June 24  2015, Wednesday
Atrial fibrillation, the silent killer: Find it, Treat it or Face it
The first manifestation of atrial fibrillation (AF) can be a stroke. Often, the first time you learn that patients have AF is when they present with a stroke.

AF is responsible for 20% to 33% of all strokes and 20% to 45% of patients who have an AF–related stroke did not have a prior diagnosis of AF, as per a report in the August 2014 issue of Thrombosis and Haemostasis

At present, the guidelines recommend opportunistic screening for asymptomatic AF in patients >65 years. This can be done with pulse palpation or an ECG.

The American Heart Association/American College of Cardiology/Heart Rhythm Society states that clinically unrecognized and asymptomatic AF is a potentially important cause of stroke and recommend efforts at early detection of AF in at–risk individuals.

A single ECG or pulse check to screen for incidental ambulatory AF in those >65 years would detect 1.4% of individuals with AF both in the general population and clinic.

Incidentally detected atrial fibrillation in asymptomatic and ambulatory patients is associated with a significantly increased risk of stroke, MI and all–cause mortality, but treating the detected arrhythmia with oral anticoagulants can significantly improve the prognosis of these patients.
IMA Goa State Level CME on “Trauma” on 23rd May 2015
Cardiology eMedinewS
  • The US Food and Drug Administration (FDA) has approved Cangrelor, an intravenous antiplatelet agent, for reducing thrombotic events in patients undergoing PCI.
  • A real-world clinical test of idarucizumab has shown that the agent safely and effectively reverses the anticoagulant effect of the direct oral thrombin inhibitor dabigatran in a group of high-risk patients undergoing emergency surgery or suffering from life-threatening bleeding. The findings were presented at the International Society for Thrombosis and Haemostasis (ISTH) 2015 Congress.
Pediatrics eMedinewS
  • Boys outnumber girls three to one for the treatment of idiopathic short stature with growth hormone, reports a new study of four US pediatric growth-hormone registries. The findings are published online in Scientific Reports.
  • A new study shows that as little as 2 minutes of high-intensity exercise four times a day had a more beneficial effect on teens' health measures than moderate intensity activity. The findings are published in the journal Metabolism: Clinical and Experimental.
Dr KK Spiritual Blog
Dharma, Artha, Kama and Moksha of Medical Profession

The eras of Ram and Krishna represent two different perceptions of life. While Rama taught us the message of truthfulness, Krishna taught us when not to speak the truth and when speaking a lie is justified.

The medical profession today cannot survive on the principles of Rama. According to principles of Krishna, a truth which if spoken may cause harm to someone and if not spoken does not cause any harm, may not be spoken. Similarly, a lie, which without harming the community may help a particular person or situation, may be spoken.

Doctors come across situations every day in their medical practice, where speaking the truth may be harmful to the patient. Quite often false hopes are given and patients of terminal cancer are not told about their exact nature of illness and the prognosis. There is no way a doctor is going to tell the patient that you are going to die in the next 24 hours even if it is medically true.

Dharma, artha, kama and moksha are the four basic purposes of life for which we are born. The basic purpose of life is to fulfill our desires in such a way that we end up in inner happiness. Fulfillment of desires should be done by following the principles of righteous or ethical earning.

Most charges in the hospital settings are different depending upon the categories chosen by the patient. A single room patient invariably has to pay more than a patient admitted in the concessional three-bed room or general ward. Even the charges of the treatment, operation theatre, investigations and consultations may be different depending upon the categories. Taking more money from the rich and helping the poor. This principle is more according to Krishna’s principle than Rama’s.

Placebo therapy is a well–established therapy in medical science, which means treating the patient without giving the actual drug to a patient. The information that the drug does not contain any ingredient is withheld from the patient in this type of therapy. As per the literature, 35% of illnesses and symptoms may resolve using a placebo and is based on the principle that the very feeling that a medicine is being given stimulates the inner body pharmacy and produces healing substances and chemicals.

Nocebo effect, on the other hand, means that if the patient is told that your illness is not going to be cured even if medicines are given they may not act as the patient’s body produces negative chemicals, which neutralize the effect of medicines that otherwise are effective.

Indian doctors were known for their social medicine, which involves proper assessing of patients’ and their families’ financial status before deciding the treatment. There is no point giving options to a family to spend 10–15 lakhs of rupees for getting an ICD device implanted in the heart, which may increase life span only by one or two years or improve quality of life for a few years to a family who cannot afford this amount of money and may have to sell their house or spend all the money saved for the marriage of their daughters.

But today, with the Consumer Protection Act applicable to the medical profession also, not informing the family may even amount to negligence.
Make Sure
Situation: An elderly patient with unstable angina presented with URTI and was found to be positive for Chlamydia pneumoniae infection.
Reaction: Start macrolides. 
Lesson: Make sure to remember that infection with Chlamydia pneumoniae has been implicated in atherosclerosis. Macrolides may have a beneficial role in atherosclerotic disease as shown in trials like CLARIFY, STAMINA.
Dr Good Dr Bad
Situation:A patient with pneumonia was to be treated as an outpatient.
Dr.Bad: Start a combination of macrolide + third–generation cephalosporin.
Dr Good: Take only a macrolide.
Lesson: Macrolide alone is safe as monotherapy in managing individuals with community–acquired pneumonia (CAP) as outpatients with no risk for drug resistance.
eMedi Quiz
The following statements about meningococcal meningitis are true, except:

1. The source of infection is mainly clinical cases.
2. The disease is more common in dry and cold months of the year.
3. Chemoprophylaxis of close contacts of cases is recommended.
4. The vaccine is not effective in children below 2 years of age.

Yesterday’s Mind Teaser:A measure of location which divides the distribution in the ratio of 3:1 is:

1. Median.
2. First quartile.
3. Third quartile.
4. Mode.

Answer for yesterday’s Mind Teaser: 3. Third quartile.
Correct Answers received from: Dr Jainendra Upadhyay, Dr Poonam Chablani, Dr K V Sarma, Dr G Madhusudhan, Dr Nikhil Kumar Mohanty, Dr Avtar Krishan.
Answer for 22nd June Mind Teaser: 3. Sound referral system.
Correct Answers received: Dr Jainendra Upadhyay, Dr Avtar Krishan.
Rabies News (Dr A K Gupta)
Do antibodies from rabies vaccination cross an intact blood–brain barrier?

No. Antibodies from vaccination do not cross an intact blood–brain barrier.
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
eIMA News

IMA News
  • June 17, 2015: Tattoo ink can appear like the spread of cancer to the lymph nodes on diagnostic imaging resulting in unnecessary treatment. Narine Grove, MD, from the University of California, Irvine report the case of a 32-year-old woman with stage 1B cervical cancer that was originally diagnosed after a colposcopic exam and then mistakenly upgraded to metastatic disease.
  • June 2013: TOI: The government banned pioglitazone, analgin and deanxit. Pioglitazone can cause  heart failure and increases the risk of bladder cancer, analgin has been discarded on grounds of patient safety. Deanxit, is a harmful combination [-FLUPENTIXOL AND MELITRACEN FIXED DOSE COMBINATION]. The ministry of health and family welfare has suspended the manufacture and sale of all three drugs under Section 26A of the Drugs and Cosmetics Act, 1940.
  • March 2014: TOI:  The Union health ministry has revoked the ban on painkiller drug analgin and allowed it to be marketed for certain medical conditions like severe pain or pain due to tumor and also to bring down temperature in refractory cases when other antipyretics fail. Also, the drug's manufacturers need to carry the stipulated condition on their package insert and promotional literature of the drug.
  • Reviewing its decision at the 65th meeting last month, the DTAB decided to revoke the suspension on analgin, and allow its sale and manufacture but with a warning that the drug is indicated for severe pain or pain due to tumour, and for bringing down temperature in refractory cases where other anti-pyretics fail.  
  • August 2014: Indian Government revoked its suspension of pioglitazone. It stipulated that the agent should not be used as first-line treatment for diabetes and that it should carry a boxed warning relating to bladder cancer. In mid-July, a meeting of the drug technical advisory board (DTAB)  recommended that pioglitazone be put back on the market.  Just a few weeks after the Drug Controller of India (DCI) had suspended Deanxit-Flupentixol and Melitracen Fixed Dose Combination (FDC) from being sold in India,  two companies which manufacture the above FDC, had filed an appeal in the Karnataka High Court. On Aug 14th, the court quashed the order of the health ministry on the grounds that a phase-IV trial of the combination was in the process of being finalized. Legal parlance aside what this means is that companies are free to carry on marketing an untested drug until it is tested!!  Anti-depressant Deanxit should be sold with a warning in red that the drug is to be sold only on the prescription of a registered psychiatrist.
  • Menopausal women experiencing a decline in executive functions, including difficulty with time management, attention, organization, memory and problem solving, may benefit from lisdexamfetamine, a drug already approved to treat attention-deficit/hyperactivity disorder (ADHD), suggests new research  published online in Psychopharmacology.
  • Sumatriptan is less effective in migraine attacks with aura than in those without, suggest new data from an analysis of previous clinical trial results, presented at the American Headache Society (AHS) 57th Annual Scientific Meeting.
  • Patients who have taken opioids for pain relief within 24 hours of esophageal pressure tomography are more likely to have esophageal dysfunction as compared to those who stopped treatment earlier, suggested new research published online in the American Journal of Gastroenterology.
  • There is a significant association between in utero exposure to the pesticide DDT and the risk for breast cancer in young women, suggests new research published online in the Journal of Clinical Endocrinology and Metabolism.    
  • Patients report meaningful improvements in vision after ocriplasmin treatment for vitreomacular adhesion, suggests new research published in JAMA Ophthalmology.
SMS of the Day
IMA Rise and Shine

Child sexual abuse: 164 A (7) CrPC: illegal to examine without consent but mandatory reporting in POCSO 19, 357 C CrPC

Dr Pillai                                                          Dr KK
Letter to Editor
Sir, this is in reference to a TV program to be telecast from 13th July 2015 titled Dr Roshini on Life OK. The clippings show the lead actress telling fellow doctors (actors) that the hospital is like a shopping mall and she will try to stop this practice, and the fellow doctors (actors) comment that the hospital is not easy to run and you cannot change the system. Sir, I need to draw your attention to such programs which for reasons best known to them try to project the doctors in poor light.  This is for your kind information and necessary action please. Dr. Anil Dhingra
Inspirational Story
The Falcon & the Branch

Once there was a king who received a gift of two magnificent falcons. They were peregrine falcons, the most beautiful birds he had ever seen. He gave the precious birds to his head falconer to be trained. Months passed, and one day the head falconer informed the king that though one of the falcons was flying majestically, soaring high in the sky, the other bird had not moved from its branch since the day it had arrived.

The king summoned healers and sorcerers from all the land to tend to the falcon, but no one could make the bird fly. He presented the task to the member of his court, but the next day, the king saw through the palace window that the bird had still not moved from its perch.

Having tried everything else, the king thought to himself, "May be I need someone more familiar with the countryside to understand the nature of this problem." So he cried out to his court, "Go and get a farmer." In the morning, the king was thrilled to see the falcon soaring high above the palace gardens. He said to his court, "Bring me the doer of this miracle."

The court quickly located the farmer, who came and stood before the king. The king asked him, "How did you make the falcon fly?" With his head bowed, the farmer said to the king, "It was very easy, your highness. I simply cut the branch where the bird was sitting."

Moral: We are all made to fly — to realize our incredible potential as human beings. But at times we sit on our branches, clinging to the things that are familiar to us. The possibilities are endless, but for most of us, they remain undiscovered. We conform to the familiar, the comfortable, and the mundane. So for the most part, our lives are mediocre instead of exciting, thrilling and fulfilling. Let us learn to destroy the branch of fear we cling to and free ourselves to the glory of flight.
Quote of the Day
Be ready when opportunity comes…Luck is the time when preparation and opportunity meet. Roy D. Chapin Jr.
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Reader Response
Dear Sir, Very informative news. Regards: Dr Kanan
Wellness Blog
Artificial Sweeteners in Sweets May Be Harmful

In a joint statement, the American Heart Association and the American Diabetes Association gave a cautious recommendation to the use of nonnutritive sweeteners to help people maintain a healthy body weight and for diabetics to aid glucose control.

These products should be considered like a nicotine patch. They are appreciably better than the real product (sugar), but not part of an optimal diet. The statement, published in both Circulation and Diabetes Care on July 9, 2012, warns that sweeteners are helpful only as long as people don’t eat additional calories later as compensation.

The term nonnutritive sweeteners cover six sweeteners including aspartame, acesulfame K, neotame, saccharin, sucralose, and plant–derived stevia. These nonnutritive substances have zero calories.

Two things may happen in terms of compensation

1.Physiological, where the body might be expecting more calories and so the individual may be hungrier and therefore may eat more

2.Psychological, where the individual thinks they are allowed to eat more sugar-rich food because they had a diet soda instead of a full–sugar soda.

When people use sweeteners there is compensation. The key is how much? Partial compensation is ok but people often completely compensate or even overcompensate, so these sweeteners have to be used smartly to be successful. Compensation seems less of a problem when these sweeteners are consumed in beverages as opposed to food.

People don’t really notice the lack of calories in a diet soda and so don’t tend to eat more, whereas if they consume a low–calorie foodstuff, they do tend to eat more as compensation.

Its better when sweeteners are used in beverages and not sweets or other foods.
One is not completely sure about the safety of these products, because their long–term use in humans has not been studied fully.

However, the artificial sweeteners on the market are almost certainly safer than consuming large amounts of sugar, which has definite harm when consumed in large amounts.

This harm, particularly when consumed in beverage form such as soda, includes increases in risks of obesity, diabetes, cardiovascular disease, and gout.

A concern, though, is that just replacing sugar with artificial sweeteners leaves a person, especially children, conditioned to high levels of sweetness, which is likely to influence their food choices adversely.
IMA Humor
Three Professionals

A Mechanical, Electrical and Computer Engineer were riding together to an Engineering Seminar; the car began jerking and shuttering.

The mechanical engineer, said, "I think the car has a faulty carburetor."

The electrical engineer said, "No, I think the problem lies with the alternator."

The computer engineer brightened up and said, "I know, let’s stop the car, all get out of the car and get back in again!"
IMA Videos
News on Maps
Press Release
Facts about child sexual abuse released by IMA

The age of a child for the purpose of child sexual abuse is up to 18 years. About 42% of the Indian population as children faces sexual abuse during their childhood and 21.9% face severe child sexual abuse (penetrative) during childhood, said Padma Shri Awardee Dr A Marthanda Pillai, National President and Padma Shri Awardee Dr K K Aggarwal, Hony Secretary General, Indian Medical Association (IMA).

The following facts were released:
  • Upto to 90% of children who are sexually assaulted are assaulted by someone known to the child.
  • Any abuser on an average abuses 21 children. Therefore the abuser needs to be rehabilitated or punished. For example, if a school teacher abuses school children, there is no point of transferring him to another school as he will get another group of children to abuse.
  • Always suspect child sexual abuse in a situation with non accidental fracture or non accidental burns.
  • One of the reasons for rising child sexual abuse is ‘adultification’ of kids.
  • In India, the new trend is youngsters indulging in child sexual abuse.
  • The Protection of Children from Sexual Offences Act (POCSO Act) 2012 does not allow identity of the victim to be released in the media.
  • Child sexual abuse is a medical emergency.
  • It is mandated that doctors, whether from Govt. or Pvt. Sector, examine the victim without delay.
  • The treatment has to be provided free of cost.
  • Police or court permission for examination is not required.
  • Every victim of child sexual abuse needs first aid for HIV, sexually-transmitted illness and emergency contraception etc.
  • Doctors can be punished for imprisonment for up to 1 year or fine or both, if they refused to examine or provide first aid to the victims of child sexual abuse.