June 2  2015, Tuesday
CT not required in appendicitis
Dr KK AggarwalWhen a patient has all the signs of acute appendicitis, waiting to get a CT scan to confirm the diagnosis is not required.

Compared with a straight–to–surgery approach, the CT strategy is linked to delayed surgery and increased risk of a burst appendix.

Pre–operative CT is not necessary in cases with straightforward signs and symptoms of appendicitis. If, after a thorough physical examination, the diagnosis is still in question, then patients should be scanned. These patients tend to be older, female and have symptoms that are not typical for acute appendicitis.
IMA-USV Vitamin D Deficiency CME held on 24-5-2015 at IMA House, New Delhi
  • The life expectancies of people with advanced melanoma may be increased with a new drug that harnesses the power of patients’ immune systems to fight their cancer. The drug, nivolumab, slowed cancer progression in melanoma patients by more than double, compared with an earlier immunotherapy drug called ipilimumab.
  • Chemotherapy, which has traditionally been considered a treatment of last resort for prostate cancer, continues to inch closer to the therapeutic frontline, suggests new research presented at the American Society of Clinical Oncology (ASCO) 2015 Annual Meeting. A new trial, Radiation Therapy Oncology Group (RTOG) 0521 now suggests it may have even greater benefit at an earlier stage: in high-risk, localized disease.
  • The eye microbiome of contact lens wearers is more similar in composition to the microbiome of their skin than the eye microbiome of non-lens wearers, suggests new research from NYU Langone Medical Center in New York City. This could possibly explain the increased likelihood of eye infections in contact lens wearers.
  • A panel of neurology and radiology experts has updated imaging protocols for patients with multiple sclerosis, recommending the use of higher-resolution three-dimensional (3D) imaging over two-dimensional (2D) imaging wherever possible because it is faster and better able to show breakthrough disease activity. The guidelines were discussed at the Consortium of Multiple Sclerosis Centers 2015 Annual Meeting.
  • A study conducted in New York found that as many as 6% of New Yorkers who get a tattoo have experienced tattoo-related rash, severe itching or swelling that has lasted more than 4 months and for some, many years. The findings, published online in the journal Contact Dermatitis, urge physicians and consumers to be aware of the risks involved with tattoos.
Dr KK Spiritual Blog
Should doctors be detached in dealing with their patients?

In dealing with patients, the traditional Patient–Doctor relationship model has been that doctor should remain cool, calm and collected at all times.

The doctor’s approach needs to be strictly scientific, logical, objective, methodical precise and dispassionate. This has been the model since the era of William Osler, the father of modern medicine. The term used is imperturbability, which means coolness and presence of mind under all circumstances.

Osler said a rare and precious gift to doctor is right of detachment. The right of detachment insulates the doctors and protects them from powerful emotions that patients display in their presence like anger, frustration, grief, rage and bewilderment. It also insulates patients from the rolling emotions that doctors may at times feel towards them.

However, a detached attitude also insulates doctors from empathizing with patients. A detached doctor may talk in a language that is over patient’s head.

Detachment is not like a light switch that you can turn on and off to suit the situation. Detachment as a practice cannot be in isolation if it becomes your personal style of distracting from the world, it may not be just for the patients but also from your colleague, family friends and even yourself.

I recall when I joined by hospital, the first lesson given to me by my boss was not to get unduly attached with patients. As part of etiquettes, we were taught not to socialize with patients. Even today the new American Guidelines talk that doctors should not socialize with their patients on social media including Facebook. Even doctors are human beings and their personal life should not be known to the patients. As far as lawsuits are concerned, it is equally true that known patients file a lawsuit much more than unknown people because over a period of time they know your weakness. One should learn to empathize with the patients and yet be detached from its results. Doctors who follow Bhagawad Gita understand this concept very well.
Cardiology eMedinewS
  • Preoperative statin use might reduce mortality risk in those undergoing coronary artery bypass surgery (CABG), but other heart drugs might not make a difference, suggests an observational study presented at the European Society of Anaesthesiology (ESA)'s Euroanaesthesia Conference.
  • A new study from Sweden shows that although individual components of a healthy so-called Nordic diet have been linked to beneficial effects on cardiovascular health, there is no evidence of an association with cardiovascular events in a general population. The study is being published in the Journal of Internal Medicine.
Pediatrics eMedinewS
  • Disease flares are common among children with juvenile idiopathic arthritis (JIA) after the disease has been controlled and also once treatment is withdrawn, suggests a large Canadian study published online in Annals of the Rheumatic Diseases.
  • Stressors in urban settings, such as noise and overcrowding, trigger poor sleep quality in young children, which appear to exacerbate symptoms if they had asthma and allergic rhinitis, suggests new research presented at the American Thoracic Society annual meeting.
Make Sure
Situation: A patient with acute rheumatic fever was directly put on penicillin prophylaxis.

Reaction: Oh my God! Why was the full initial course of penicillin not given?

Lesson: Make sure that patients with acute rheumatic fever are initiated on antibiotic therapy to eradicate GAS carriage. Treatment should proceed as delineated for streptococcal pharyngitis, whether or not pharyngitis is present at the time of diagnosis.
Dr Good Dr Bad
Situation: A female chain smoker wanted to know her risk of diabetes.

Dr. Bad: There is no risk.

Dr. Good: You are at high risk.

Lesson: Women who smoke =25 cigarettes per day have a nearly twofold risk of developing type 2 diabetes (Diabetes Care. 2011 Apr;34(4):892-7).

(Copyright IJCP)
Inspirational Story
Kindness with Class

We had just finished thirteen miles of hiking in the Smokey Mountains. We were tired and our muscles ached as we made our way back to New England. The cramped car ride to the airport followed by a two hour flight left our legs in worse condition than they were when we first came off the mountain we just climbed.

When I heard that two seats in first class on our next flight were available for a small upgrade fee, I jumped at the opportunity. We agreed to blow our budgets and paid the fee to upgrade our tickets. Our spirits lifted immediately. At least we would end our adventure in comfort and style.

Our travel has always been arranged on a budget, so flying first class was a new experience for us. As we boarded the plane, we felt as if we were part of an elite group. We took our seats and were happy to join the other few passengers who could fly in such luxury. It was almost as if we had a sense of pride to be sitting with the group of people that surrounded us.

As we chatted away about hiking, waterfalls and bears, I could hear people around us talking about busy schedules and business meetings. It wasn't long before I realized that these people were accustomed to flying in luxury. They are important people I thought to myself.

We noticed that the stewardess was working non–stop to ensure the comfort of the first class passengers. She could not walk by a seat without receiving an order. I thought about how much she must love her job as she smiled kindly at each person while attending to their needs.

As the stewardess walked by our seats near the end of the flight, I looked at her and said, "Thank you and I hope you have a great night". She stopped at our seats with a look of disbelief on her face, bent down, looked at me and said, "Excuse me". I repeated my words and she smiled in a rather funny way, almost as if I had asked her a question that she did not know how to answer.

After a few moments the stewardess walked back to our seats. She asked us what company we were traveling for. "I can tell you work with the public," she said. "Why do you think so?" I asked. She answered very quietly "because you are the only passenger here to say thank you or stop to say something nice to me tonight and I really appreciate your kindness."

The sense of belonging to the elite group of people in first class disappeared as we heard her words. Our seats in luxury offered us more than a comfortable ride. We were reminded that without kindness, we would be flying in no class.
Wellness Blog
Honey excellent for Cough

A spoonful of honey can quieten children’s’ night time cough and help them and their parents sleep better.

When compared to the cough syrup ingredient dextromethorphan or no treatment, honey came out on top. According to a study from Archives of Paediatrics and Adolescent Medicine, the results are so strong that it can be said that honey is better than no treatment and dextromethorphan was not in children with upper respiratory infections (URIs). There is currently no proven effective treatment for cough due to an URI like the common cold. While dextromethorphan is widely used, there is no evidence that it works, and it carries risks.

Honey is used around the world as a home remedy for cough, and might provide a safe, effective alternative to cough medicine.

To investigate its role, the researchers compared buckwheat honey, a honey–flavoured dextromethorphan preparation, and no treatment in 105 children who had sought treatment for night time coughs due to colds. Among the three groups, children given honey had the greatest reduction in cough frequency and severity, and the most improved sleep, as did their parents. Its sweet, syrupy quality may be soothing to the throat, while its high antioxidant content could also be a factor. Honey also has antimicrobial effects.

Honey is not recommended for infants younger below one year of age because of the risk of botulism spores.
eMedinewS Humor
Experiment on a Dog

Some scientists decided to do the following experiments on a dog.

For the first experiment, they cut one of the dog’s legs off, and then they told the dog to walk. The dog got up and walked, so they learned that a dog could walk with just three legs.

For the second experiment, they cut off a second leg from the dog, and then they told the dog once more to walk. The dog was still able to walk with only two legs.

For the third experiment, they cut off yet another leg from the dog and once more they told the dog to walk. However, the dog wasn’t able to walk with only one leg.

As a result of these three experiments, the scientists wrote in their final report that the dog had lost its hearing after having three legs cut off.
eMedi Quiz
IRIS commonly occurs after how many weeks of ART initiation

a. 1-4 week
b. 2-12 weeks
c. 12-24 weeks
d. After 6 months

Yesterday’s Mind Teaser: A hybrid teledematology is

a. Combination of store and forward and mobile teledematology
b. Combination of store and forward and video conference
c. Combination of online discussion group and author-based second opinion teledermatology
d. Combination of online discussion group and video conference

Answer for yesterday’s Mind Teaser: b. Combination of store and forward and video conference

Correct Answers received from: Dr K C Sharma, Dr Poonam Chablani, Daivadheenam Jella.

Answer for 31st May Mind Teaser: a. Videoconference

Correct Answers received: Dr Avtar Krishan.
Rabies News (Dr A K Gupta)
Do antibodies from rabies vaccination cross an intact blood–brain barrier?

No. Antibodies from vaccination do not cross an intact blood–brain barrier.
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
Press Release
Best time to have a heart attack is week days

The best time to have a heart attack is a week day, 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 Indian Medical Association (IMA).

Your chances for surviving a cardiac arrest are 13.4 percent worse if you are admitted to the hospital on the weekend versus a weekday, he further added. Even after taking into account factors such as hospital size and location and the person's age, gender and other illnesses, the lower survival rate remains the same.

According to Richard M. Dubinsky, of the University of Kansas Medical Center in Kansas City, a higher death rate among patients admitted on weekends may be due to lack of resources for treating cardiac arrest.

The findings come from researchers analyzing a national database containing a 20 percent sampling of all U.S. hospital admissions for cardiac arrest from 1990 to 2004. The analysis included 67,554 admissions. During cardiac arrest, the heart slows or stops working, and brain death can occur in just 4 to 6 minutes.
eIMA News
IMA Swachch Bharat Swastha Bharat
Observe IMA Hygiene Hour Every Friday 4-5 PM. Do one hour cleanliness awareness drive.
Lady doctor being beaten up.
IMA not in favour of exit exam
TOI has reported that the Government is planning to start an exit exam for MBBS doctors.

IMA the largest body of medical professional was never consulted for the same.

How can you have another exam after passing MBBS.

The need is to start NEET, quality at entrance level and not at exit level.

IMA wants NEET to be implemented immediately.

Govt on one hand says that they want AYUSH doctors with half baked training can practice modern medicine and on the other hand says after passing MBBS you are not qualified to practice

Government has never been able to ban quackery, which should be their priority.

Why extra exam other than PG exam.

IMA is against any exam to start practice once you have passed MBBS exam
Rationale for switching from trivalent OPV to bivalent OPV
Currently, the risks associated with the type 2 component of tOPV outweigh the benefits.

Since 1999, type 2 wild poliovirus has not been detected.

The type 2 component of tOPV: – Causes more than 90% of vaccine-derived polio viruses (VDPVs)

Causes approx. 40% of vaccine-associated paralytic polio (VAPP) cases

Interferes with the immune response to poliovirus types 1 and 3 in tOPV

IPV introduction will help to: – Reduce risks associated with the withdrawal of OPV type 2

Facilitate interruption of transmission with the use of monovalent OPV type 2 in the case of outbreaks

Hasten eradication by boosting immunity to poliovirus types 1 and 3.
Coming dates for the Polio Endgame Plan
May 2015 World Health Assembly consider a resolution on the OPV switch

December 2015: At least 1 dose of IPV introduced into routine immunization programmes in all countries

April 2016 Withdraw type 2 OPV globally

2020? After all wild polioviruses have been fully eradicated, withdraw all OPVs
Key Resolutions and Decisions: 68th World Health Assembly – 26th May
Item 14.6 Health and Environment: The adoption of the resolution A68/A/CONF./2 Rev.1 on Air Pollution signals historic progress on responding to global challenges to both health and the environment. In addition to voicing their support for the resolution, several Member States voiced their frustration that the links between climate change, and in particular its root causes – socio-economic factors that mainly originate in non-health sectors, and health were not made more explicit. On a positive note, the resolution contains very strong reference to the links between air pollution and NCDs and highlights the existing Global NCD architecture. The resolution requests the Director-General to significantly strengthen WHO’s capacities in the field of air pollution and health and to present to the 69th WHA a road map for an enhanced global response to air pollution.

The International Union Against Tuberculosis and Lung Disease and the NCD Alliance delivered a joint statement.

Statement by The International Union Against Tuberculosis and Lung Disease on behalf of the NCD

Alliance 68th World Health Assembly Statement on Agenda Item 14.6

Chairperson, distinguished delegates,

Thank you for the opportunity to deliver this statement on behalf of The Union and the NCD Alliance, a global civil society network working to elevate the profile of NCDs on the global development agenda.

Health and climate are intrinsically interlinked, and it is of utmost importance to address these two central components of sustainable development in tandem. The Paris climate agreement later this year is our last chance to prevent catastrophic and irrevocable consequences for people and our planet. It is equally a unique opportunity to promote and capitalize on dual wins. While we strongly welcome the resolution on air pollution, we also call on Member States and WHO to:
  1. Act on the evidence, which clearly links health to climate beyond air pollution alone. Environmental determinants of health and NCDs extend far beyond air pollution. To limit focus and action is a grave missed opportunity.
  2. Strengthen collaboration across sectors. The root causes, and therefore solutions, of climate change, health and NCDs are found in the energy, agriculture, transport, urban planning, industry, and trade sectors. Active modes of transport, healthy diets and sustainable food systems, industry regulation, and climate-sensitive allocation of subsidies offer clear co-benefits. We call on WHO to collaborate with UNEP, recalling article 5c of Resolution 1/7 of the Environmental Assembly. We also call on the WHO NMH cluster to strengthen collaboration with the WHO Dept of Protection of the Human Environment.
  3. Ensure stringent monitoring and accountability. Reflecting these sector-specific interventions, indicators and monitoring frameworks must be developed which incentivise multisectoral action and hold individual sectors to account.
NCDs and climate are defining challenges of our generation, and simultaneously present an opportunity for monumental longterm gain. The NCD Alliance stands ready to support Member States and the WHO in pioneering a dual movement for climate and health.
Heat stroke
1. What happens to the body as a result of exposure to extreme heat?

Exposure to extreme heat results in hyperthermia - elevation of core body temperature above the normal diurnal range of 36 to 37.5ºC - due to failure of thermoregulation. Hyperthermia is not synonymous with the more common sign of fever, which is induced by cytokine activation during inflammation, and regulated at the level of the hypothalamus. A temperature above 40ºC (or 104ºF) is generally considered to be consistent with severe hyperthermia.

The body maintains the temperature by balancing heat dissipation with heat load. The body's heat load results from both metabolic processes and absorption of heat from the environment. As core temperature rises, the preoptic nucleus of the anterior hypothalamus stimulates efferent fibers of the autonomic nervous system to produce sweating and cutaneous vasodilation.

In a hot environment, the body loses heat mainly via evaporation; but this becomes ineffective above a relative humidity of 75%. When environmental temperature exceeds skin temperature, then the other major methods of heat dissipation—radiation (emission of infrared electromagnetic energy), conduction (direct transfer of heat to an adjacent, cooler object), and convection (direct transfer of heat to convective air currents)—cannot efficiently transfer heat. (Source: Uptodate)

2. What should I do if I see someone with any of the warning signs of heat stroke?

The management of nonexertional (classic) heat stroke involves ensuring adequate airway protection, breathing, and circulation; rapid cooling and treatment of complications. It is mandatory to continuously monitor core temperature with a rectal or esophageal probe. Once a temperature of 38 to 39ºC (100.4 to 102.2ºF) has been achieved, then cooling measures should be stopped to reduce the risk of iatrogenic hypothermia. (Source: Uptodate)

3. What should I do if I work in a hot environment?

Ensure adequate fluid intake and frequent lemon water sugar salt drinks. All summer natural drinks are okay.

4. What is the best clothing for hot weather or a heat wave?

Wear loose cotton clothes.

5. How can people protect their health when the environmental temperatures are extremely high?
  • Avoid direct sun exposure
  • Take plenty of fluids
  • Use umbrella
6. What steps can be taken to cool the body during heat exhaustion?

Evaporative cooling is the method used most often to treat classic heat stroke and heat exhaustion because it is effective, noninvasive, easily performed, and does not interfere with other aspects of patient care.
With evaporative cooling, the naked patient is sprayed with a mist of lukewarm water while fans are used to blow air over the moist skin.

Other effective cooling methods are less commonly used in patients with classic heat stroke. Immersing the patient in ice water (cold water immersion) is an efficient, noninvasive method of rapid cooling but it complicates monitoring and intravenous access, and may be harmful to the elderly.

An alternative method that allows greater access to the patient is water ice therapy (WIT), in which the patient is placed supine on a porous stretcher positioned on top of a tub of ice water. Medical personnel continuously pour ice water from the bath onto the patient and massage major muscle groups with ice packs to increase skin vasodilation.

Applying ice packs to the axillae, neck and groin (areas adjacent to major blood vessels) is another effective cooling technique, but may be poorly tolerated by the awake patient. (Source: Uptodate)
Indian Medical Association- Students Wing
We are hereby writing to you on behalf of Indian Medical Association- Students Wing
  1. Pan Karnataka Anti Tobacco Campaign being organised by IMA-SW on May 31 on the occasion of world No Tobacco day.
  2. Bangalore: Flash mobs and street plays in Orion Mall and Mantri Mall to encourage smokers to quit from 1 pm onwards.
  3. Mysore: A play depicting the Ill effects of tobacco in K R Hospital premises and a lecture to the medical and para medical students on "How to counsel and guide a patient who wants to quit?"
  4. Davangere: Flash mob in Ram & Co circle and Mandipet and interaction with the public on the topics "Harmful effects of tobacco" and "How to quit?" Timings: 4 pm - 7 pm.
  5. Kolar: Poster designing and oration competition on 30th May for all the college and school students. Street play competition on 31st May in main bus stand.
  6. Mangalore: Flash mobs and public talk in City central mall from 2 pm - 7 pm.
Manoop Kumaraswamy

National Chairman, Public Health IMA SW
Hospital negligence leads to death of Emirati man, court rules
A hospital and its regulating company are responsible for the death of a 65-year-old Emirati for being too slow to treat him, the appeals court ruled.

The victim’s CAT scan showed him to be developing a stroke and the hospital was negligent in its treatment, which lead to his death.

The court ordered the company to pay the victim’s widow Dh50,000 as a financial compensation, and Dh200,000 as a moral compensation with a 5 per cent annual legal interest for both the widow and his daughters.

A medical responsibility committee was assigned by the Court of First Instance to investigate the case, and it discovered that the victim’s diagnosis, treatment plan and methods fell short of regular health standards and did not follow global guidelines, therefore it was considered a clear case of medical negligence.

The Court of First Instance originally ordered the hospital and regulating company to co-pay the widow Dh50,000 for financial damages, and Dh900,000 for moral damages, the latter of which was to be shared with her daughters.

The name of the hospital and company was not disclosed as an appeal to the cassation court may be possible.

(Source: The National UAE)
World No Tobacco Day: Govt stresses on need to check illicit trade
By: PTI updated on: Sunday, May 31 New Delhi

The Indian Medical Association (IMA) today demanded displaying of pictorial warning messages on erectile dysfunction and early ageing on tobacco products.

Citing a survey, which found that young men feared erectile dysfunction and early ageing due to tobacco products most, the Association called for strong warnings on the cover of these products.

“IMA advocates for increasing the size of the pictorial warnings on tobacco products. Besides the cancer warnings, the government should also include pictorial warning messages about early ageing and erectile dysfunction,” said Dr A Marthanda Pillai, national president, IMA, and Dr K K Aggarwal, secretary general of IMA, and president of HCFI.

The survey conducted by IMA and Heart Care Foundation of India (HCFI) found that the two most important aspects that youth fear about tobacco usage are “tobacco products can lead to erectile dysfunction in men” and “tobacco consumption can lead to early ageing”.

Dr Aggarwal further said that they support increase in taxes on tobacco products and hailed the order of governments in Punjab, Haryana and Chandigarh that banned complete use of nicotine under the provisions of Poison Act of 1919 and Poison (Possession and Sale) Rules of 2015.

“These three states have placed nicotine in the category of poison. IMA wants this to be implemented in all other states and Union Territories too,” he said.

IMA has written to the Health Minister demanding this ban at national level also.

IMA will also be training all general practitioners in tobacco cessation so that quit-tobacco facilities are available to those who want to stop the habit.

It has already advised its 2.5 lakh members to ask enquire with their patients their smoking habits and offer help in quitting.
Quote of the Day
A creative man is motivated by the desire to achieve, not by the desire to beat others. Ayn Rand
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