May 2  2015, Saturday
editorial
All about depression
Dr KK Aggarwal
  • Depression is a major public health problem as a leading predictor of functional disability and mortality.
  • Optimal depression treatment improves outcome for most patients.
  • Most adults with clinical significant depression never see a mental health professional but they often see a primary care physician.
  • A non–psychiatric physician 50% of times misses the diagnosis of the depression.
  • All depressed patients must be enquired specifically about suicidal ideations.
  • Suicidal ideation is a medical emergency
  • Risk factors for suicide are psychiatric known disorders, medical illness, prior history of suicidal attempts or family history of attempted suicide.
  • The demographic reasons include older age, male gender, marital status (widowed or separated) and living alone.
  • About 1 million people commit suicide every year globally.
  • Around 79% of patients who commit suicide contact their primary care provider in the last one year before their death and only one-third contact their mental health service provider.
  • Twice as many suicidal victims had contacted their primary care provider as against the mental health provider in the last month before suicide.
  • Suicide is the 10th leading cause of death worldwide and accounts for 1.2% of all deaths.
  • The suicide rate in the US is 10.5 per 100,000 people.
  • In the US, suicide is increasing in middle aged adults.
  • There are 10–40 non–fatal suicide attempts for every one completed suicide.
  • The majority of suicides completed in US are accomplished with fire arm (57%), the second leading method of suicide in US is hanging for men and poisoning in women.
  • Patients with prior history of attempted suicide are 5–6 times more likely to make another attempt.
  • Fifty percent of successful victims have made prior attempts.
  • One of every 100 suicidal attempt survivors will die by suicide within one year of the first attempt.
  • The risk of suicide increases with increase in age; however, young adults and adolescents attempt suicide more than the older.
  • Females attempt suicide more frequently than males but males are successful three times more often.
  • The highest suicidal rate is amongst those individuals who are unmarried followed by those who are widowed, separated, divorced, married without children and married with children in descending order.
  • Living alone increases the risk of suicide.
  • Unemployed and unskilled patients are at higher risk of suicide than those who are employed.
  • A recent sense of failure may lead to higher risk.
  • Clinicians are at higher risk of suicide.
  • The suicidal rate in male clinicians is 1.41 and in female clinicians it is 2.27.
  • Adverse childhood abuse and adverse childhood experiences increase the risk of suicidal attempts.
  • The first step in evaluating suicidal risk is to determine presence of suicidal thoughts including their concerns and duration.
  • Management of suicidal individual includes reducing mortality risk, underlying factors and monitoring and follow up.
  • Major risk for suicidal attempts is in psychiatric disorder, hopelessness and prior suicidal attempts or threats.
  • High impulsivity or alcohol or other substance abuse increase the risk.
IMA,IJCP,HCFI
eMedipics IMA,IJCP,HCFI
Team IMA at Nepal
News
  • Some preliminary studies suggested that garlic might lower blood cholesterol levels slightly. But one study on the safety and effectiveness of three garlic preparations (fresh garlic, dried powdered garlic tablets, and aged garlic extract tablets) found no effect on cholesterol levels.
  • Intensive management of type 1 diabetes can reduce the risk of having a diabetes-related eye surgery by nearly 50 percent.
  • Fewer pregnant women had cesarean section births in Canadian hospitals that took part in a C-section review program The intervention program included onsite training in best-practice guidelines for C-sections.
  • No one completely understands why or how heart failure increases the risk of atrial fibrillation (Afib). But it is abundantly clear that the risk increases with the severity of structural disease.
IMA,IJCP,HCFI
Extra skeletal benefits of vitamin D
  • There is geographic and racial variation in blood pressure, with risk of hypertension increasing from south to north in the Northern hemisphere. One proposed explanation for the association with latitude is that exposure to sunlight may be protective, either because of an effect of ultraviolet radiation or of vitamin D
  • In normotensive and hypertensive individuals, there is an inverse association between 25-hydroxyvitamin D (25(OH)D) concentration and blood pressure
  • A meta-analysis of eight randomized trials examining the effects of vitamin D supplementation on blood pressure in hypertensive (=140/90 mmHg) men and women showed a small but significant reduction in diastolic blood pressure (J Hypertens 2009; 27:1948.)
  • A subsequent trial in 283 black adults (approximately 50 percent with hypertension) showed that vitamin D supplementation significantly decreased systolic blood pressure (Hypertension 2013; 61:779.)
  • In a meta-analysis of 19 prospective studies (65,994 patients), there was an inverse relationship between serum 25(OH)D levels (ranging from 8 to 24 ng/mL (20 to 60 nmol/L)) and risk of cardiovascular disease (relative risk (RR) of 1.03, 95% CI 1.00-1.60, per 10 ng/mL (25 nmol/L) decrement in serum 25(OH)D) (Circ Cardiovasc Qual Outcomes 2012; 5:819.)
  • In the National Health and Nutrition Examination Study (NHANES) 2001 to 2004, the prevalence of coronary heart disease (angina, myocardial infarction) was more common in adults with 25(OH)D levels <20 ng/mL compared with =30 ng/mL Am J Cardiol 2008; 102:1540.
  • Vitamin D status is lower in individuals with obesity and with type 2 diabetes, but the causality of this relationship is unknown.
  • In nearly all human studies, obesity is associated with low 25(OH)D concentrations (101).
  • A large genetic study of more than 40,000 individuals showed that higher body mass index (BMI; and the genes that predispose for obesity) decreases serum 25(OH)D levels, whereas lower 25(OH)D levels (or the genes that are associated with reduced serum concentration of 25(OH)D) have, at most, very small effects on obesity (Postgrad Med J 2010; 86:18.).
  • A meta-analysis of 21 prospective studies showed an inverse relationship between circulating 25(OH)D levels and the risk of type 2 diabetes (relative risk (RR) 0.62, 95% CI 0.54-0.70, for patients with the highest versus lowest category of 25(OH)D levels) (Diabetes Care 2013; 36:1422.).
  • Low levels of 25-hydroxyvitamin D (25(OH)D) are frequently found in patients with depression or Alzheimer’s disease
  • In a meta-analysis of 31 studies, insufficient serum 25-hydroxyvitamin D (25(OH)D) concentrations were associated with a higher risk of gestational diabetes, pre-eclampsia, and small for gestational age infants (BMJ 2013; 346:f1169.).
  • However, the absence of a dose response relationship between serum 25(OH)D and reported complications and the inclusion of studies that measured the 25(OH)D levels with variable precision raise significant doubt about the effects of vitamin D deficiency on the reported outcomes.
  • Epidemiologic studies suggest that low 25-hydroxyvitamin D (25(OH)D) levels (especially <10 to 20 ng/mL (25 to 50 nmol/L)) are associated with higher mortality.
Dr KK Spiritual Blog
What are Satvik offerings in Vedic literature?
  1. Food Offerings: Panchashasha (grains of five types – brown rice, mung or whole green gram, til or sesame, mashkalai (white urad dal) or any variety of whole black leguminous seed, jowar or millet)
  2. Panchagobbo (Five items obtained from cow: milk, ghee or clarified butter, curd, cowdung and gomutra), curd, honey, brown sugar, three big noibiddos, one small noibiddo, three bowls of madhupakka (a mixture of honey, curd, ghee and brown sugar for oblation), bhoger drobbadi (items for the feast), aaratir drobbadi mahasnan oil, dantokashtho, sugar cane juice, an earthen bowl of atop (a type of rice), til oil (sesame oil).
  3. Water offerings: Ushnodok (lukewarm water), coconut water, sarbooushodhi, mahaoushodhi, water from oceans, rain water, spring water, water containing lotus pollen.
  4. Three aashonanguriuk (finger ring made of kusha).
  5. Puja Items: Sindur (vermillion), panchabarner guri (powders of five different colours – turmeric, rice, kusum flowers or red abir, rice chaff or coconut fibre burnt for the dark colour, bel patra or powdered wood apple leaves), panchapallab (leaves of five trees – mango, pakur or a species of fig, banyan, betal and Joggodumur or fig), pancharatna (five types of gems – gold, diamond, sapphire, ruby and pearl), panchakoshay (bark of five trees– jaam, shimul, berela, kool, bokul powdered in equal portions and mixed with water), green coconut with stalk, three aashonanguriuk (finger ring made of kusha).
Cardiology eMedinewS
  • Three years after transcatheter aortic-valve replacement (TAVR), 61% of individuals with severe symptomatic aortic stenosis who receive the new valve remain alive, reported data from the UK Transcatheter Aortic Valve Implantation (TAVI) Registry published in JACC: Cardiovascular Interventions.
  • Women who undergo breast cancer radiotherapy do not face an increased risk for subsequent heart conduction problems requiring a pacemaker as a result of their treatment, suggests new research reported at the European Society for Radiotherapy and Oncology (ESTRO) 3rd Forum.
Pediatrics eMedinewS
  • The recommendation from physicians that 11- and 12-year-old girls receive the human papillomavirus (HPV) vaccine is often not strong enough, and is certainly not as strong as it is for 13- to 15-year-old girls, suggests new research presented at the Pediatric Academic Societies (PAS) 2015 Annual Meeting.
  • Girls may be diagnosed with autism spectrum disorder (ASD) later than boys because their symptoms are less severe, points new research presented at the Pediatric Academic Societies (PAS) annual meeting.
Make Sure
Situation: A patient with pyogenic meningitis developed complications.

Reaction: Oh my God! Why was an antibiotic not given when meningitis was suspected?

Lesson: Make sure that the first dose of antibiotic is given at the time when meningitis is suspected.
Dr Good Dr Bad
Situation: A patient of CAD developed dengue.
Dr Bad: Start paracetamol.
Dr Good: Start paracetamol and stop low–dose aspirin.
Lesson: In dengue, lose–dose aspirin needs to be stopped.
(Copyright IJCP)
eMedi Quiz
The commonest variation in the arteries arising from the arch of aorta is:

1.Absence of brachiocephalic trunk.
2.Left vertebral artery arising from the arch.
3.Left common carotid artery arising from brachiocephalic trunk.
4.Presence of retroesophageal subelavian artery.

Yesterday’s Mind Teaser: All of the following regarding aromatase inhibitors are correct except

1. Unlike tamoxifen, AI's are associated with an increased risk of endometrial cancer.
2. AI's have been shown to reduce bone density, and increase the risk of fractures.
3. Aromatase inhibitors are not indicated in premenopausal women.
4. The musculoskeletal symptoms associated with the AI's are transient.

Answer for yesterday’s Mind Teaser: 1. Unlike tamoxifen, AI's are associated with an increased risk of endometrial cancer.
Correct Answers received from: Dr Avtar Krishan, Dr Jainendra Upadhyay, Daivadheenam Jella, Dr. G. Madhusudhan.
Answer for 30th April Mind Teaser: A. Hypertension and aging
Correct Answers received: Dr Poonam Chablani, Dr KV Sarma, Dr K Raju, Dr Madhusudhan G.
IMA,IJCP,HCFI
Quote of the Day
If we wait until our lives are free from sorrow or difficulty, then we wait forever. And miss the entire point. Dirk Benedict
eMedinewS Humor
Getting Rid of the Problem

A farmhand is driving around the farm, checking the fences. After a few minutes he radios his boss and says, "Boss, I’ve got a problem. I hit a pig on the road and he’s stuck in the bull–bars of my truck. He's still wriggling. What should I do?"

"In the back of your truck there’s a shotgun. Shoot the pig in the head and when it stops wriggling you can pull it out and throw it in a bush." The farm worker says okay and signs off. About 10 minutes later he radios back. "Boss I did what you said, I shot the pig and dragged it out and threw it in a bush."

"So what’s the problem now?" his Boss snapped.

"The blue light on his motorcycle is still flashing!"
Rabies News (Dr A K Gupta)
How should you approach a patient requiring RIGs, when none is available?
  1. Thorough wound cleansing.
  2. ESSEN IM vaccination with double dose on day 0 and refer the patient to RIG center.
IJCP Book of Medical Records
IJCP’s ejournals
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
eIMA News
Team IMA Nepal Initiative:
Team IMA saw 400 patients today.

5 surgeries were done.

Tomorrow three teams will go in different directions in remote areas to do service. Manipal team joined hands with IMA team today

Dialysis patients got 20 times more cardiopulmonary resuscitation (CPR) in the hospital than other admitted patients and had far worse long-term survival afterward, a Medicare study showed.

The rate was 6.3% among more than 600,000 patients with end-stage renal disease studied (for an annual incidence of 1.4 per 1,000 hospital days) compared with 0.3% in a sample of other hospitalized patients. (April 27 in JAMA Internal Medicine.)
  • IMA Banaras Branch team reached Kathmandu today at 5pm. Dr. Arvind Singh, Hon.Sec., IMA Banaras Branch
Subject :- Regarding Post Graduated Degree of University of Seychelles by correspondence course.

It has been noticed that in recent years many medical Graduates particularly who have obtained Post Graduate Diploma of college of Physicians and Surgeons Mumbai are displaying Post Graduate Degree of University of Seychelles.
  1. Whether any foreign University qualification can be displayed or used on letterhead unless it is granted certificate of additional qualification or recognized by MCI or any state medical council.
  2. Whether this degree of University of Seychelles is a proper Post Graduate Degree in medicine or a Fake Degree.
  3. Can One Claim to be a specialist in that particular field on obtaining this Post Graduate Degree of University of Seychelles.
(KRISHNA PARATE, Chairman IMA NPPS)

Answer IMA:
  1. MCI Ethics Regulations: 1.4.2 Physicians shall display as suffix to their names only recognized medical degrees or such certificates/diplomas and memberships/honours which confer professional knowledge or recognizes any exemplary qualification/achievements.
  2. 7.20 A Physician shall not claim to be specialist unless he has a special qualification in that branch.
  3. 7.20 talk about special qualification and does not talk about MCU recognized qualification. The word recognised is missing 4. 1.4.2 talks about the suffix, it talks about recognized medical degree (means MCI) but also has 'or' which is for non MCI recognised certificates
Camp Liberty- Patient dies for delay in diagnosis of sigmoid colon tumor
Letter to Editor

Dear Dr Aggarwal
,

Mr. Jalal Abedini died on Friday, 17 April 2015, of an inexplicable delay in diagnosis of sigmoid colon tumor. It is needless to emphasize that at our own hospital in previous Camp Ashraf; Colonoscopy, barium enema and C-T scans were routine procedures at our own capacity to address.

Recently former top-ranking U.S. officials (PDF) urged PM Al-Abadi “to prevent further loss of life due to lack of timely access to medical care, we urge you to direct that the government of lraq set up a hospital at Camp Liberty, under the supervision of the Ministry of Health. The residents of Camp Ashraf are prepared to pay the expense of this hospital. The residents already own much of the necessary medical equipment located in Camp Ashraf; like the force protection equipment also remaining there, and thus should be available for transfer…”

They warned that “In the past six months, there has been no measurable improvement in the conditions and dangers endured by the residents.” and pointed out that “While we recognize the difficult security challenges confronting Iraq today, the safety and protection of the Camp Liberty residents can and must be assured.”
Safety Tips for Hospital Workers
Watch for signals that may be associated with impending violence:

Verbally expressed anger and frustration

Body language such as threatening gestures

Signs of drug or alcohol use

Presence of a weapon
MCI Regulation to know:
7.18 In the case of running of a nursing home by a physician and employing assistants to help him / her, the ultimate responsibility rests on the physician.
MCI News
: N O T I C E All the visitors are requested to specify the purpose for which they want to meet with the officials of the Council. No official of any medical college is allowed to go to any section of the office. If they have any clarification or grievance, they should seek prior appointment with the President/Secretary/Chairman (Administration & Grievance Committee). By Order President, MCI

Team IMA Haryana

Team IMA Haryana would hereby like to express its profound appreciation and gratitude to your (Dr K K Aggarwal) extremely generous gesture of physically travelling from Delhi to Panipat to attend the Local IMA Haryana Branch Presidents & Secretaries Meeting on Sunday, 26th April 2015 at Panipat as the Chief Guest.

The value of our event was significantly enhanced by your sagacious guidance and advice regarding how best to handle the various burning issues that are troubling medical professionals in general and IMA members in particular in the state of Haryana. All delegates were immensely appreciative of your presence and words of wisdom and through this note we wish to convey their sentiments to you. Thank you, once more, Sir, for all your efforts.

IMA NABH initiative

IMA – NABH initiative is the flagship programme and legacy of IMA 2015

Objectives:
  • To assist hospitals to achieve international standards in patient care and safety.
  • To increase the viability of small and medium hospitals by value addition.
  • To assist hospitals to countenance CEA .
  • To provide hospitals an affordable access to accreditation.
NABH

NABH Objective is to operate accreditation and allied programs in collaboration with stakeholders focusing on patient safety and quality of healthcare. Accreditation standards for HCO were developed in 2006. However only 249 hospitals have achieved accreditation across the country as large number of hospitals face challenges and difficulties in implementing all the standards.

SHCO Approximately 50,000 health care organizations are functioning in our country out of which significant number fall under the Small Health Care Organizations which is less than 50 beds according to NABH definition. Lack of knowledge, poor insurance coverage and other challenges are the road block for enhancing the quality of care to obtain accreditation.

Entry Level Standards

To be more inclusive and encourage HCOs and SHCOs to join the quality journey, NABH has developed Pre Accreditation Entry Level standards, in consultation with various stakeholders in the country, as a stepping-stone for enhancing the quality of patient care and safety.Certification standards is divided into 10 chapters, which have been further divided into 41 standards. Put together there are 149 objective elements incorporated within these standards which is almost one-fourth of the full accreditation standards. SHCO entry level requirements focus on the most critical elements important for patient safety. This makes accreditation affordable and will encourage the hospitals to adopt quality initiative and to attain the next stage (progressive level) and eventually full accreditation. These are easily achievable, sustainable, and are equally applicable to both government and private hospitals. These standards can be adopted as minimal empanelment criteria by the insurance industry.

Breakup of standards at all levels

Patient Centered Standards
  • Access, Assessment and Continuity of Care (AAC)
  • Care of Patients (COP)
  • Management of Medication (MOM)
  • Patient Rights and Education (PRE)
  • Hospital Infection Control (HIC)
Organisation Centered standards
  • Continuous Quality Improvement (CQI)
  • Responsibilities of Management (ROM)
  • Facility Management and Safety (FMS)
  • Human Resource Management (HRM)
  • Information Management System (IMS)
Type
No. of Standards
No. of Objective Elements
Pre Accreditation Entry Level Standards for Small Health Care organisation (Less than 50 beds)
41
149

Full Accreditation Standards   For Small Health Care Organisations  (Less than 50 beds)

61
289
Pre Accreditation Entry Level Standards for Hospitals(More than 50 beds)
45
167
Full Accreditation Standards For Hospitals (More than 50 beds)
102
636

IMA’s intervention is decisive. IMA’s execution is through IMA HBI. IMA ‘s objective is to help the small and medium hospitals to survive and remain viable. Value addition with entry level NABH will empower their entitlement. IMA brings NABH entry level accreditation at much lesser cost than private players. Cost cutting will be effected through cluster formation and training in groups.

Fee - NABH (Entry level accreditation)
  • Hospitals:
    Application Fee Rs 2000/-
    Certification fee Rs 25,000/-
  • Small Health Care Organisations(SHCOs):
    Application Fee Rs 1000/-
    Certification fee Rs 10,000/-
Fee - IMA HBI (Entry level accreditation)
  • Hospitals: Rs 50,000
  • Small Health Care Organisations(SHCOs): Rs 30,000
Whom to contact
  • IMA Hospital Board of India, Sitaram Hospital, Lane No.-6,Dhule-424001,Maharashtra, raviwankhedkar@gmail.com, natsechbi@gmail.com; 09422296495
  • Chairman , IMA HBI; Dean Hospital, Punalur-691 305, Kerala, rvasokan@gmail.com, 09847061563
Sonal Namaste
Diarrhea Prevention

To reduce subsequent episodes of diarrhea, malnutrition, and delays in physical and mental development.

Recommendations
  • Exclusive breastfeeding until age six months
  • Continued breastfeeding with complementary foods until two years of age.
  • Complementary feeding may be considered in younger infants if growth is inadequate.
  • The consumption of safe food and water.
  • Water brought to a rolling boil for at least five minutes is optimal for preparing food and drinks for young children.
  • Handwashing after defecating, disposing of a child's stool, and before preparing meals.
  • The use of latrines; these should be located more than 10 meters and downhill from drinking water sources.
Media
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Inspirational Story
I Tried to Climb the Mountain Today

I tried to climb the mountain today. As I inched my way up the path, I felt overwhelmed, so I had to turn back. I tried to climb the mountain today. On my journey, darkness started to fall, and I was full of fear, so I had to return to a safe place.

I was ready to climb the mountain today. But it was so hot outside, I thought I better stay in my nice air-conditioned house and rest up for tomorrow’s attempt. I was about to climb the mountain today. But I had so many other things to do, so instead of climbing the mountain I took care of much more important tasks. I washed my car, mowed the grass and watched the big game. Today the mountain will just have to wait.

I was going to climb the mountain today. But as I stared at the mountain in its majestic beauty, I knew I stood no chance of making it to the top, so I figured why even bother trying. I have forgotten about climbing the mountain today; until a friend came by and asked me what I was up to lately. I told him I was thinking about climbing that mountain some day. I went on and on about how I was going to accomplish this task.

Finally, he said, "I just got back from climbing the mountain. For the longest time I told myself I was trying to climb the mountain but never made any progress. I almost let the dream of making it to the top die. I came up with every excuse of why I could not make it up the mountain, but never once did I give myself a reason why I could. One day as I stared at the mountain and pondered, I realized that if I didn’t make an attempt at this dream all my dreams will eventually die.""The next morning, I started my climb."

He continued, "It was not easy, and at times I wanted to quit. But no matter what I faced, I placed one foot in front of the other, keeping a steady pace. When the wind tried to blow me over the edge, I kept walking. When the voices inside my head screamed "stop!" I focused on my goal never letting it out of sight, and I kept moving forward. At times, I was ready to quit, but I knew I had come too far. Time and time again, I reassured myself that I was going to finish this journey. I struggled to make it to the top, but I climbed the mountain!"

"I have to be going," my friend said. "Tomorrow is a new day to accomplish more dreams. By the way, what are you going to do tomorrow?" I looked at him, with intensity and confidence in my eyes, and said, "I have a mountain to climb."
Events
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Reader Response
I appreciate the article of yours on earthquake, it is timely and informative, perhaps the article is aimed at lay people. Any disaster is a highly demanding and requires rapid action, the principle of managing situation should be based on acronym KISS (Keep It Simple for Stupids). I suggest that list of drugs should be simple and minimal, e.g. iv fluids, ringers lactate is sufficient as first line of IV fluid (as trauma is the commonest sickness in earthquake) similarly other drugs can be rationalized. Since this news letter is official publication of esteemed national organisation whenever any drug is quoted it should be preferably in generics Thanking you sir. Gopal Krishna Rao
IMA Videos
News on Maps
Cure-in-India Initiative to boost innovation in Indian healthcare and medical device industry
New Delhi: A Summit on ‘India the Future Global Healthcare Hub’ was held today at PHD House. Moderating a Session in the Summit, Padma Shri Awardee, Dr K K Aggarwal, Hony Secretary General, IMA said that IMA and PHD Chamber of Commerce have co-organized the Panel Discussion to come forward and promote a concept of Cure-in-India.

Once approved by the Govt. of India, any indigenous medical product is of good quality and should be promoted.

No reimbursement should be given for foreign devices for those drugs and devices, which are available from indigenous reliable sources.

The Govt. should not allow price variation in drugs of more than 10%. During epidemics, there should be a cap on pricing of medical facilities.

The cost of treatment should be transparent and there should be no hidden charges.

The Panel Discussion was organized by PHD Chamber of Commerce to promote medical tourism in India. The panelists included Dr Himangi Bhardwaj, Dr Harsh Wardhan, Mr Nitin Mahajan, Dr Harvinder Popli and Mr Pradeep Multani.