April 2  2015, Thursday
editorial
Summer Diarrhea Treatment
Dr KK AggarwalMost summer diarrhea is watery, effortless and painless diarrhea with no mucous or blood. They need no antibiotics. The only treatment is oral rehydration solution.

One loose motion is equivalent to loss of one glass of fluid. If a patient has passed 10 loose motions, he needs 12 glasses of ORS apart from normal requirement of fluids and one glass for every loose motion passed again.

For up to 12 loose motions, a patient can be managed as an outpatient but if the loose motions are more than 12 he needs observation and if the numbers of loose motions are more than 40, he needs intensive treatment.

The main complication is renal shut down, which occurs if the blood pressure remains low for more than few hours. During diarrhea, one should make sure that he or she passes urine every 6–8 hours. If no urine is passed for eight hours, this may indicate an impending renal failure.
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IMA-GFATM RNTCP PPM Annual Review National Workshop (29th March 2015)
News
  • The American Academy of Sleep Medicine (AASM) has taken the first steps to develop measures to help evaluate the quality of care for five common sleep disorders: restless legs syndrome (RLS), insomnia, narcolepsy, obstructive sleep apnea (OSA) in adults and OSA in children. The report is published in the current issue of the Journal of Clinical Sleep Medicine.
  • Ivermectin cream 1% is significantly more effective than metronidazole cream 0.75% in the treatment of papulopustular rosacea, suggests a new study presented at the American Academy of Dermatology 73rd Annual Meeting.
  • During inpatient medical emergencies, intraosseous access can have a significantly higher first-attempt success rate and significantly shorter placement time compared to landmark guided central venous catheterization, with fewer complications, suggests a recent study published online in Critical Care Medicine.
  • Tacrolimus and infliximab may help some patients with severe ulcerative colitis (UC) avoid colectomy, suggests new research published online in BMJ Open Gastroenterology.
  • A study presented at the American Academy of Orthopaedic Surgeons 2015 Annual Meeting has shown that the risk for heterotopic ossification after hip arthroscopy is 11 times lower when the nonsteroidal anti-inflammatory drug (NSAID) naproxen is used.
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Dr KK Spiritual Blog
Why are Doctors called God?

Modern medicine is only couple of hundred years old. Prior to that traditional medicine was used based on the local needs of the country; the oldest of them being the Indian Ayurvedic system of medicine originating from the Atharveda.

Doctors in India, since Vedic times, have been equated to God. This has continued today even after modern medicine has taken over. No other profession whether priests, lawyers, judges, politicians, commands the same status as that of medical doctors. Medical profession is the noblest profession.

The role of a doctor is to remove the miseries and save the life of a person and that is one reason most of us think that a medical doctor has been given designation equivalent to that of God. But it has many other perspectives also.

A common man’s perspective of God is a force, which can do and undo anything, for whom nothing is impossible, who is the final decision maker, whose decision cannot be challenged, who can give an instantaneous relief, who can punish and reward and he who overcomes miseries. He can also answer the unknown as he is supposed to know everything. In Bhagwad Gita and other Vedic texts, GOD is equated to consciousness, a network of energized information, a force which cannot be burnt by fire, wet by water, dried by air or cut by weapon; a force which is omnipotent, omnipresent and omniscient and still ever–pervading.

A trained qualified medical doctor who has his understanding based on the mind, body and soul has nearly the same characteristics. He overcomes miseries, mystifies his presence as soon as he touches the patient, gives immediate relief, which begins right from the time he gives a healing touch to the patient, his decision often is considered final and his decisions are almost predictable to 100%.

God is the person on whom one has blind belief and faith. At the time when a person is sick or in acute emergency the same belief and faith in doctors is seen.

Deepak Chopra in his book ‘How to Know God’ has explained God of different levels. According to him, God is a person from amongst the society with one step higher level of consciousness. He describes, as per the Vedic text, seven different levels of consciousness a person can posses and they are at the level of fight and flight, reactive consciousness, restful alertness consciousness, intuitive consciousness, creative consciousness, sacred consciousness and unified consciousness. If we take this as the classification then even a ruler of the society may be considered God by many people. But if you take universal criteria then a person who has achieved sainthood, who sees the same consciousness in everybody, treats individuals without caste, creed and religion, who overcomes miseries of people irrespective of their age, status or paying capacity is GOD. A doctor fits into these criteria.

For him every patient is same and his job is to remove his or her miseries at that particular moment. Probably, this is another reason why doctors have been regarded as God at every level of perception and from every segment of the society.

Most people have fear of death, fear of unknown, fear of loss and fear of disability. Whenever there is an unknown fear they think of God. A medical doctor is also remembered whenever there is a health crisis.

Ayurvedic text clearly describes chapters & chapters on the subject ‘how to predict death’. It describes symptoms, which, if present, with certainty one can say that this person is going to die in how many hours, days, months or years. That level of prediction gives public a feeling that doctors are God because they have seen doctors for thousands of years giving verdict that this person is not going to survive after a particular period and that used to happen.

According to Bible every work God does he does through his messenger. Medical doctors are the only certified universal messenger of God in the society. Rest all become God for a particular period, for a particular instance or a particular person.

Health is not mere absence of disease but a state of physical, mental, social, spiritual, environmental and financial well being. This definition fully was used by the Eastern philosophy and Eastern pathies. Modern doctors, however, practice more often an instant practice with emphasis on quick treatment, handling acute emergencies and lifestyle illnesses. They hardly take mental and spiritual health into consideration. That may be one reason why slowly people are withdrawing the status of God from the doctors. They have started equating a medical doctor with any other marketing profession.

Out of four purposes of life: dharma, artha, kama and moksha, dharma is the most important. The literal meaning of dharma is to hold. God is the force with 100% dharma in his life. Dharma of a doctor is to treat and save the life of a person at any cost. One recalls the movie Achanak where the doctor saved the life of a person who has been sentenced to death and the day he saves him the police officer takes him for hanging. The movie ends with a message that a doctor has to do his dharma and police officer has to do his.

At the time of miseries, a doctor is treated as a healer. Nobody bothers whether the doctor came from which religion, caste, race or whether the doctor is male, female or from third gender. People do not bother about the ill habits or out of profession activities of the doctor; they are only concerned about the fact that doctor is a universal healer and overcomes the miseries of everybody who approaches him. A doctor provides free treatment to those who cannot afford or comes to an emergency ward without any money.

Putting doctors under Consumer Protection Act is the biggest blunder done by the government. How can one make God accountable? Can a child born blind at birth abuse or curse God for making him blind?

I think all of us should introspect and remember that doctor is the messenger of God born to remove miseries of the sick individuals.
Quote of the Day
The will to win, the desire to succeed, the urge to reach your full potential... these are the keys that will unlock the door to personal excellence. Confucius
Beneficiaries of Sameer Malik Heart Care Foundation Fund
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Cardiology eMedinewS
  • A new retrospective study of patients with type 2 diabetes taking metformin and sulfonylureas and newly treated with either a dipeptidyl peptidase 4 (DPP-4) inhibitor or insulin as third-line therapy has revealed that adding insulin was associated with an increased risk of cardiovascular events compared with the DPP-4 inhibitor. The results were presented at the recent Diabetes UK Professional Conference.
  • Adding peanuts to a meal possibly benefits vascular health, suggests new research presented at the American Society for Nutrition's Scientific Sessions & Annual Meeting during Experimental Biology 2015.
Pediatrics eMedinewS
  • A neuroimaging study provides additional evidence that prenatal exposure to common air pollutants (polycyclic aromatic hydrocarbons) may contribute to cognitive and behavioral impairment in children. The findings are published online in JAMA Psychiatry.
  • Ebola is more deadly for children under the age of 5 years than for older children and adults, suggests new research published in the New England Journal of Medicine.
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Make Sure
Situation: In an STD clinic, a 23–year–old heterosexual male presenting with dysuria and urethral discharge was prescribed azithromycin to cover a suspected Chlamydia trachomatis infection.
Reaction: Oh my God! Why didn’t you advise the same treatment for his partner also?
Lesson: Make sure to remember that in such cases, it is essential that both the partners are treated.
Dr Good Dr Bad
Situation: A patient on Mediclaim developed a recurrence of illness after three months.
Dr. Bad: It will not be covered under Mediclaim.
Dr. Good: Yes, it will be covered as it is a fresh illness.
Lesson: Occurrence of the same illness after lapse of 105 days from the date of discharge from the Hospital / nursing home from where the treatment was taken is considered as fresh illness for the purpose of Mediclaim policy.

(Copyright IJCP)
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eMedi Quiz
Injury to radial nerve in lower part of spiral groove:

1. Spares nerve supply to extensor carpi radialis longus.
2. Results in paralysis of anconeus muscle.
3. Leaves extension at elbow joint intact.
4. Weakens pronation movement.

Yesterday’s Mind Teaser: The cells belonging to the following type of epithelium are provided with extra reserve of cell membrane:

1. Transitional
2. Stratified squamous
3. Stratified cuboidal.
4. Stratified columnar.

Answer for yesterday’s Mind Teaser: 1. Transitional
Correct Answers received from: Viswanatha Sarma, Dr G Madhusudhan, Daivadheenam Jella, Dr Avtar Krishan
Answer for 31st March Mind Teaser: 3. Lateral rectus and abducent nerve.
Correct Answers receives: Dr Madhusudhan G, Daivadheenam Jella, Dr Avtar Krishan, Raju Kuppusamy.
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
More Suggestions for Medical Emblem
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IMA NEWS
Sonal Namaste
Hand hygiene is as important in the community as in the hospital.
Facts about Tuberculosis (TB)
Is XDR TB treatable?

XDR-TB is even more difficult to treat successfully, as there are very few drugs left to which the organism is still sensitive. Due to this, XDR-TB is often referred to as “virtually untreatable form of TB”.
'India must build on polio drive experience to tackle measles'
The Indian Medical Association (IMA) today emphasised that India should build on its polio eradication campaign experience to ensure more children get vaccinated against measles.

PTI | 31 March 2015, 7:27 PM IST

The Indian Medical Association (IMA) today emphasised that India should build on its polio eradication campaign experience to ensure more children get vaccinated against measles.

Addressing a press conference on the occasion of Measles Immunisation Day today, IMA National President Dr A Marthanda Pillai and Secretary General Dr KK Aggarwal said, "India should build on its polio eradication campaign experience to said ensure more children get vaccinated against measles."

"In a single polio vaccine strategy 2.3 million vaccinators should go door-to-door, visiting 191 million homes to vaccinate 172 million children a year," they said in a joint statement.

March 31 is observed as Indian Medical Association's Measles Immunisation Day.

"Measles is still one of the leading causes of death in young children. A highly contagious disease, measles spreads like wildfire in communities where children are unvaccinated. Since the virus reduces immunity, children who have had measles - especially those who are undernourished - may die of pneumonia, diarrhea and encephalitis later on.

"More than one third of all measles deaths worldwide (around 56,000 in 2011) are among children in India. Awareness needs to be created about the need and safety of measles vaccination. 4 per cent of the under five mortality in India is due to measles," said Dr Anupam Sachdeva, Chairman, Pediatrics, Director, Pediatric Hematology Oncology at Sir Ganga Ram Hospital.

Every year around 3 million cases of measles are seen and about 900,000 children die because of measles around the world. In India everyday, 500 children die because of measles.

"All unvaccinated newborns are at danger from measles. Usually children become susceptible to measles around the age of nine months, probably because they are protected up to this period by the antibodies against measles, received from their mothers," said Dr Ajay Gambhir, Head Neonatology and Pediatrics, Saroj Hospital and Heart Institute. (MORE) PLB SMN
Conference Update
Prevention and pharmacological management of no-reflow
Dr Haresh G Mehta, Mumbai
  • Most patients present late, not within the golden hour.
  • Angiographic no-reflow is defined as TIMI 0-1 in absence of spasm, stenosis, dissection or thrombus of the pericardial vessel.
  • It is observed in unstable coronary syndromes, but can be seen in stable angina also.
    About 25-30% of AMI treated with primary or rescue angioplasty may have no-reflow with potentially adverse outcomes.
  • Pathophysiology: microvasculature damage
  • Diagnosis by myocardial contrast echo, myocardial scintigraphy, cardiac MRI.
  • Diagnosis with surrogates: ST segment analysis at ECG, myocardial blush grade at coronary angiography.
  • TIMI perfusion grades: Grade 0 has the highest mortality; grade 3 has the lowest, so it is important to establish flow rapidly.
  • Intra coronary vasodilator so for no reflow: verapamil, adenosine, sodium nitroprusside, NTG, epinephrine; NTG is the weakest of the lot; NTP is potent and longer acting
  • Dose: Epinephrine intracoronary dose 50-100 μg, NTG boluses of 100-200 µg up to 4 doses, Adenosine boluses of 20-60 µg up to 2400 μg
  • Refractory no-reflow: IC epinephrine if patient is hypotensive; TPA 10-20 mg in thrombotic lesions.
  • Management of no-reflow: Maintain a normal BP and rhythm; we have to have a sinus rhythm to get better outcomes. Exclude mechanical causes fir impaired flow such as thrombus, dissection at angioplasty or stent site
  • To prevent reflow: anticipate the problem, avoid pre dilatation, avoid post dilatation of the stent, use thrombosuction pre and post as per thrombus load, use drugs judiciously preferably via micro catheter, maintain diastolic BP to augment coronary flow, use vasodilators frequently or high doses.
OCT in ACS
Dr K Latchumanadas, Chennai
  • You cannot predict who will have an uncovered strut.
  • Continue DAP if no complications especially if they are diabetic.
Role of routine thrombectomy in AMI
Dr Prabhakar Shetty,
Bangalore
  • Routine aspiration thrombectomy in STEMI prevents distal embolism, lowers the incidence of no-reflow, reduces atherosclerotic burden, visualization of coronary anatomy, facilitates direct stent deployment: it is economical.
  • Aspiration thrombectomy is safe; no study has shown adverse effect. Surrogate endpoints such as ST resolution and MBG have shown consistent improvements in all trials; mortality benefit at 1 year; it decreases the number and length of the stent. There is a strong trend towards lower incidence of SAT and re MI.
  • Guidelines: manual thrombus aspiration is reasonable for patients undergoing primary PCI (class IIa) 2011 ACCF/AHA/SCAI PCI, 2013 ACCF/AHA STEMI, 2012 ESC STEMI
  • TASTE trial supports thrombus aspiration (favorable trends in all clinical end points, 60% decrease in relative risk reduction in stent thrombosis at 30 days; 40% reduction in acute MI at 30 days); supports thrombosuction (decrease in the number and length of stents, difficult to show mortality benefit in low risk AMI subset, no increase in stroke risk)
  • TASTE trial Limitations: Registry based, 4697 patients not randomized, ascertainment bias, high risk patients under represented, use of 6F aspiration catheter
  • Ongoing US-based trial: TOTAL (ThrOmbecTomy with percutaneous coronary intervention (PCI) versus PCI alone in patients with STEMI undergoing primary PCI)
Role of OCT guidance in bifurcation PCI with BVS
Dr G Sengottuvelu,
Chennai
Though the advantages of bioresorbable vascular scaffolds (BVS) are promising in type A lesions, Dr Sengottuvelu said with his experience and emerging data have shown their feasibility in bifurcation lesions with good early outcomes. Being radiolucent with bulkier struts, post implantation, their results need to be assessed by appropriate intravascular imaging techniques for optimal outcomes particularly in complex lesions. He showed in their experience that “challenges in bifurcation lesions while using BVS is to obtain optimal expansion without exceeding the recommended BVS limits and Snuggle balloon dilatation helps achieve this in bifurcation lesions as opposed to traditional kissing balloon’. Their initial experience in using ABSORB BVS in bifurcation lesions with different strategies showed it is safe to jail the side branch and Provisional T stenting strategy and in selected cases TAP technique is feasible with OCT showing optimal deployment with good outcome.
The strategy of high pressure snuggle has shown promising intermediate term outcome with good apposition seen by OCT imaging. Dr Sengottuvelu showed in his presentation fascinating 3D OCT reconstruction images of BVS implantation in complex bifurcations showing excellent results.
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Reader Response
With respect to Smokeless Tobacco ban in Delhi, it is a very good news and all other states should follow suit. But I am distressed with apathy of all Governments in banning cigarettes. Even IMA seems to be lukewarm to this agenda. Is it due to the influential cigarette lobby and are the effects of smoking less in comparison to chewing tobacco? Is there any logical explanations for this? Govind Lal Sharma
Inspirational Story
To Risk
  • To laugh is to risk appearing a fool.
  • To weep is to risk appearing sentimental.
  • To reach out to another is to risk involvement.
  • To expose feelings is to risk exposing your true self.
  • To place your ideas and dreams before a crowd is to risk their loss.
  • To love is to risk not being loved in return.
  • To live is to risk dying.
  • To hope is to risk despair.
  • To try is to risk failure.
But risks must be taken because the greatest hazard in life is to risk nothing. The person who risks nothing, does nothing, has nothing is nothing.

He may avoid suffering and sorrow, but he cannot learn, feel, change, grow or live. Chained by his servitude he is a slave who has forfeited all freedom. Only a person who risks is free. The pessimist complains about the wind, the optimist expects it to change and the realist adjusts the sails.
Wellness Blog
Women above 65 to take extra care of their health
  • Women aged 65 and above should take low dose aspirin routinely to prevent heart attack and paralysis.
  • All women are urged to exercise a minimum of 30 minutes per day, but women who need to lose weight or maintain weight loss are now advised to engage in 60 to 90 minutes of moderate–intensity activity on most, or preferably all, days of the week.
  • A heart–healthy diet should be rich in fruits, whole grains and fiber foods with a limited intake of alcohol and sodium.
  • Saturated fat should be reduced to less than 7 percent of calories.
  • Women at very high risk for heart disease should try to lower their LDL ("bad") cholesterol to less than 70 mg/dL.
  • Women aged 65 and over should consider taking low-dose aspirin on a routine basis, regardless of their risk.
  • Aspirin has been shown to prevent both heart attacks and stroke in this age group.
  • The upper dose of aspirin for high-risk women is 325 mg per day.
  • Hormone replacement therapy, selective estrogen receptor modulators and/or antioxidant supplements such as vitamins C and E should not be used to prevent heart disease.
  • Folic acid should also not be used to prevent cardiovascular disease.
  • Women should eat oily fish or some other source of omega–3 fatty acids at least twice a week.
  • Women should not only quit smoking but should use counseling, nicotine replacement or other forms of smoking cessation therapy.
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IMA Humor
For crying out loud

With all the new technology regarding fertility, an 88–year–old woman was able to give birth to a baby recently. When she was discharged from the hospital and went home, various relatives came to visit.

"May we see the new baby?" one of them asked. "Not yet," said the mother. "I’ll make coffee and we can visit for a while first." Another half hour passed before another relative asked, "May we see the new baby now?"

"No, not yet," said the mother. A while later and again the guests asked, "May we see the baby now?" "No, not yet," replied the mother.

Growing impatient, they asked, "Well, when can we see the baby?"

"When it cries!" she told them.

"When it cries?" they gasped. "Why do we have to wait until it cries?"

"Because, I forgot where I put it."
Hypertension that is resistant to treatment
Blood pressure that remains above the target level despite taking three medications to lower it is called resistant hypertension. High blood pressure that is under control but requires four or more medications to treat it, is also considered resistant to treatment.

As many as 25 to 30% people with high blood pressure may have resistant hypertension in India said Padma Shri, Dr. B C Roy National Awardee & DST National Science Communication Awardee, Dr K K Aggarwal, President Heart Care Foundation of India and Honorary Secretary General IMA.

Older age and obesity are two major risk factors for the condition. People with resistant hypertension have a high cardiovascular risk.

Successful treatment of resistant hypertension requires consideration of lifestyle factors, diagnosing and treating secondary causes, and using multiple drug treatments effectively. Lifestyle factors include weight, salt intake and alcohol consumption.
  • Losing weight can lower blood pressure and reduce the number of medications needed to control blood pressure.
  • Reducing salt intake can lower blood pressure.
  • Reducing alcohol consumption can help lower blood pressure.
Health conditions that can contribute to resistant hypertension include: obstructive sleep apnea, renal parenchymal disease, primary aldosteronism and renal artery stenosis. Treating these conditions may improve blood pressure control.

Drugs that increase blood pressure, such as non-steroidal anti-inflammatory drugs (NSAIDs), should be reduced or halted, if possible, in patients with resistant hypertension.

Diuretics are often underused in people with resistant hypertension. Patients may benefit from adding mineralocorticoid receptor antagonists (MRAs) to their treatment regimens. MRAs treat primary aldosteronism, which is found in about 20 percent of people with resistant hypertension.
Rabies News (Dr A K Gupta)
What are monoclonal antibodies?

Monoclonal antibodies are important reagents used in biomedical research, in diagnosis of diseases, and in treatment of such diseases as infections and cancer. These antibodies are produced by cell lines or clones obtained from animals that have been immunized with the substance that is the subject of study. The cell lines are produced by fusing B cells from the immunized animal with myeloma cells.