large-scale study to evaluate how changes in the Air Quality Index (AQI) impacts admission of patients with respiratory and cardiovascular complaints. Following up on a landmark study conducted Dr J N Pande, former head, dept. of medicine at AIIMS from 1997-98, this would be the first study on the subject in the last 18 years. AIIMS will be part of a three-center initiative funded by the Indian Council of Medical Research (ICMR). The other two participating centers are the Dept. of Pediatrics, Lady Hardinge Medical College and Vallabhbhai Patel Chest Institute. “This study will cover adult and pediatric population and look at admissions in respiratory and cardiovascular diseases, which are increasingly being associated with air pollution. We have early ethical clearances for the study, and will try to start from January to capture the seasonal variation in pollutants,“ said Dr Randeep Guleria, head of respiratory medicine, AIIMS… (Indian Express)
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Specialty Updates
• Increasing the number of cycles of in vitro fertilization (IVF) to more than three or four may boost success rates for infertile women up to the age of 42, suggested a new study published in JAMA. Researchers noted that six IVF cycles yielded the highest live birth rates.

• The negative health implications of obesity may not be counteracted by high aerobic fitness, suggests new research published in the International Journal of Epidemiology.

• The most common skin toxicities associated with epidermal growth-factor receptor tyrosine kinase inhibitors (EGFR-TKIs) used in the treatment of non-small-cell lung cancer (NSCLC), are acne-like lesions, itching, dry skin, and nail bed inflammation, reported a Taiwanese study published online in JAMA Dermatology. The skin toxicities were similar, for the most part, with three different TKIs: afatinib, gefitinib, and erlotinib.

• Early cholecystectomy is more effective and less costly than delayed cholecystectomy or watchful waiting in patients with acute cholecystitis, suggests new research published online in the Journal of the American College of Surgeons.

• Administration of oral ivermectin to whole communities can significantly decrease the prevalence of scabies and impetigo, suggest results of a new study published in the New England Journal of Medicine.

• Use of cardiac resynchronization therapy with a defibrillator (CRT-D) significantly lowers risks for adverse clinical outcomes in heart-failure patients with advanced chronic kidney disease (CKD) compared with use of a defibrillator by itself, suggests new research published in the Journal of the American College of Cardiology.

• Doctors do not always correctly estimate the weight of stroke patients, especially overweight ones, which can result in underdosing of thrombolysis, suggests a new study published online in Stroke. Missing the mark on dosing can affect clinical outcomes, report the authors.

• Researchers from Korea report in the journal Liver Transplantation that a regimen of hepatitis B immunoglobulin (HBIG) and hepatitis B virus (HBV) vaccine protects pediatric recipients of core antibody-positive livers from developing HBV infection.
Legal Quote
Bolam v. Friern Hospital Management Committee (1957) 2 All ER 118

”… a doctor is not negligent, if he is acting in accordance with such a practice, merely because there is a body of opinion that takes a contrary view. At the same time, that does not mean that a medical man can obstinately and pig-headedly carry on with some old technique if it has been proved to be contrary to what is really substantially the whole of informed medical opinion.” ”
The switch from trivalent to bivalent oral polio vaccine

18th December, 2015

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Why do we not offer Vanaspati Ghee at the time of cremation or worship?

Vanaspati Ghee is never offered to God at the time of Aarti in the Diya or to the dead body at the time of cremation. Only pure ghee is offered. It is considered a bad omen to offer Vanaspati ghee at the time of the cremation ritual even though the consciousness has left the body. What is not offered to God should not be offered to our consciousness and this is the reason for this ritual in a temple. Vanaspati ghee increases bad cholesterol and reduces level of good cholesterol in the blood. On the other hand, pure ghee only increases bad cholesterol but does not reduce the level of good cholesterol. The medical recommendation is that one should not take more than 15 ml of oil, ghee, butter or maximum ½ kg in one month. It is a spiritual crime to offer vanaspati ghee to God.
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The Year in Medicine 2015: News That Made a Difference
New guidelines for breast cancer screening

The American Cancer Society updated its breast cancer screening guidelines for women at average risk of developing the disease in October. It now recommends annual screening with mammography at age 45 and not 40 as previously recommended. And at 55 years of age, women can transition to screening every 2 years. An update from the International Agency for Research on Cancer Working Group found that women between 50 and 69 years of age who undergo screening mammography have about a 40% reduced risk for death from breast cancer. In a report, the Breast Cancer Surveillance Consortium suggested that women with high-density breasts who have an elevated 5-year breast cancer risk score would benefit from supplemental imaging … (Medscape)
Mandrola's Top 10 Cardiology Stories 2015
SGLT-2 Inhibitors show encouraging results amidst concerns

The EMPA-REG Outcome trial presented at a European diabetes meeting has been called a landmark trial as for the first time a drug for diabetes has lowered mortality rates. The study found that patients with type 2 diabetes and established cardiovascular disease receiving empagliflozin (Jardiance, Boehringer Ingelheim/Lilly), a sodium glucose cotransporter-2 (SGLT-2) inhibitor, were less likely to die than those taking placebo. However, the mechanism how these drugs reduce mortality rates is still not clear. Also, the FDA issued warnings about ketoacidosis and bone fractures with these drugs (Source: Medscape)
NIMHANS, Bangalore dedicated to the nation as an institute of national importance

The President of India, Shri Pranab Mukherjee dedicated the National Institute of Mental Health and Neuro-Sciences (NIMHANS), Bangalore to the nation as an Institute of national importance on Tuesday. He also inaugurated the Magneto Encephalography Research Center and NIMHANS Heritage Museum on the occasion. The President said there is increasing realization across the world today that there can be no health without mental health. India’s first comprehensive mental health policy was notified in last October on the occasion of World Mental Health Day which covers several aspects of mental health – including the rights of the mentally ill, the need to provide support to care givers, decriminalization of suicide –and other progressive policy initiatives. The policy, supported by the “Mental Health Action Plan 365“, spells out the specific roles of the Central Government, the State Governments, local bodies and civil society. The President also urged the Government to ensure that due priority is given to human resource development in the field of mental healthcare and delivery… (PIB)
California details 59 cases of rare polio-like syndrome

In the last three years, 59 cases of acute flaccid myelitis have been identified in California and reported in the December 22/29 issue of JAMA. Most cases of this rare polio–like syndrome have occurred in children and young adults, and the precise cause remains unclear. “A viral etiology seems most likely, although it may not be a single virus that is causing all of the cases. We identified enterovirus species in samples from 15 of 45 patients tested. Enterovirus D68 was the most commonly detected entity in 9 of the 15 samples,“ said Keith Van Haren, MD, from Lucile Packard Children's Hospital and Stanford University, Palo Alto, California… (Medscape)
56% of young girls, 30% of young boys in India are anemic

One out of two adolescent girls in India suffers from anemia, while one of every three young boys is anemic, according to a latest assessment by the health ministry done along with UNICEF. The large prevalence of the disease assumes significance also because adolescence marriage and pregnancy are common in India, particularly in rural areas. Anemia during pregnancy increases the risk for mortality and illness for the mother as well as the new born. Children born to anemic mothers also often have low reserves of iron which if left unaddressed can affect their growth and development. India has the largest number of adolescents aged 10-19 years in the world. The government's Weekly Iron & Folic Acid Supplementation (WIFS) Program will mainly target adolescent girls and boys between classes 6 to 12 as well as out-of-school adolescent girls… (Times of India – Sushmi Dey)
AAP updates preventive care schedule, highlights vision exams

A policy statement by the American Academy of Pediatrics (AAP) recommends that instrument-based devices for pediatric vision screening may be used to assess the risk for ocular problems in infants as young as 12 months and should be repeated at well– child visits from age 24 months through 5 years. AAP also recommends direct visual acuity testing with age-appropriate symbols for 4- and 5-year-old children and cooperative 3– year– olds, and changes the recommendation for routine vision screening at age 18 years to a risk assessment only. The statement is published in the January 2016 issue of the journal Pediatrics… (Medscape)
7 healthy habits to maximize your productivity every day

1.Start your day the night before. Make sure that you know what is on your calendar for the next day. Get anything you need in the morning set aside and ready at night.

2. Move first thing. Getting out of bed and making your body move gets the blood flowing and the brain synapses connecting again. Go for a walk or a gym.

3.Tame your brain. Meditation or mindfulness practice is an essential workout for your head. It only takes 10 to 20 minutes in the morning to adopt a practice that can really help you effectively manage your day, and your life.

4. Get help with staying organized. To be efficient, you need to be organized.

5.Remember to eat. Don’t skip meals. Eat healthy. Your body and your brain need fuel.

6.Batch your time. Time batching is an efficient way to get some uninterrupted productivity time Keep aside 1-2 hours to problem solve, think, brainstorm and otherwise handle the work you need to do without being disturbed.

7.Disconnect from work. When you leave work in the evening, try to disconnect from work. Give time to your family.

IPC Code to know

IPC 192

Fabricating False Evidence: Whoever causes any circumstance to exist or makes any false entry in any book or record, [OR ELECTRONIC RECORD] or makes any document [OR ELECTRONIC RECORD] containing a false statement, intending that such circumstance, false entry or false statement may appear in evidence in a judicial proceeding, or in a proceeding taken by law before a public servant as such, or before an arbitrator, and that such circumstance, false entry or false statement, so appearing in evidence, may cause any person who in such proceeding is to form an opinion upon the evidence, to entertain an erroneous opinion touching any point material to the result of such proceeding, is said “to fabricate false evidence“.
Shri JP Nadda, Union Health Minister and Ms Priyanka Chopra, UNICEF Goodwill Ambassdor at the launch of the media campaign of Weekly Iron and Folic acid Supplementation program
Bioethical issues in medical practice
Protecting the privacy and confidentiality of patients

Smita N Deshpande
Head, Dept. of Psychiatry, De–addiction Services
PGIMER-Dr. Ram Manohar Lohia Hospital
Park Street, New Delhi

You are a member of an informal discussion group of doctors who meet regularly to discuss difficult cases. At all these discussions, the conversation is frank and detailed, with all details of the patients, social situation, family issues etc. are discussed threadbare. Sometimes this discussion spills over into the hospital lifts, corridors and canteens. When these issues are really interesting, you discuss them at home with your spouse– a doctor– as well. Many times the name, address, and other details of patients are discussed as well.

a) Do such discussions breach medical confidentiality?
b) At which places should medical cases be discussed?
c) Should interesting medical cases be discussed at home?

Any suggestions? Do write in!

Adapted from: Bioethics Case Studies (AUSN and EEI, November 2013):

Responses received

• Medical discussions of difficult cases are very important from the doctor’s point of view and also from the patient’s point of view. They should definitely be discussed at home, in medical get-togethers, but not in lifts, hotels and public places. Medical science is based on discussions and exploration of the knowledge what one has. Dr BR Bhatnagar

• As regards Bioethical issues as deliberated above, may I suggest to keep discussion anonymous, important material for discussion are clinical facts and not the identification of the patient. This way perhaps we may not breach the confidentiality issues. Dr VJ Mahhadik
Gaining Weight Losing Strength versus Losing Weight Gaining Strength

When we gain weight, we must acquire more strength and when we lose weight, we must lose the strength. This is a fundamental medical principle.

If we gain weight and feel weak, it is a disease and when we lose weight and gain strength, we are recovering from the disease. One should not gain more than 5kg of weight after the age of 20 years. Any weight gain after this will only be due to accumulation of fat, which leads to insulin resistance. Insulin resistance does not allow food to convert into energy. In the state of insulin resistance, whatever you eat, it is converted into fat and since it is not converted into energy, you feel weak. When you reduce insulin resistance by drugs or walking, the metabolism becomes normal and whatever you eat gets converted into energy and you start gaining strength.
WP(C) No.8706/2015 titled “Indian Medical Association Vs. Union of India & Anr (NCERT)” Delhi High Court, New Delhi

Click here to read the proposed changes
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Inspirational Story
Each Person Shines His Own Way

A samurai who was known for his nobility and honesty, went to visit a Zen monk to ask him for his advice. When the monk had finished his prayers, the Samurai asked, "Why do I feel so inferior? I have faced death many times, have defended those who are weak. Nevertheless, upon seeing you meditating, I felt that my life had absolutely no importance whatsoever.“ “ Wait. Once I have attended to all those who come to see me today, I shall answer you.“ replied the monk. The samurai spent the whole day sitting in the temple gardens, watching the people go in and out in search of advice. He saw how the monk received them all with the same patience and the same illuminated smile on his face. At nightfall, when everyone had gone, he demanded: “ Now can you teach me?“

The master invited him in and led him to his room. The full moon shone in the sky, and the atmosphere was one of profound tranquility. “ Do you see the moon, how beautiful it is? It will cross the entire firmament, and tomorrow the sun will shine once again.“ “ But sunlight is much brighter, and can show the details of the landscape around us: trees, mountains, clouds.“ “ I have contemplated the two for years, and have never heard the moon say: why do I not shine like the sun? Is it because I am inferior?“

“ Of course not." answered the samurai. “ The moon and the sun are different things, each has its own beauty. You cannot compare the two.“ “ So you know the answer. We are two different people, each fighting in his own way for that which he believes, and making it possible to make the world a better place; the rest are mere appearances.“
IRIS commonly occurs after how many weeks of ART initiation

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

Yesterday’s Mind Teaser: Counseling and health and occupational screening require which of the following teledermatology tools?

a. Videoconference
b. Mobile teledermatology
c. Store and forward teledermatology
d. Online discussion group

Answer for Yesterday’s Mind Teaser: a. Videoconference

Answers received from: Daivadheenam Jella, Dr.B.R.Bhatnagar, Dr AVTAR KRISHAN

Answer for 22nd December Mind Teaser: a. Mobile teledermatology

Answers received from: Dr Avtar Krishan
Readers column
Dear Prof A Marthanda Pillai, This is a great initiative. Getting our students early into IMA activities augurs well for our profession. Congratulations. Dr Roy Abraham Kallivayalil
Customer: I have a huge problem. A friend has placed a screen saver on my computer, but every time I move the mouse, it disappears.
Press Release
Indian Medical Association to organize its annual Central Council Meet on Dec 27-28, 2015

Over 1000 IMA leaders will deliberate and discuss achievements of 2015, plan for 2016 and address the key healthcare issues being faced by the Indian population

The Indian Medical Association is organizing its annual Central Council Meet on Saturday & Sunday 27th-28th December 2015 at Hotel Le Meridian, New Delhi. Over 1000, Central Council members of the IMA from across the country will attend the meeting. The agenda is to deliberate and discuss various issues impacting the overall healthcare delivery system of India. Major achievements of 2015 will be recognized, and the challenges addressed. The new President of the Indian Medical Association for the year 2016 will also take oath.

Honorable Health Minister of Delhi Shri JP Nadda will interact with the IMA leadership on Day 1 and share his views on the healthcare scenario of the country and the issues, which need to be addressed jointly by the government and associations like IMA. Shri Rajyawardhan Rathore – Minister of State for Information & Broadcasting, Dr Jitendra Singh, Hon’ble Minister of State of Science & Technology and Dr Mahesh Sharma, Minister of State for Culture, Tourism & Civil Aviation will address the meeting on Day 2.

In addition to this, dignitaries such as Senior Advocate – Shri Sidharth Luthra, Former ASG - Shri Maninder Singh, TV Anchor – Mr Rajat Sharma, Member of Parliament– Shri Sanjay Jaiswal and Addl. Health Secretary –Shri CK Mishra will hold special sessions for the attendees.

Addressing the press conference today, Padma Shri Awardee, Dr A Marthanda Pillai - National President, IMA and Padma Shri Awardee, Dr K K Aggarwal – Hony Secretary General, IMA, in a joint statement, said, “During the past one year, the Indian Medical Association has taken several notable steps to help make the medical profession more transparent, accountable and effective. A prominent win for the medical profession being the amendment of the NCERT books to remove lines detrimental to the nobility of the medical profession in India. In addition to this, the IMA also succeeded in convincing the government to form a first of its kind inter–ministerial meet involving five Ministries to look into the demands made by IMA to help reduce the incidence of violence against doctors in the country. These demands include the amendment of Clinical Establishment Act, PCPNDT Act, Capping of Compensation, issues against medical violence and the issue of Crosspathy practice by medical practitioners“.

During the year 2015, IMA also suggested amendments to the proposed ART Bill under governmental debate. They released a self–code of conduct for medical establishments and digital and social code of conducts for doctors.

In line with our honorable Prime Minister Shri Narendra Modi‘s campaign, IMA also launched a Digital IMA campaign and upgraded its infrastructure to allow the National body to communicate with all its 2.5-lakh members digitally. A weekly live webcast and webinar are held every Thursday by the IMA to update and educate doctors from across the nation on important healthcare matters.

Some of the key projects undertaken by the IMA this year include those aimed at raising awareness about Vitamin D deficiency, the importance of safe water and air, the need to switch from trivalent to bivalent vaccination for polio eradication amongst others.

IMA will also be intervening in the BSC Community Health case tabled at the Hon‘ble High Court.