December 26   2015, Saturday
Dr KK AggarwalDr KK Aggarwal Revisiting Cardiology 2015

• PCSK9 Inhibitors Released Into the Real World: FDA approved the injectable monoclonal antibodies evolocumab and alirocumab which induce dramatic drops in LDL cholesterol.

• SPRINT: SPRINT compared lowering blood pressure to 120 mm Hg against a more lenient goal of 140 mm Hg in high-risk older adults. The data safety monitoring board stopped the trial early because of an increased number of cardiac events in the lenient-BP arm. Efficacy of intense BP control came at a cost: more drugs were required, and more subjects in the intense-BP arm experienced syncope, acute kidney injury, and electrolyte abnormalities

• Coffee and Fat Are Back: Two major reversals included the allowance of moderate caffeine intake and removal of limits on dietary cholesterol. In 2015, a consensus grew that refined sugars promote illness

• AF Treatment: STAR-AF 2 trial found that additional ablation beyond pulmonary–vein isolation in patients with advanced forms of AF did not improve outcomes.

•LEGACY trial and CARDIO–FIT trials showed that weight loss and gains in fitness delivered potent antiarrhythmic effects.

• ARREST–AF Substrate study, showed that risk-factor modification worked by improving electrical and structural properties of human atria.

Breaking News

IDSA recommends aggressive treatment of candidiasis

Updated guidelines from the Infectious Diseases Society of America (IDSA) for managing Candida infections recommend first-line treatment for candidemia with an echinocandin such as caspofungin, rather than fluconazole, as echinocandins kill, rather than inhibit, these pathogens. They also advocate consultation with infectious disease specialists for the early identification of different Candida strains, optimal antifungal treatment, and better patient outcomes. A step-down approach is recommended i.e., initiating treatment with an intravenous antifungal such as an echinocandin and then switching to an oral treatment, such as fluconazole. Candidiasis should be considered in patients who deteriorate with no obvious cause, have unexplained fever, have an elevated white blood cell count, have recently undergone abdominal surgery, or have a central venous catheter, according to the new guidelines. They also recommend the removal of a catheter as early as possible in candidemia if the catheter is the presumed source and can be safely removed. Other intravascular devices should also be removed. The new guidelines are published online December 16 in Clinical Infectious Diseases… (Medscape)

Centre to take help of pharmacists for healthcare delivery

Union government is working to expand its healthcare delivery formats to include the pharmacists who would interface with the doctors in the drug therapy compliances in patient care. This will not only in the hospital setting for patient care but also for clinical trials where the pharmacist will play an indelible role to keep tabs on the adverse drug monitoring and systematic review of therapy protocols… (Pharmabiz - Nandita Vijay)
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Specialty Updates
• Environmental factors may lead to autism, and the condition is far more prevalent in those who were extremely premature babies, suggests new research published in Cerebral Cortex.

• Environmental factors may lead to autism, and the condition is far more prevalent in those who were extremely premature babies, suggests new research published in Cerebral Cortex.

• Human papillomavirus (HPV) testing, as well as vaccination, should become an essential part of cervical cancer screening and prevention, suggests an update of cervical cancer screening guidelines released by the American College of Obstetricians and Gynecologists (ACOG). The practice bulletin was published in Obstetrics & Gynecology.

• In patients with bipolar depression, adding the anticonvulsant medication lamotrigine to quetiapine may improve outcomes in comparison with quetiapine monotherapy; however, concurrent use of folic acid may reduce the additive effect of lamotrigine, suggests a new study published online in Lancet Psychiatry.

• Researchers at the University of Georgia have found that pathogens, like salmonella, can survive for at least six months in cookies and crackers. The findings are published in the Journal of Food Protection.

• Sleeping more than nine hours a night, and sitting too much during the day could be a hazardous combination, particularly when added to a lack of exercise, suggests a new study published in the journal PLOS Medicine. Researchers noted that a person who sleeps too much, sits too much and isn't physically active enough is more than four times as likely to die early as a person without those unhealthy lifestyle habits.

• A new study, published in the Journal of Heart and Lung Transplantation, demonstrated a definitive connection between frailty and survival after a lung transplant procedure. Researchers suggest that we may be able to help patients live longer with fewer complications after a transplant by intervening early to prevent or lessen the severity of frailty.

• A one-step screening approach [International Association of the Diabetes and Pregnancy Study Groups (IADPSG)] for gestational diabetes (GDM) increased the rate of diagnosis and treatment of the disease in mothers, but did not improve neonatal outcomes compared with the more commonly used two-step screening [USING THE CARPENTER-COUSTAN CRITERIA CUTOFFS], suggested a new study published online in Obstetrics & Gynecology.
Relieve stress by changing the interpretation

Stress is the reaction of the body or the mind to the interpretation of a known situation. Stress management, therefore, involves either changing the situation, changing the interpretation or taming the body the yogic way in such a way that stress does not affect the body. Every situation has two sides. Change of interpretation means looking at the other side of the situation. It is something like half glass of water, which can be interpreted either as half empty or half full. Studies have shown that anger, hostility and aggression are the new risk factors for heart disease. It has been shown that even recall of anger can precipitate a heart attack. Many studies have shown that when doctors talk positive in front of unconscious patients in ICU, their outcome is better than those if doctors talk negative.

The best way to practice spiritual medicine is to experience silence in the thoughts, speech and action. Simply walking in the nature with silence in the mind and experiencing the sounds of nature can be as effective as 20 minutes of meditation. Twenty minutes of meditation provides the same physiological parameters as that of 7 hours of deep sleep.
Legal Quote
Martin F. D'Souza vs Mohd. Ishfaq, 3541 of 2002, dated 17.02.2009

”A doctor accused of negligence should not be arrested in a routine manner simply because a charge has been leveled against him. Unless his arrest is necessary for furthering the investigation or for collecting evidence or unless the investigating officer feels satisfied that the doctor proceeded against would not make himself available to face the prosecution unless arrested, the arrest should be withheld.”
The switch from trivalent to bivalent oral polio vaccine

18th December, 2015

SAGE October 2015 recommendations

All 156 OPV–using countries and territories must switch within a 2-week switch window (from 17 April to 1 May)
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The Year in Medicine 2015: News That Made a Difference
Physician-assisted suicide legalized in California

In October, California became the fifth state in the United States to permit physician-assisted suicide. Gov. Jerry Brown signed into law a bill approving the controversial, yet growing, practice called assisted dying. The four other states are Montana, Oregon, Vermont, and Washington. Many other states, including Colorado, have bills pending. Passage of the California law came after the California Medical Association changed its position from opposition to neutrality on the issue. This trend has been seen in other states as well. Organized medicine has traditionally opposed physician-assisted suicide, calling it a violation of the imperative to “do no harm.“ (Medscape)
Mandrola's Top 10 Cardiology Stories 2015
Cutting the Cord in Pacing

The Achilles' heel of cardiac pacing devices is the lead. This year began the wireless revolution in cardiac pacing. Both the NanoStim LP leadless pacemaker (St Jude Medical) and the Micra TPS (Medtronic) performed well. Both devices have earned CE Mark in Europe, and FDA approval is likely. One way to look at these devices is that the impact will be small because single-chamber ventricular pacing accounts for a small proportion of devices. That's true; but this is the first of many (wireless) disruptions to come in cardiac pacing. Two more thoughts: a leadless pacemaker is placed through a femoral sheath. That means any cardiologist can implant it. Look for a rise in the number of single-chamber device implants. Second, think forward 5 years. It's likely that a leadless pacemaker will be combined with a subcutaneous ICD generator to make a leadless ICD. (Medscape)
IPC Code to know

IPC 304

Punishment for Culpable Homicide Not Amounting to Murder: Whoever commits culpable homicide not amounting to murder, shall be punished with imprisonment for life, or imprisonment of either description for a term which may extend to ten years, and shall also be liable to fine, if the act by which the death is caused is done with the intention of causing death, or of causing such bodily injury as is likely to cause death; or with imprisonment of either description for a term which may extend to ten years, or with fine, or with both, if the act is done with the knowledge that it is likely to cause death, but without any intention to cause death, or to cause such bodily injury as is likely to cause death.
5 points order of Nainital High Court
Digital IMA
Brazil declares emergency as over 2400 babies born with deformities, due to brain-damaging virus

The situation in Brazil has turned rather grim, as a mosquito-borne virus is believed to have been causing infants to be born with brain damage. This has left the Brazilian health authorities in distress. Zika, as the pathogen is referred to, was first discovered 70 years ago, in the forest monkeys of Africa. It is also being compared to the dreaded virus, West Nile that often proved fatal after brief spells of mild symptoms. On November 28, after the autopsy of a child, who had succumbed to microcephaly the Brazilian Health ministry found the Zika virus. The virus could be traced back to the mothers of all the affected babies as well.“This is an unprecedented situation, unprecedented in world scientific research,“ said the ministry‘ s statement, as reported by CNN. With 29 cases of fatality in infants and Brazil investigating more than 2,400 cases, which has sharply risen from previous year's 147, the situation has turned alarming … (DNA India)
Three new health schemes to be launched

The health ministry is set to launch three schemes to mark the birthday of the former Prime Minister Atal Bihari Vajpayee. The three schemes, driven by information technology initiatives, are focused on maternal care, tuberculosis treatment and tobacco control measures. The first scheme, Kilkari, will entail reaching out to pregnant women particularly in rural areas and providing them with health tips as well as alerts on routine treatments, checkups as well as tips on nutritional diet and supplements. Under the programme, 72 audio messages will be sent to pregnant women through phone. The second scheme is a tobacco control program that would be implemented through missed calls. People consuming any tobacco product and wanting to quit can leave a missed call to register themselves with the government. The third is a tuberculosis detection program which will help suspected patients in proper diagnosis of the disease as well locate a nearest treatment center will the entire gamut of services required for treatment. (Times of India - Sushmi Dey)
Karnataka govt not to permit online sale of drugs till clear guidelines are available

The Karnataka government has now categorically stated that online sale of drugs would not be permitted until the Union government comes out with its clear–cut guidelines. The online sale of drugs will not be permitted until the rules are in place, said Karnataka health and family welfare minister UT Khader adding that there was some confusion over this issue with no clarity on the system of e–pharmacy… (Pharmabiz– Nandita Vijay)
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
Exercise impact on the knee

Different exercises produce different impacts on the knee joints. The best and safest exercises causing minimum impact on the knee for patients post knee replacement or knee arthritis are walking, biking, hiking, riding an exercise bike, riding an elliptical trainer and walking on the treadmill. In sports one can play doubles tennis and not singles. One can also participate in downhill or cross–country skiing.

The maximum stress–producing exercises are jogging and golf swings.


• Biking generates the least force, producing impact of about 1.3 times the person’s body weight.

• Treadmill walking was next best, producing forces of 2.05 times the body weight.

• Walking on level ground generated forces of 2.6 times the body weight.

• A game of tennis produces forces of 3.1 to 3.8 times the body weight; serving produces the highest impact.

• Golf swings produces forces of 4.5 times body weight on the forward knee and 3.2 times body weight in the opposite knee.

• Jogging produced forces of 4.3 times body weight.
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
Success depends upon maturity!

Maturity is many things. It is the ability to base a judgment on the big picture, the long haul. It means being able to resist the urge for immediate gratification and opt for the course of action that will pay off later. One of the characteristics of the young is “ I want it now.“ Grown-up people can wait. Maturity is perseverance–the ability to sweat out a project or a situation, in spite of heavy opposition and discouraging setbacks, and stick with it until it is finished. The adult who is constantly changing friends and changing mates is immature. He/she cannot stick it out because he/she has not grown up. Maturity is the ability to control anger and settle differences without violence or destruction. The mature person can face unpleasantness, frustration, discomfort and defeat without collapsing or complaining. He/she knows he cannot have everything his/her own way every time. He/she is able to defer to circumstances, to other people-and to time. He/she knows when to compromise and is not too proud to do so.

Maturity is humility. It is being big enough to say, “ I was wrong.“ And, when he/she is right, the mature person need not experience the satisfaction of saying,“ I told you so.“ Maturity is the ability to live up to your responsibilities, and this means being dependable. It means keeping your word. Dependability is the hallmark of integrity. Do you mean what you say-and do you say what you mean? Unfortunately, the world is filled with people who cannot be counted on. When you need them most, they are among the missing. They never seem to come through in the clutches. They break promises and substitute alibis for performance. They show up late or not at all. They are confused and disorganized. Their lives are a chaotic maze of broken promises, former friends, unfinished business and good intentions that somehow never materialize. They are always a day late and a dollar short.

Maturity is the ability to make a decision and stand by it. Immature people spend their lives exploring endless possibilities and then doing nothing. Action requires courage. Without courage, little is accomplished.

Maturity is the ability to harness your abilities and your energies and do more than is expected. The mature person refuses to settle for mediocrity. He/she would rather aim high and miss the mark than low-and make it. Maturity is the art of living in peace with that which cannot be changed, the courage to change that which should be changed, no matter what it takes, and the wisdom to know the difference.
The extent to which ionisation of a drug takes place is dependent upon pKa of the drug and the pH of the solution in which the drug is dissolved. which of the following statements is not correct.

1. pKa of a drug is the pH at which the drug is 50% ionized.
2. Small changes of pH near the pKa of a weak acidic drug will not affect its degree of ionisation.
3 .Knowledge of pKa of a drug is useful in predicting its behaviour in various body fluids.
4. Phenobarbitone with a pKa of 7.2 is largely ionized at acid pH and will be about 40% non-ionised in plasma.

Yesterday’s Mind Teaser: 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

Answer for Yesterday’s Mind Teaser: b. Medina-Ramirez reaction

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

Answer for 23rd December Mind Teaser: b.2-12 weeks

Answers received from: Dr Jainendra Upadhyay, Dr Avtar Krishan
Readers column
Dear Sir, There appears to be factual error in the column of switch over from tOPV to bOPV. We have to withdraw tOPV from the system whereas in your column it is written bOPV. Suresh Seth
A Horoscope for the Workplace

Middle Management/Department Management/Team Leaders: Catty, cut–throat, yet completely spineless, you are destined to remain at your current job for the rest of your life. Unable to make a single decision you tend to measure your worth by the number of meetings you can schedule for yourself. Best suited to marry other “Middle Managers,“ as everyone in your social circle is a “Middle Manager.“
Press Release
The day after Christmas is hazardous for your heart

December 26th is historically one of the most dangerous days of the year for people vulnerable to cardiac problems, including heart attacks, arrhythmias, sudden cardiac death and heart failure.

Studies indicate that heart-related deaths increase by nearly 5% during holidays, perhaps because patients delay seeking treatment for heart attacks and also because hospital staffing patterns change. The study found quiet ER on Christmas Day with a sudden surge on December 26. It was also found that daily visits to hospitals for heart failure increased by 33% during the four days after Christmas.

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 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”.

Winter is anyway known to be notorious for heart attacks, heart failures, and arrhythmias. Cold weather is hard on the heart. Blood vessels constrict, which raises blood pressure. Blood also clots more readily. Frigid temperatures increase strain on the heart, and too much physical exertion can worsen the burden and trigger a heart attack. Alcohol if consumed in excessive amount during Christmas can trigger atrial fibrillation, a form of irregular heartbeat. If it persists, atrial fibrillation can end up with stroke.

But cold weather isn't the only culprit. After Christmas Day, many people confuse the signs of a heart attack -- like shortness of breath or chest pains -- with indigestion from a heavy dinner. If you're having a heart attack, studies show that you must not wait longer than 12 hours to be treated. It is essential if people at high risk of heart attacks notice any unusual symptoms; they consult their doctor to rule out any emergency.
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