December 28   2015, Monday
Dr KK AggarwalDr KK Aggarwal Fat but fit no longer good for health

A recent study published online December 20 in the International Journal of Epidemiology has challenged the current concept that by being physically fit, individuals who are obese can fully compensate mortality risk. The study suggests that physically fit obese men are at higher risk for death than men who are of normal weight but are physically unfit. And it also found a graded association between aerobic fitness at the age of 18 years and the risk of early death.

The study by Gabriel Högström, PhD, a postgraduate student in the Dept. of Community Medicine and Rehabilitation at Umeå University, Sweden, and colleagues, drew data from the Swedish Military Conscription Registry and included 1,317,713 Swedish men (mean age, 18 years) conscripted into the Swedish military between 1969 and 1996. At the time of conscription, the men underwent baseline assessments that included aerobic fitness testing, in which they cycled until fatigue caused them to stop. The researchers looked at all-cause and cause-specific death, using national registers. Mortality information came from the National Cause of Death Registry.

During a mean follow-up of 28.8 years, 44,301 of the men died. After adjusting for age and conscription year, men with the highest aerobic fitness levels had 51% lower risk for all-cause death (hazard ratio [HR], 0.49; 95% con?dence interval [CI], 0.47 - 0.51vs those with the lowest fitness levels. Similar findings resulted from analyses of weight-adjusted fitness (HR, 0.52; 95% CI, 0.50 - 0.54).

Alcohol and narcotic abuse had the strongest associations with death (HR, 0.20; 95% CI, 0.15 - 0.26).
Obese men benefited less than normal-weight men from being physically fit (P < .001). Normal-weight men in all levels of aerobic fitness had lower risk for all-cause mortality (30% - 48%; P < .05 for all) compared with obese men with the highest levels of aerobic fitness.

The benefits of aerobic fitness decreased as weight increased. After adjusting for age and year, normal-weight men in the upper half of aerobic fitness had 34% lower risk for death than those in the lower half (HR, 0.66; 95% CI, 0.64 - 0.68). This benefit decreased to 28% in overweight men, and disappeared entirely in men with the highest levels of obesity… (Medscape)
Breaking News

Govt caps prices of another 106 drugs

The government has revised the national list of essential medicines (NLEM) to add 106 more drugs while 70 other drugs, which are not prescribed frequently or where better alternatives are now available in the market, have been taken off the list in order to bring down prices of medicines for critical diseases like cancer, HIV and diabetes. This means, the total number of essential medicines, prices of which are capped by the government, would increase from 348 to 384, including diagnostic agents and contraceptives. The move following recommendations from a core committee formed by the health ministry is expected to make many important drugs affordable or at least reduce their prices significantly to bring relief to patients… (Times of India - Sushmi Dey)

Study finds strong inheritance component in 12 cancers

Scientists have found strong evidence for inherited components in 12 different kinds of deadly cancers. This raises hope for earlier detection and better targeting of therapy. The new study confirmed the role of inherited genes in breast and ovarian cancer, surprisingly, stomach cancer too was found to have an inherited component. The study also evaluated cancers of the prostate, lungs, brain and nervous system, uterus, blood, etc. The study published in the journal Nature Communications was carried out by researchers from several US universities including Washington University, St. Louis, Ohio State University, Brown University and Medical College Wisconsin… (Times of India – Subodh Varma)
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Specialty Updates
• Eating potatoes may increase the risk of type 2 diabetes and replacing them with whole grains may lower this risk, suggested a study published online in Diabetes Care.

• For patients with gram-negative bloodstream infections (BSI) who present with a beta-lactam allergy, treatment with a beta-lactam (BL) antibiotic from an alternative class carries a lower risk of clinical failure than treatment with a non-beta-lactam (NBL) antibiotic, suggested a new study published online in the Journal of Allergy and Clinical Immunology.

• A meta-analysis including more than 600,000 patients in more than 100 studies revealed that antihypertensive therapy significantly decreased the risks of major cardiovascular (CV) events, including stroke and heart failure, and all-cause mortality, almost regardless of baseline BP levels and comorbidities. The findings are published December 23 in the Lancet.

• New research, published in PLOS ONE, has found that lower levels of antibodies in saliva are associated with of an elevated risk of mortality, and could be an early indicator of risk.

• A single infusion of a powerful antibody called VRC01 can suppress the level of HIV in the blood of infected people who are not taking antiretroviral therapy (ART), reported scientists at the National Institutes of Health in a paper published December 23 in Science Translational Medicine.

• Zinc levels in breast milk may serve as an indicator of breast function during lactation, suggests new research published online in the Journal of Mammary Gland Biology and Neoplasia.

• A new study suggests that the fear of spiders could be eradicated in just 2 minutes with a single dose of a commonly used beta-blocker – propranolol - and exposure to the creepy critters themselves. The findings are published in the journal Biological Psychiatry.

• Switching from the older Zapletal reference values to the newer Global Lung Function Initiative (GLI) values can result in improved asthma treatment, suggests new research to be published online in Pediatrics.

• An analysis based on data from previously published literature suggests it is more cost effective to treat all suspected cases of onychomycosis with oral terbinafine than to perform confirmatory diagnostic tests beforehand, although confirmatory testing before treatment with the expensive topical medicine efinaconazole, 10 percent, was associated with reduced costs, suggested an article published online in JAMA Dermatology.

• New research published in the journal Neurology suggests that individuals infected with hepatitis C virus may be at greater risk for Parkinson's disease.
Positive Attitudes

All those out there who feel you are at your wits end wondering how things don’t ever work out for you, can now relax and dwell on all those failures that life has taken you through and turn failure into success.

• Failure doesn’t mean you are a failure. But it does mean you haven’t succeeded yet.
• Failure doesn’t mean you have accomplished nothing. It does mean you have learned something.
• Failure doesn’t mean you have been foolish. It does mean you had a lot of faith.
• Failure doesn’t mean you’ve been discouraged. It does mean you were willing to try.
• Failure doesn’t mean you don’t to do. It does mean you have to do it in a different way.
• Failure doesn’t mean you are inferior. It does mean you are not perfect.
• Failure doesn’t mean you have wasted your life. It does mean you have a reason to start afresh.
• Failure doesn’t mean you should give up. It does mean you must try harder.
• Failure doesn’t mean you’ll never make it. It does mean it will take a little longer.
• Failure doesn’t mean God has abandoned you. It does mean God has a better idea.
Legal Quote
V. N. Shrikhande vs Anita Sena Fernandes on 20 October, 2010 Civil Appeal No.8983 of 2010

“If the concerned forum is prima facie satisfied that the complainant is a `consumer' as defined in Section 2(d) and there is a `defect', as defined in Section 2(f) in relation to any goods or there is `deficiency in service' as defined in Section 2(g) read with Section 2(o) and the complaint has been filed within the prescribed period of limitation then it can direct that the complaint may be proceeded with.”
The switch from trivalent to bivalent oral polio vaccine

18th December, 2015

Global Action Plan (GAP) for laboratory containment

• Phase I: Preparation for containment of poliovirus type 2
• Phase II: Poliovirus type 2 containment period
o Phase IIa: Containment of WPV2
o Phase IIb: Containment of OPV2/Sabin2 poliovirus
• Phase III: Final poliovirus containment
o Phase IIIa: Final containment of all WPV
o Phase IIIb: Final containment of all OPV/Sabin polioviruses
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The Year in Medicine 2015: News That Made a Difference
Skyrocketing drug prices in the news

Both branches of Congress in the United States have launched investigations into high drug prices. In November, a US Senate panel began a bipartisan probe into companies that have hiked prices on life-saving drugs. A House of Representatives committee said it would hold a 2016 hearing on the issue. The inquiries come as a result of huge price increases for several drugs, including a 5000% price increase for pyrimethamine (Daraprim), a decades-old drug that treats toxoplasmosis, by its manufacturer Turing Pharmaceuticals, from $13.50 to $750 a tablet. In an early campaign promise, Democratic presidential candidate Hillary Clinton said she would cap prescription drug costs at $250 per month. She also urged regulators to determine how to quickly bring lower-cost generic drugs to market. Turing has since said it would lower the price to a more reasonable level. (Medscape)
Mandrola's Top 10 Cardiology Stories 2015
Say no to bridging for most patients

The rationale for periprocedural bridging in patients taking anticoagulants is that exposing them to a higher risk of bleeding will be offset by fewer thrombotic events. Many nonrandomized observational trials had failed to show a net benefit for bridging. This year an observational study and one large randomized clinical trial demonstrated that bridging resulted in higher bleeding rates and no lowering in thrombotic events. In the observational trial, bleeding was 17 times higher with bridging. Investigators from the BRIDGE trial excluded high-risk patients with mechanical valves and previous stroke. So the answer for these patients is still not clear. For most, though, less is clearly more… (Medscape)
IMA NHB – Tamil Nadu

IMA HBI, NABH Master Training Program on NABH Entry Level Accreditation

December 18-19
IMA Marthandam Branch, Tamil Nadu

On behalf of IMA NHB along with NABH HQ, a 2-day intensive training for trainers to enable hospitals to get empowered for NABH Entry Level Accreditation was held in IMA Marthandam Hall. The faculty Dr Kashipa Pirate, Assistant Director NABH and Mrs Lallu Joseph, Principal Assessor NABH participated along with CEO Dr KK Kalra to provide this intensive training. There was an overwhelming response from various hospitals for registration and we had to forcibly close and yet 56 delegates participated in this workshop. We started at 9.00am on 18th and continued up to 7.30pm in the night and followed on 19th from 9.00am to 5.00pm. It was an enchanting training session with interactive discussions on each chapter and standards required for Entry Level Accreditation. The participants were given an in-depth understanding of the NABH accreditation and they were encouraged by the motivation talks, practical difficulties in getting NABH by Dr JA Jayalal, President-elect IMA who got full accreditation recently.

The veterans of IMA NHB Prof Dr V Varadarajan and co-ordinator of Accreditation Dr Sreedhar and many office bearers, Past Secretary Dr CN Raja, Past President Dr M Balasubramanian and President-elect Dr TN Ravisankar participated as delegates. Dr KK Kalra CEO participated in the press meet and explained the need and components of NABH Accreditation.

The valedictory function was held at 4.30pm with National President Dr A Marthanda Pillai as Chief Guest along with NABH CEO Dr KK Kalra and IMA HBI Chairman Dr RV Ashokan as Guest of Honor. Dr Pillai lauded the efforts of IMA Tamil Nadu and initiative of Dr JA Jayalal on this important training. Members were grouped in a WhatsApp group with NABH trainers from day one after the training. We presume to take up minimum 50 hospitals in this financial year and help them get accredited with entry-level NABH Accreditation with the help of these delegates who got trained and the faculties of NABH.

It was a worthy initiative of IMA Tamil Nadu. Special thanks to Dr K Kalra for providing all help and training kit to all the delegates and also the NABH official Training certificate to all the delegates. The two faculties deserve special appreciation for their untiring effort to clear all the doubts and promise to continue to support our group through WhatsApp.

Prof Dr JA Jayalal
President-elect IMA Tamil Nadu

Academic coordinator IMA CGP
Member TN Medical council

AIIMS inaugurates project to reduce waiting time for patients

The All India Institute of Medical Sciences (AIIMS) in Delhi launched an appointments system on Friday to reduce the long queues outside its outpatient department (OPD). The project, executed by the government’s National Informatics Centre (NIC) and software services firm Tata Consultancy Services Ltd (TCS), aims to reduce the waiting period from an average of six hours to two. The project was envisaged in 2014 to improve accountability and transparency at AIIMS’s OPD, making it more patient-friendly. The integration software was developed by NIC, while TCS helped complete the system by developing processes for crowd management… (LiveMint –Nikita Mehta)
IPC Code to know

IPC 306

Abetment of Suicide:
If any person commits suicide, whoever abets the commission of such suicide, shall be punished with imprisonment of either description for a term which may extend to ten years, and shall also be liable to fine.
IMA NATCON - 2015, 76th Annual Meeting of Central Council of Indian Medical Association at New Delhi
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
Cycling can cause erectile dysfunction

Age, diabetes, hypertension, obesity, high lipids, smoking, drugs, heart disease, upright cycling for more than 3 hours a week can cause erectile dysfunction (ED) in males. Those who ride bicycles for more than 3 hours a week should do so in a reclining position and not upright position. A man is considered to have ED when he cannot acquire or sustain an erection of sufficient rigidity for sexual intercourse. Any man may, at one time or another during his life, experience periodic or isolated sexual failures. The term "impotent" is reserved for those men who experience erectile failure during attempted intercourse more than 75% of the time. Heart disease increases the risk for later ED; ED also may be an early warning sign of future heart disease. Men with erectile dysfunction without an obvious cause (e.g., pelvic trauma), and who have no symptoms of heart disease, should be screened for heart disease prior to treatment since there are potential cardiac risks associated with sexual activity in patients with heart disease.

Eight of the 12 most commonly prescribed medications list impotence as a side effect and it is estimated that 25% of cases of ED are due to drugs. Depression, stress, or the drugs used to treat depression can result in ED. Neurologic causes include stroke, spinal cord or back injury, multiple sclerosis, or dementia. In addition, pelvic trauma, prostate. Surgery or priapism may cause ED.

A less obvious, but of increasing importance, has been the possible association of ED with bicycling. Anything that places prolonged pressure on the pudendal and cavernosal nerves or compromises blood flow to the penile artery can result in penile numbness and impotence. Cycling-induced impotence, is primarily a problem of serious cyclists and has been reported to occur in Norwegian men competing in a 540 km bicycle race. The penile numbness is attributed to the pressure on the perineal nerves whereas the erectile dysfunction is thought to be due to a decrease in oxygen pressure in the pudendal arteries.

Recreational cyclists, those who cycle for less than 3 hours per week and men who cycle in a reclining position avoid the sustained intense pressure on the penile nerve and artery and are less likely to experience sexual side effects. Continued cycling in a seated upright position can reduce the penile oxygen levels lasting 10 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
Don’t Sweat the Small Stuff

One day an expert in time management was speaking to a group of students and, to drive home a point, used an illustration those students will never forget. As he stood in front of the group of high–powered overachievers, he said, "Okay, time for a quiz." Then he pulled out a one–gallon, wide mouthed Mason jar and set it on the table in front of him. Then he produced about a dozen fist–sized rocks and carefully placed them, one at a time, into the jar. When the jar was filled to the top and no more rocks would fit inside, he asked, "Is the jar full?" Everyone in the class said, "Yes." Then he said, "Really?" He reached under the table and pulled out a bucket of gravel. Then he dumped some gravel in and shook the jar, causing pieces of gravel to work themselves down into the space between the big rocks.

Then he asked the group once more, "Is the jar full?" By this time the class was on to him. "Probably not," one of them answered. Good!" he replied. He reached under the table and brought out a bucket of sand. He started dumping the sand in the jar and it went into all the spaces left between the rocks and the gravel. Once more he asked the question, "Is the jar full?" No!" the class shouted. Once again he said, "Good!" Then he grabbed a pitcher of water and began to pour it in until the jar was filled to the brim. Then he looked at the class and asked, "What is the point of this illustration?" One eager student raised his hand and said, "The point is, no matter how full your schedule is, if you try really hard you can always fit some more things in!"

“No," the speaker replied, "That’s not the point. The truth this illustration teaches us is: If you don’t put the big rocks in first, you’ll never get them in at all. What are the ‘big rocks’ in your life? "Your children… Your loved ones… Your education… Your dreams… A worthy cause… Teaching or mentoring others… Doing things that you love… Time for yourself… Your health… Your significant other." "Remember to put these BIG ROCKS in first or you’ll never get them in at all. If you sweat the little stuff (the gravel, the sand) then you’ll fill your life with little things to worry about that don’t really matter, and you’ll never have the real quality time you need to spend on the big, important stuff (the big rocks).

So, tonight or in the morning, when you are reflecting on this short story, ask yourself this question: What are the ‘big rocks’ in my life? Then, put those in your jar first."
Which one of the following is a recognized x-ray feature of rheumatoid arthritis?

1. Juxta-articular osteosclerosis.
2. Sacroilitis.
3. Bone erosions.
4. Peri-articular calcification.

Yesterday’s Mind Teaser: High resolution computed tomography of the chest is the ideal modality for evaluating:

1. Pleural effusion.
2. Interstitial lung disease.
3. Lung mass.
4. Mediastinal adenopathy.

Answer for Yesterday’s Mind Teaser: 2. Interstitial lung disease.

Answers received from: Dr.K.Raju, dr poonam chablani, Daivadheenam Jella, Dr.Bitaan Sen & Dr.Jayashree Sen

Answer for 26th December Mind Teaser: 4. Phenobarbitone with a pKa of 7.2 is largely ionized at acid pH and will be about 40% non-ionised in plasma.

Answers received from:Dr.K.Raju, dr poonam chablani, Daivadheenam Jella
Readers column
Nice compilation Prof S Arulrhaj a genius with plenty of vision and advance planning. Regards. Satish Chugh
What’s for Dinner?

I have my changed my system for labeling homemade freezer meals. I used to carefully note in large clear letters, "Meatloaf" or "Pot Roast" or "Steak and Vegetables or "Chicken and Dumplings" or "Beef Pot Pie." However, I used to get frustrated when I asked my husband what he wanted for dinner because he never asked for any of those things. So, I decided to stock the freezer with what he really likes. If you look in my freezer now you’ll see a whole new set of labels. You’ll find dinners with neat little tags that say: "Whatever," "Anything," "I Don’t Know," "I Don’t Care," "Something Good," or "Food." My frustration is now reduced because no matter what my husband replies when I ask him what he wants for dinner, I know that it is there waiting.
Press Release
76th Annual Meeting of Central Council of IMA held in New Delhi

The 76th Annual meeting of Central Council of Indian Medical Association (IMA) was organised today at Hotel Le Meridien, New Delhi. Addressing a gathering over 1000 Central Council members of IMA, Mr Sidharth Luthra, Former Solicitor General, Govt. of India said that there should be uniform procedure for handling cases of medical negligence against doctors. The landmark judgement by the Supreme Court of India in Jacob Mathew v. State of Punjab should be followed by the police authorities in letter and spirit. The Medical council of India (MCI) should be given more powers to handle such situations.

Dr A Marthanda Pillai, National President and Dr SS Aggarwal, President (Elect) said in a joint statement that IMA will come out with standard protocols for common diseases. Addressing the gathering, Dr KK Aggarwal Honorary Secretary General IMA said that IMA will be updating the MCI Code of Ethics, Doctor-Pharma relationship and the relationship of doctors with allied segments like Nurses and Chemists.

The meeting will conclude tomorrow with an address by Shri JP Nadda, Hon’ble Union Minister of Health and Family Welfare.

Dr SS Aggarwal from Jaipur will take over as National President IMA in the installation meeting to be held on December 28, 2015.