December 25   2015, Friday
Dr KK AggarwalDr KK AggarwalSudden cardiac arrest may not be as sudden as presumed to be

Sudden cardiac arrest may not be as sudden as has been thought. About 50% of victims of sudden cardiac arrest have tell-tale warning signs that their heart is in danger of stopping in the month preceding their attack. Those symptoms can include any combination of chest pain and pressure, shortness of breath, heart palpitations, and flu-like sensations (such as nausea, back pain and/or abdominal pain). While less than 20% of those who experience symptoms actually reach out for potentially lifesaving emergency medical assistance.

According to a new study, sudden cardiac arrest is the ultimate heart disease, where you die within 10 minutes. And less than 10 percent actually survive.

Cardiac arrest is not the same as a heart attack. A cardiac arrest occurs when electrical activity of the heart is disturbed and the heart stops working, while a heart attack is the result of arterial blockage that cuts off blood flow to the heart.

The study by Dr Sumeet Chugh, associate director of the Heart Institute and director of the Heart Rhythm Center at Cedars-Sinai Medical Center in Los Angeles and colleagues involved 840 patients, aged 35 to 65, whose symptoms were tracked prior to experiencing a cardiac arrest between 2002 and 2012. The study found that 50% of men and 53% of women had at least some warning symptoms before their hearts stopped. More than nine in 10 of those who had symptoms said they resurfaced 24 hours before their cardiac arrest. Chest pain, was the most common symptom among men, while shortness of breath was the most common among women.

These signs should not be ignored, more so in the presence of risk factors for heart disease viz. high blood pressure, cholesterol, diabetes, know heart disease or family history of heart problems.

The study findings are published in the Jan. 5 issue of the Annals of Internal Medicine.

(Medline Plus)
Breaking News

ADA does away with use of word ‘diabetic’ when referring to people with diabetes

The American Diabetes Association (ADA) has released its 2016 Standards of Medical Care with a fundamental shift to a patient-centered focus and shared decision making. Other recommendations include consideration of aspirin for women aged 50 and older (a change from women >60 previously); antiplatelet use in patients younger than 50 with multiple risk factors and addition of ezetimibe to moderate-intensity statin therapy in select patients with diabetes. The ADA continues to maintain that HbA1c level less than 7% is a reasonable goal for many nonpregnant adults but more stringent goals such as less than 6.5% may be suitable for select group of patients who can achieve it without significant hypoglycemia, while less than 8% may be an appropriate target for those with severe hypoglycemia or limited life expectancy. The BP goal in people with diabetes is less than 140/90 mmHg.

The word ‘ diabetic‘ will no longer be used by the ADA when referring to people with diabetes. Though it will be used to as an adjective e.g. “diabetic kidney disease,“ which replaces the term “nephropathy“. Another change in terminology is the use of "atherosclerotic cardiovascular disease (ASCVD)" as a more specific term than simple "CVD." (Medscape)

FDA approves Selexipag for Pulmonary Arterial Hypertension

The US Food and Drug Administration (FDA) has approved the orphan drug selexipag (Uptravi, Actelion) for treatment of adults with pulmonary arterial hypertension (PAH). Selexipag is an oral IP prostacyclin receptor agonist that relaxes muscles in the walls of blood vessels to dilate blood vessels and decrease the elevated pressure in the vessels supplying blood to the lungs. The benefit of selexipag was "consistent across pre-specified patient subgroups such as disease etiology, functional class and baseline PAH therapy, including patients already receiving combination therapy with an endothelin receptor antagonist and a PDE-5 inhibitor… (Medscape)
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Specialty Updates
• Infection with the hepatitis C virus (HCV) significantly increases the risk for Parkinson's disease (PD), suggests new research published online December 23 in Neurology.

• A meta-analysis, based on data from the Causal Analysis Research in Tobacco and Alcohol (CARTA) consortium, published in the December 2015 issue of Circulation: Cardiovascular Genetics, found that part of the cardiovascular risk of smoking may operate through increasing the resting heart rate.

• A new study suggests that metformin has potential to prevent or treat preeclampsia, a pregnancy complication that can be life-threatening and currently has no cure. The findings are published in the American Journal of Obstetrics and Gynecology.

• Serum immunoglobulin E (sIgE) levels are not clinically useful for predicting food allergy in infants with atopic dermatitis (AD), suggests a new study published in the December issue of Pediatrics.

• Both acute kidney injury and chronic kidney disease were common in patients undergoing major vascular surgical procedures and were associated with an increase in long-term cardiovascular-specific death compared with patients with no kidney disease, reported a study published online in JAMA Surgery.

• Experimentally induced feelings of sadness increased serum blood levels of the inflammatory protein interleukin-18 (IL-18) and also changed levels of stress-related opioids in the brain, but these effects were reduced when a neutral mood was induced, reported new research published in Molecular Psychiatry.

• Prefabricated foot orthoses and rocker-sole footwear were similarly effective at reducing foot pain in patients with osteoarthritis (OA) of the first metatarsophalangeal (MPT) joint, but patients wore the orthoses more and experienced fewer adverse events than with the rocker-sole shoes, suggested new research published in Arthritis Care & Research.

• New study suggests that women on blood thinners can take estrogen-containing contraception or hormone replacement therapy without an increased risk of blood clots or uterine bleeding. The findings are published online December 22 in Blood.
Never hurt the ego of a person

It is a well-known Vedic fact that if you hurt the ego of a person, he will never forgive you, especially, if you have insulted or implicated him in character assassination, or have cast implications about financial embezzlement or you call a woman as old or a man as impotent in public. For example, if I hurt ego of a chowkidaar, next time if a patient comes to the hospital gate and asks where Dr. KK Aggarwal is, he only has to whisper, “ Which Aggarwal? The one whose cases never survive?“

Also never hurt the ego of a person who is drunk. Under the influence of alcohol, a person loses his capacity to judge persons and situations. If you provoke him, he can be destructive and aggressive.
Legal Quote
Jacob Mathew vs State of Punjab and Anr: 5th day of August 2005: 334/2005/SCI/ 144-145 of 2004,

”To prosecute a medical professional for negligence under criminal law it must be shown that the accused did something or failed to do something which in the given facts and circumstances no medical professional in his ordinary senses and prudence would have done or failed to do. The hazard taken by the accused doctor should be of such a nature that the injury which resulted was most likely imminent.”
The switch from trivalent to bivalent oral polio vaccine

18th December, 2015

Rationale for switching from trivalent OPV to bivalent OPV

Currently, the risks associated with the type 2 component of tOPV outweigh the benefits.

• Since 1999, naturally occurring type 2 wild poliovirus has not been detected
• The type 2 component of tOPV
o Causes > 90% of vaccine-derived polio viruses (VDPVs)
o Causes approx. 30% of vaccine-associated paralytic polio (VAPP) cases
o Interferes with immune response to poliovirus types 1 and 3 in tOPV
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The Year in Medicine 2015: News That Made a Difference
PCSK9 inhibitors for treating high cholesterol get FDA green signal

The US Food and Drug Administration (FDA) approved two drugs, alirocumab (Praluent, Sanofi/Regeneron) and evolocumab (Repatha, Amgen) in a new drug class, which is expected to be a game-changer in managing cholesterol. These drugs are proprotein convertase subtilisin kexin 9 (PCSK9) inhibitors and differ from statins in their mechanism and mode of delivery. These have potential to change management of high LDL-cholesterol levels. However, the costs of the drugs have been controversial. … (Medscape)
Mandrola's Top 10 Cardiology Stories 2015
NOAC Reversal Agents

The dabigatran reversal agent idarucizumab (Praxbind, Boehringer Ingelheim) was approved by the FDA in October. And as per a study published online in the New England Journal of Medicine, the factor Xa reversal agent andexanet alfa safely reversed the anticoagulant effect of apixaban and rivaroxaban in older volunteers. Andexanet is likely to get FDA approval soon. (Source: Medscape)
IPC Code to know

IPC 204

Destruction of Document to Prevent its Production as Evidence: Whoever secrets or destroys any document [OR ELECTRONIC RECORD] which he may be lawfully compelled to produce as evidence in a Court of Justice, or in any proceeding lawfully held before a public servant, as such, or obliterates or renders illegible the whole or any part of such document [OR ELECTRONIC RECORD] with the intention of preventing the same from being produced or used as evidence before such court or public servant as aforesaid, or after he shall have been lawfully summoned or required to produce the same for that purpose, shall be punished with imprisonment of either description for a term which may extend to two years, or with fine, or with both.
22nd MTNL Perfect Health Mela, the annual flagship event of the Heart Care Foundation of India
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
Water Hygiene

Safe water is an essential commodity for prevention of most water and food–borne diseases like diarrhea, typhoid and jaundice. These diseases are 100% preventable. All of them can be lethal if not prevented, diagnosed or treated in time. Transmission of parasitic infections can also occur with contaminated water. Here are a few tips:

Travelers should avoid consuming tap water.
• Avoid ice made from tap water.
• Avoid any food rinsed in tap water.
• Chlorination kills most bacterial and viral pathogens.
• Chlorination does not kill Giardia cysts.
• Chlorination does not kill amoeba cysts.
• Chlorination does not kill Cryptosporidium.
• Boiled water is safe.
• Treated water is safe.
• Bottled water is safe.
• Carbonated drinks, wine and drinks made with boiled water are safe.
• Freezing does not kill the organisms that cause diarrhea. Ice in drinks is not safe unless it has been made from adequately boiled or filtered water.
• Alcohol does not sterilize water or the ice. Mixed drinks may still be contaminated.
• Hot tea and coffee are the best alternates to boiled water.
• Bottled drinks should be requested without ice and should be drunk from the bottle with a straw rather than with a glass.
• Boiling water for 3 minutes followed by cooling to room temperature will kill bacterial parasites.
• Adding two drops of 5% sodium hydrochloride (bleach) to quarter of water (1 liter) will kill most bacteria in 30 minutes.
• Adding 5 drops of tincture of iodine to a quarter of water (1 liter) will kill bacteria within 30 minutes.
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
It‘s All Good

I heard the story told recently about a king in Africa who had a close friend that he grew up with. The friend had a habit of looking at every situation that ever occurred in his life (positive or negative) and remarking, “This is good!“ One day the king and his friend were out on a hunting expedition. The friend would load and prepare the guns for the king. The friend had apparently done something wrong in preparing one of the guns, for after taking the gun from his friend, the king fired it and his thumb was blown off. Examining the situation the friend remarked as usual, "This is good!“ To which the king replied, "No, this is NOT good!" and proceeded to send his friend to jail.

About a year later, the king was hunting in an area that he should have known to stay clear of. Cannibals captured him and took them to their village. They tied his hands, stacked some wood, set up a stake and bound him to the stake. As they came near to set fire to the wood, they noticed that the king was missing a thumb. Being superstitious, they never ate anyone that was less than whole. So untying the king they sent him on his way.

As he returned home, he was reminded of the event that had taken his thumb and felt remorse for his treatment of his friend. He went immediately to the jail to speak with his friend. “You were right" he said, “It was good that my thumb was blown off.“And he proceeded to tell the friend all that had just happened. “And so I am very sorry for sending you to jail for so long. It was bad for me to do this.“

“No,“ his friend replied, “ this is good!“ “What do you mean, ‘this is good‘! How could it be good that I sent my friend to jail for a year?“ “ If I had NOT been in jail, I would have been with you.“
The exaggerated lepromin test seen in cases of Lucio phenomenon is called as:

a. Mitsuda's reaction
b. Medina-Ramirez reaction
c. Fischer's test
d. Fernandez reaction

Yesterday’s Mind Teaser: 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

Answer for Yesterday’s Mind Teaser: b.2-12 weeks

Answers received from: Dr Jainendra Upadhyay, Dr.Bitaan Sen & Dr.Jayashree Sen, Daivadheenam Jella, Dr.K.V.Sarma.

Answer for 23rd December Mind Teaser: a. Videoconference

Answers received from: Dr Avtar Krishan.
Readers column
Nicely framed sir. IMA is on the right path and making difference in our thought process and sense of achievability. Together we can and will achieve our goal. Dr VK Monga, Delhi
A woman customer called the Canon help desk with a problem with her printer.
Tech support: Are you running it under windows?
Customer:“No, my desk is next to the door, but that is a good point. The man sitting in the cubicle next to me is under a window, and his printer is working fine.“
Press Release
Foods to avoid for a healthy heart
Here are 15 ways to help you achieve this goal

With Christmas and New Year’s approaching and the temperatures dropping by the day, people have a tendency to over-indulge in unhealthy food to keep themselves warm and ward away winter depression.

There is also a sudden increase in the amount of alcohol consumed by a person as their social engagements increase and celebrations begin. It is extremely important to raise awareness about the impact such habits one has on a person’s health specially those with existing lifestyle diseases, children and the elderly.

Speaking about this, Padma Shri Awardee Dr. A Marthanda Pillai – National President and Padma Shri Awardee Dr. KK Aggarwal – Honorary Secretary General IMA in a joint statement said. “The tendency to over-indulge during the winter and festive months can have severe health implications on people. It is important to educate people about the importance of following a healthy diet, getting regular exercise and staying away from alcohol for a healthy heart. It is a known fact that the number of heart attack and sudden cardiac arrest cases rise during the winters. It is essential that people limit the consumption of food high in trans fats, sugar and salt and replace them with fresh fruits and vegetables to stay healthy”.

A few food items, which one should avoid or restrict, include:

Processed meats: Eat none or less than 2 servings (2-3 ounces) per week. Processed meats are those preserved using salts, nitrites or other preservatives. They include hot dogs, bacon, sausage, salami and other deli meats, including deli ham, turkey, bologna and chicken. Long-term observational studies have found that the worst types of meats for the heart are those that are processed.

Highly refined and processed grains and carbohydrates: Eat none or at most 7 servings (1 ounce) per week. Studies have linked whole grain intake - in place of starches (like potatoes) and refined carbohydrates (like white bread, white rice and low-fiber breakfast cereals) - to a lower risk of heart disease, diabetes, and possibly stroke. Whole grains are also linked to lower weight gain over time. Whole grains lower blood pressure and cholesterol, and may improve blood vessel function and reduce hunger.

Refined or processed foods include white bread, white rice, low-fiber breakfast cereals, sweets and sugars, and other refined or processed carbohydrates. High levels of processing remove many of the most healthful components in whole grains, such as dietary fiber, minerals, phytochemicals and fatty acids. High levels of processing also destroy the food’s natural structure. For example, eating a food made of finely milled oats (e.g., Cheerios) or grains (e.g., typically finely milled whole-grain bread) produce much higher spikes in blood sugar than less-processed versions such as steel-cut oats or stone-ground bread. Moreover, processing often adds many ingredients that are less healthy, particularly trans fats, sodium and sugars.

Also, some research shows that fructose is metabolized differently than other sugars, in a way that increases the liver’s production of new fat. Fructose represents about half of the sugar in sweeteners like high-fructose corn syrup or sucrose (found in cane sugar and beet sugar). That’s not to suggest that you never eat a slice of pie or white bread - just make them an occasional treat rather than a regular part of your diet.

Soft drinks and other sugary drinks: Drink none or at most seven 8-ounce servings per week (one 8-ounce serving per day). The examples are sodas, sweetened fruit drinks, and sports drinks. A 12-ounce can of soda contains the equivalent of 10 teaspoons of table sugar. Diet sodas are sugar-free or low in calories, but have no nutrients.

Sugary drinks have all the same ill effects on the heart as highly refined and processed carbohydrates. The body does not compute the calories you ingest in liquid form in the same way as it does the calories you take in from solid foods. So if you add a soda to your meal, you are likely to eat about the same amount of calories from the rest of your food as if you drank water instead. The soda calories are just ‘added on.’ In addition to the other harms of highly refined and processed carbohydrates, sugary drinks also increase your chances of weight gain.