September 27   2015, Sunday
eMedinewS
Lowering BP of No Help in Acute Stroke
Dr KK Aggarwal
1. The terms "breakthrough" or "promising" in US FDA new drugs may make the public think the drug is more effective than it actually is

2. Even healthcare professionals are also likely to be misled.

3. The FDA Safety and Innovation Act, passed in 2012, allows the drug regulator to give certain drugs "breakthrough" status.

4. Breakthrough drugs are those intended to treat a serious or life-threatening condition and for which there is preliminary evidence of a substantial improvement over existing therapies on at least one clinically significant endpoint. These clinical endpoints can be surrogate outcomes, which may or may not prove clinically meaningful.

5. Tamar Krishnamurti, PhD, from the Department of Engineering and Public Policy, Carnegie Mellon University, Pittsburgh, Pennsylvania, in a randomized, controlled trial, had 597 US adults read 1 of 5 short vignettes about a recently approved breakthrough-designated drug for metastatic lung cancer. The researchers found that adding "breakthrough" or "promising" to the vignette increased the percentage of adults rating the drug as "very effective" or "completely effective" compared with a facts-only vignette. Adding these descriptive terms also significantly increased the percentage of people believing that the evidence supporting the drug was "strong" or "extremely strong"

6. The investigators also asked all participants which of two drugs they would take for a potentially life-threatening illness: one was described as "breakthrough," and the other was described without using the term. The vast majority – 92% – chose the "breakthrough" drug.

7. Source: Medscape based on September 21 in a research letter in JAMA Internal Medicine.
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Dr V Mohan, Director MDRF, Ms Anne Belton, Vice-President IDF and Andy Wilson, Vice President, Abbott Fund at a press meet at Chennai to release results of a new WINGS GDM model of care
News
WINGS GDM Model of Care improves health of mother and child

Results of a new GDM Model of Care (http://www.idf.org/women-india-gdm-strategy-wings), a part of the WINGS (Women in India with GDM Strategy) program, a collaboration between International Diabetes Federation (IDF), Madras Diabetes Research Foundation (MDRF) and supported by an unrestricted grant from the Abbott Fund were released at a press meet at Chennai.

The program addresses the hidden epidemic of gestational diabetes in India and provides community-based interventions for women with GDM in low resource settings. It was piloted in Tamil Nadu in India involving more than 2,100 women. After implementation of the Model of Care, women with GDM were found to have pregnancy outcomes similar to pregnant women without GDM, i.e. the general population of Tamil Nadu.About 96% of women returned for follow-up after delivery, a record of sorts in India where post-partum follow up rates are usually between 10 to 20%. The WINGS project demonstrated that through an intensive and continued effort, universal post-partum follow up is achievable, thereby creating an opportunity for prevention of type 2 diabetes. Also, pregnancy outcomes in these women can be improved.
Dr KK Spiritual Blog
Debts in Mythology

It is said that there are three debts which everybody has to pay in his/her lifetime. In Vedic language, they are called Dev Rin, Pitra Rin and Rishi Rin.

In medical language the body consists of soul, physical body, mind, intellect and ego. The soul is given to us by God or Devtas (Dev Rin), the physical body by our parents (Pitra Rin) and the mind, intellect and ego by our Gurus (Rishi Rin).

In terms of computer language, if I see my body as a computer, then my body as a computer is made by my parents; operating software and my inner internet represent the soul or consciousness given by the Devtas and the application software i.e. Word, Excel and Power point which we learn over a period of time are given to us by our Gurus. Therefore, we have to pay all these three debts while we are still alive.
Inspirational Story
The Midas Touch

We all know the story of the greedy king named Midas. He had a lot of gold and the more he had the more he wanted. He stored all the gold in his vaults and used to spend time every day counting it.

One day while he was counting a stranger came from nowhere and said he would grant him a wish. The king was delighted and said, "I would like everything I touch to turn to gold." The stranger asked the king, Are you sure?" The king replied, "Yes." So the stranger said, "Starting tomorrow morning with the sun rays you will get the golden touch." The king thought he must be dreaming, this couldn’t be true. But the next day when he woke up, he touched the bed, his clothes, and everything turned to gold. He looked out of the window and saw his daughter playing in the garden. He decided to give her a surprise and thought she would be happy. But before he went to the garden he decided to read a book. The moment he touched it, it turned into gold and he couldn’t read it. Then he sat to have breakfast and the moment he touched the fruit and the glass of water, they turned to gold. He was getting hungry and he said to himself, "I can’t eat and drink gold." Just about that time his daughter came running and he hugged her and she turned into a gold statue. There were no more smiles left. 

The king bowed his head and started crying. The stranger who gave the wish came again and asked the king if he was happy with his golden touch. The king said he was the most miserable man. The stranger asked, "What would you rather have, your food and loving daughter or lumps of gold and her golden statue?" The king cried and asked for forgiveness. He said, "I will give up all my gold. Please give me my daughter back because without her I have lost everything worth having." The stranger said to the king, "You have become wiser than before" and he reversed the spell. He got his daughter back in his arms and the king learned a lesson that he never forget for the rest of his life.
Scientific awareness on personal hygiene and prevention from obesity among school going children
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Make Sure
Situation: An adult undergoing bronchoscopic biopsy developed infective endocarditis.

Reaction: Oh my God! Why was IE prophylaxis not given?

Lesson: Make sure, that all procedures of the respiratory tract that involve incision or biopsy of the respiratory mucosa include IE prophylaxis.
Wellness Blog
Snorers at risk of sudden death

The interrupted night time breathing of sleep apnea increases the risk of dying. Sleep apnea is a common problem in which one has pauses in breathing or shallow breaths during sleep.

Studies have linked sleep apnea during snoring to increased risk for death. Most studies were done in sleep centers rather than in the general community. A study published in the journal Sleep has suggested that the risk is present among all people with obstructive sleep apnea. The size of the increased mortality risk was found to be surprisingly large.

The study showed a six–fold increase, which means that having significant sleep apnea at age 40 gives you about the same mortality risk as somebody aged 57 who does not have sleep apnea.

For the study, the researchers collected data on 380 men and women, 40 to 65 years old, who participated in the Busselton Health Study. Among these people, three had severe obstructive sleep apnea, 18 had moderate sleep apnea, and 77 had mild sleep apnea. The remaining 285 people did not suffer from the condition. During 14 years of follow–up, about 33 percent of those with moderate to severe sleep apnea died, compared with 6.5 percent of those with mild sleep apnea and 7.7 percent of those without the condition. For patients with mild sleep apnea, the risk of death was not significant and could not be directly tied to the condition.

People who have, or suspect that they have, sleep apnea should consult their physicians about diagnosis and treatment options.

Another study by researchers from the University of Wisconsin has also shown that severe sleep apnea was associated with a three–fold increased risk of dying. In addition, for those with moderate to mild sleep apnea, the risk of death was increased 50 percent compared with people without sleep apnea. Sleep apnea is also linked to future heart attacks and with thickened wall thickness of the neck artery.
Dr Good Dr Bad
Situation: A patient came with non–responding cough.

Dr. Bad: It may be TB.

Dr. Good: Rule out acidity.

Lesson: Chronic cough along with dysphonia/hoarseness, globus pharyngeus, mild dysphagia, chronic cough and nonproductive throat clearing are often important otolaryngologic manifestations of occult or silent GERD. (Laryngoscope 1991;101:1)
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Reader Response
Dear Sir, Very informative news. Regards: Dr Karan
eMedinewS Humor
TEACHER: George, go to the map and find North America.
GEORGE: Here it is!
TEACHER: Correct. Now, class, who discovered America?
CLASS: George!
Rabies News (Dr A K Gupta)
Can IDRV be given in private hospital?

The ID route has been permitted to be used in selected anti–rabies clinics having an adequate number of patients (at least 5/day) seeking post–exposure prophylaxis against rabies every day to make IDRV viable and cost–effective.
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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
News
  • Patients with diabetic peripheral neuropathy who used a capsaicin 8% patch (Qutenza, Astellas Pharma) had more relief from pain and better sleep quality than those who received a placebo patch, according to a phase 3 study reported at the European Association for the Study of Diabetes (EASD) 2015 Meeting. P(Medscape)
  • Congratulations: During the 30th CMAAO General Assembly held at Myanmar, Dr K K Aggarwal, Honorary Secretary General IMA, was elected as the Chairman standing Committee on ‘resolution’ for the year 2015-17. National Medical associations of the following Member countries, India, Korea, Australia, Japan, Indonesia, New Zealand, Philippines and Taiwan will be the members. Dr K K Aggarwal was also nominated as the nodal person for CMAAO ‘Child Sexual abuse” project. All NMAs need to coordinate with him on the said subject.
  • Using apheresis to remove a serum protein called soluble Fms-like tyrosine kinase-1 (Sflt-1) may help pregnant women with severe preeclampsia safely delay delivery, according to a pilot study published online September 24 in the Journal of the American Society of Nephrology.
  • A case-control study found that the strongest risk factors for the potentially catastrophic complication of diffuse alveolar hemorrhage (DAH) in patients with lupus were low platelet counts and low levels of complement C3.
  • Higher levels of air pollution may increase risk of Alzheimer's disease in those who carry a gene associated with the debilitating brain disorder. The researchers detected detrimental impact of air pollution on cognitive abilities of children carrying a version of the apolipoprotein E gene associated with the risk for Alzheimer disease. (TOI< Sep 25, 2015)
  • Central venous catheterization of the subclavian vein was associated with the lowest risk for bloodstream infections and symptomatic thrombosis compared with insertions at the jugular or femoral veins, according to a randomized controlled trial published in the September 24 issue of the New England Journal of Medicine.
  • Ankylosing spondylitis (AS) was associated with increased risk for death, particularly in poor patients, in patients with multiple health problems, and in patients who had had hip replacements, according to a study published in the Annals of the Rheumatic Diseases.
  • Tom Bourne, MD, PhD, consultant gynecologist and professor, Queen Charlotte's and Chelsea Hospital, Imperial College London, United Kingdom, and colleagues report that current guidelines regarding ultrasonographic diagnosis of miscarriage may still be associated with misdiagnoses and should be updated to reflect new evidence.
  • Taking hypertension medication before bed rather than in the morning not only lowers nighttime blood pressure (BP) but protects against new-onset diabetes, according to research presented in Diabetologia. Sleeping BP -- but not daytime or 48-hour ambulatory BP -- was found to be a significant predictor of new-onset diabetes and may be a novel target for prevention.
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Bioethical issues in medical practice
A patient’s right to information

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

Final Comments

The treating doctor is asked by his doctor colleague NOT to disclose an end of life cancer to his apparently healthy father. One day the father came for consultation alone and asked the treating doctor point blank- what is wrong with me? What should the treating doctor do- tell the entire truth, tell a white lie, or do you have any other suggestions?

A very large number of informed and wise readers provided responses for which we are grateful. Replies were received from (in no particular order, affiliations shortened)

1. Sreenivas Vishnubhatla, Prof of Biostatistics, AIIMS, New Delhi

2. Vasantha Peter

3. Ranjita Thakur

4. Dr Pratibha Pereira

5. Dr Ajithkumar K

6. Dr. B.B. Singh, IPR Attorney, High Court , Mumbai

7. Nita Mawar

8. Saradha Suresh

9. Prabha Desikan, Prof & Head Microbiology, BMHRC (ICMR), Bhopal (MP)

10. Dr. Barna Ganguly, Prof & Head Pharmacology, PSMC, Karamsad, Gujarat

11. Rema Devi, St. John's Medical College, Bangalore

12. Dr. Ratinder Jhaj, Asso. Prof. Pharmacology, AIIMS, Bhopal

13. Olinda Timms

14. Rakesh Biswas, Professor, Medicine, LN Medical College, Bhopal

15. Astrid Lobo Gajiwala

16. Pooja 17. N.N.Mishra, Asstt Prof & Head/Bioethics Consultant, BRA Bihar University, Muzaffarpur, Bihar.

18. Triptish Bhatia,PhD, PGIMER-Dr Ram Manohar Lohia Hospital, New Delhi

19. Dr. Shalini Makkar, Asst. Prof., Forensic Medicine PGIMER-Dr. RML Hospital New Delhi

20. Dr Manik S. Ghadlinge, Asst. Prof., Pharmacology, PGIMER- Dr RML Hospital, New Delhi

21. Prof. Dr. U. Gauthamadas, Prof & Head Psychiatry, MAP IMSR, Chennai

22. Dr. T. P. Yadav, Professor Pediatrics, PGIMER-Dr. RML Hospital, New Delhi

23. Swapna Sundar, CEO, IDome Strategies Advisors Pvt. Ltd., Kilpauk, Chennai.

24. Dr A.S. Valan, India EIS officer, NCDC, New Delhi.

25. Dr. Ajith

26. Nalini A.

27. Sini Joseph, Clinical Psychologist, Central Institute of Psychiatry, Ranchi.

28. Sharanya.K, Gerontologist/ Psychotherapist

Here is a summary of their opinions.

Patients trust and respect their doctor and expect him/her to tell them the truth. Withholding pertinent information violates a patient's autonomy rights and violates the fundamental duties of a physician. Not revealing the truth may create a deep scarring effect on him to the extent that father-son, patient-doctor relations may get strained (M. Ghadlinge). On a moral note, Dr. T.P. Yadav opined that the treating doctor should have impressed upon the son that his father is entitled to know the truth. Post the demise, would the son and the consultant physician be guilt-free if they went ahead and hid the truth or would they come to terms with it? (S. Kumar).

The patient has a right to happiness in the terminal stages of his life. But while the doctor son has a ‘right’ to know about his father’s illness, the father has the right to decide other issues in his own life, for which he needs to know the diagnosis. The very fact that the father/patient came alone means he suspects the diagnosis (N. Mawar, S. Suresh, T. Bhatia).

Persons need to be helped in their journey to death and to spend their days peacefully (R. Thakur). Patients usually have a well-developed sense about their state of health and some may wish to prepare for death; denying them information can only lead to distress and confusion (O. Timms). The trust of the patient is more important than the trust of the doctor's friend (S. Vishnubhatla). Contrarily, Dr. U. Gauthamdas suggested that the patient be told the truth and be asked not to reveal it to his doctor son. Dr. B. B. Singh feels that "If a person has lived with dignity, let him die with dignity a few weeks later, don't tell him anything”.

The experience, attitude, skill of physician & timing of communication is of utmost importance for communicating such news. The doctor needs to ensure that a support system is in place (with counsellor / family / friends/ contacts with cancer survivors' groups) before telling the patient the truth about his condition (P. Desikan). Breaking bad news is a communication skill that can be learned (O. Timms). The MCI has guidelines on the matter too ethical conduct prescribed under the extant rules and regulations, including Code of Ethics Regulations, 2002 (S. Sundar).

Opinions were varied as to when and how the doctor should do so. Should he inform the patient’s doctor son first? Should he inform the patient first and them the son? Should he call both son and patient and explain the diagnosis in a subsequent visit?

What do YOU think? Ponder and consider, for many ethical dilemmas which are not laid down in law, need to be tackled thoughtfully and considerately.

Please keep your thinking cap on for subsequent dilemmas and send in your replies – and new dilemmas you face in medical practice to ijcp12@gmail.com.
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Insanity: doing the same thing over and over again and expecting different results. Albert Einstein
eIMA Quiz
During rapid sequence induction of anesthesia:
1. Slick’s maneuver is not required.
2. Pre-oxygenation is mandatory.
3. Suxamethonium is contraindicated.
4. Patient is mechanically ventilated before end tracheal incubation.

Yesterday’s Mind Teaser: What percentage of your diet should fat make up?

A. About 10 percent of your daily calories.
B. About 20 percent of your daily calories.
C. About 30 percent of your daily calories.
D. About 40 percent of your daily calories.
E. There is no recommended amount of fat; you should strive to eat as little of it as possible.

Answer for Yesterday’s Mind Teaser: C. About 30 percent of your daily calories.

Answers received from: Viswanatha Sarma,

Answer for 25th September Mind Teaser: c) It is associated with APC mutation

Correct Answers received from: Dr Poonam Chablani, Viswanatha Sarma,
Press Release
A Heart Healthy Prescription

Cardiovascular disease (CVD) is one of the leading Global causes of morbidity and premature mortality contributing to over 17.5 million deaths every year

The increasing incidence of cardiac diseases is causing serious concern amongst the medical fraternity of India. The primary reasons for this include the lifestyle irregularities of the 21st century Indian. In addition to this, early signs of heart disease are often ignored or not taken seriously causing grave problems in the future.

According to Padma Shri Awardees, Dr A Marthanda Pillai Indian Medical Association (IMA) and Dr KK Aggarwal Honorary Secretary General IMA and President Heart Care Foundation of India,  “The number of heart patients in India can be drastically reduced if every individual lives a healthy and balanced lifestyle and immediately makes necessary lifestyle modifications whenever heart disease symptoms are reported. People often get fooled by misconceptions about heart diseases and hence, it becomes really important to understand the facts associated with your heart. For instance women often continue to believe that they can never suffer from heart disease. However, this is a myth. Similarly, it is often believed that heart disease only happens in those above the age of 55. The reality is that in the present day and age, heart disease is increasingly common in people in the age group of 30-40 years.”

“Heart disease prevention and education must from the very onset because the seeds of heart disease are sown in teenagers and young adults. Over the years, the plaque in the wall of the arteries continues to clog them causing heart attacks and episodes of sudden cardiac arrest. Hypertension, diabetes, and obesity must be kept under check since they all can lead to heart attacks", he added.

According to reports,more women have died from heart attacks than men in past 30 years. Doctors recommend that everyone regardless of their gender get regular cholesterol level and blood pressure checked as in the case of women,they rarely experience conventional symptoms such as heartache or pain in the chest.

Lifestyle modifications are key for the reversal of CAD. If you have to consume alcohol, drink in moderation. Drinking excessive amounts of alcohol causes raised blood pressure, which is one of the most important risk factors for having a heart attack or a stroke. Increases in your blood pressure can also be caused by weight gain from excessive drinking. Obesity too leads to cardiovascular ailments.

Additionally, the difference between good and bad cholesterol must be understood. While some fat is good for the body, consuming a high-trans-fat diet can cause plaque deposit over the long runA healthy and balanced diet is key for a healthy heart. An over-dependence on junk food, consumption of saturated and trans fats, food containing high salt and sugar levels cause obesity, high cholesterol, hypertension and diabetes, all key risk factors for heart disease. A healthy diet must consist of items, which have low levels of saturated fats, fresh fruits and vegetables.

You should immediately break away from the thinking that ‘exercising is too risky if you have a heart disease’ as doctors recommend regular exercises to people with heart issues. Also, Regular exercise is important to strengthen one's, heart, lower blood pressure, keep obesity under control, burn off stress, boost your self-esteem and help you sleep better. By regularly exercising for at least 30 minutes three to four times a week, one can keep their heart healthy. Aerobic exercise particularly is beneficial for patients with a tendency to get heart disease.

Heart’s care continues for as long as you live. In addition to this, heart disease can develop again after you have got yourself treated. Many individuals suffer heart attacks twice or thrice in their lives. But the best remedy to totally undo all the damage is by start following a healthy regime that will make you less prone to all the heart casualties.

Formula of 80 to live a healthy life till the age of 80 years

1. Keep your abdominal circumference less than 80cm

2. High blood pressure and its risks, keep the lower reading at 80

3. Keep your blood sugar below 80mg

4. Bad cholesterol levels should be lesser than 80mg

5. Keep the pulse lower than 80 beats per minute

6. Eat a balanced diet and avoid cereals for 80 days in a year

7. Walk 80 minutes a days and brisk walk 80 minutes a week

8. Do not consume alcohol and if you do consume alcohol in moderation, not more than 80 grams in a week for men and two weeks for women