July 2  2015, Thursday
eMedinewS
editorial
White Rice Most Dangerous
Dr KK Aggarwal
  • White rice is much more dangerous in terms of glycemic index than white bread. It has glycemic index of 102.
  • We often tell people not to take cola drinks but they eat white bread. The glycemic index for white bread is 100% and that for cola drink is 90%.
  • Traditional Indian drinks like Rooh Afza, Khas Khas may also contain more than 10% sugar.
  • The recommended sugary drink does not contain more than 2-3% sugar, which is the amount present in oral rehydration solution.
  • People leave a cola drink and take mashed potato, which has glycemic index that is more than that of a cola drink (102 versus 90).
  • Pizza has a glycemic index of 86.
  • Table sugar has a glycemic index of 84, while that of jam is 95.
  • French fries have a glycemic index of 95.
  • Most people add sugar in food and snacks because sugar is a preservative. Less the sugar, earlier the food will be spoiled.
  • To avoid refined carbohydrates in diet, if one has to choose than the most dangerous is white rice, followed by white bread and then comes white sugar.
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eMedipics IMA,IJCP,HCFI
Indian Medical Association celebrates Doctor’s Day across all its state branches
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TRENDO 2015
The 3rd Annual meeting of the Endocrine Society of Tamil Nadu and Puducherry will be held in Kodaikanal on 11th and 12th of July 2015. TRENDO 2015 is proposed to address latest updates, emerging concepts, clinical applications and controversies in diabetes, thyroid disorders, gonadal problems, pituitary disorders, metabolic bone disease and adrenal diseases.
News
  • Grapefruit and orange juices, if consumed in large amounts, may put us at a modest higher risk of melanoma, the deadliest form of skin cancer, possibly from ingesting photosensitizing compounds found in citrus, suggests a new study published in the Journal of Clinical Oncology.
  • New research suggests that high doses of baclofen, a drug commonly used to treat spasticity, supports alcohol-dependent patients in maintaining abstinence from alcohol and is reasonably well tolerated. The findings were presented at the 12th World Congress of Biological Psychiatry.
  • Women with post-traumatic stress disorder have up to a 60% higher chance of a heart attack or stroke, reported a new study published in the journal Circulation.
  • The American Thoracic Society (ATS) has released a policy statement with recommendations for clinicians and the general public on achieving good-quality sleep and getting enough sleep. The statement is published in the American Journal of Respiratory and Critical Care Medicine.
  • New guidelines suggest that only drinking when thirsty is the healthiest way for athletes to keep hydrated, reducing the risk of exercise-associated hyponatremia. The new 2015 exercise-associated hyponatremia (EAH) Consensus Guidelines are published in the Clinical Journal of Sport Medicine.
Cardiology eMedinewS
  • The American Heart Association/American Stroke Association (AHA/ASA) has updated its guidelines on endovascular treatment for acute ischemic stroke, strongly recommending its use in certain patients. The "2015 AHA/ASA Focused Update of the 2013 Guidelines for the Early Management of Patients With Acute Ischemic Stroke Regarding Endovascular Treatment" was published online June 29 in Stroke.
  • Appropriate (but not inappropriate) shocks from implantable cardioverter defibrillators (ICDs) may be a risk factor for increased cardiovascular mortality, suggests new research presented at the European Heart Rhythm Association (EHRA) EUROPACE-CARDIOSTIM 2015 meeting.
Pediatrics eMedinewS
  • Umbilical cord milking resulted in higher systemic blood flow than delayed cord clamping among preterm cesarean-delivered infants, suggested the findings of a randomized controlled trial published online June 29 in Pediatrics.
  • For pregnant women with type 1 diabetes, good control of blood sugar might make a difference in how well their child does in school years later, suggests a new study published in Diabetes Care.
Dr KK Spiritual Blog
Panchamrit body wash

Panchamrit is taken as a Prasadam and is also used to wash the deity. In Vedic language, anything which is offered to God can also be done to the human body. Panchamrit bath, therefore, is the original and traditional complete bath prescribed in Vedic literature. It consists of the following:
  • Washing the body with milk and water, where milk acts like a soothing agent.
  • This is followed by washing the body with curd, which is a substitute for soap and washes away the dirt from the skin.
  • The third step is washing the body with desi ghee, which is like an oil massage.
  • Fourth is washing the body with honey, which works like a moisturizer.
  • Last step is to rub the skin with sugar or khand. Sugar works as a scrubber.
A Panchamrit bath is much more scientific, cheaper and health-friendly.
Inspirational Story
Helping Yourself

Well my story starts 3 years ago. I was working in a retail store; I like to talk to everybody and know what’s going on in their lives. I remember this one girl who started working there a few months after me. I remember always seeing her. I don’t know why but for a weird reason we would never talk. We would just see each other and smile. She would always smile in a really happy way until one day when we got to work in the same department again. She smiled as if she was the happiest girl in the world. I went up to her and asked "What’s wrong with you?" She answered "Why?" I said, "I could feel you're very sad and you're always trying to hide it."

Her mouth just dropped as if I had discovered her deepest secret, so we started talking. She told me why she was feeling like that and why she was trying to hide it. Time went by and we became good friends. She’d always tell me I had changed her life in so many ways. I could not imagine. I would just smile, not really understanding what she meant by that. Today this girl is one of my best friends. I really don’t know what I would do without her. She has been there for me in every possible way a friend could be.

I guess what I’m trying to say is you never know when you’re helping yourself. I helped this girl never knowing that at the same time I was helping myself by finding a truthful friend.

So the next time you see a stranger and they look like they need someone who will listen to them, listen to what they have to say. You never know, you might just end up helping yourself.
Wellness Blog
Sleep deprivation and sleep apnea are both bad for the heart

Both sleep deprivation and sleep apnea have been linked to a higher risk of heart disease.

Over time, inadequate or poor quality sleep can increase the risk of heart disease. Short–term sleep deprivation is linked with high cholesterol, high triglycerides and high blood pressure.

Sleep apnea makes people temporarily stop breathing many times during the night. Up to 83% of people with heart disease also have sleep apnea.

In sleep apnea, the oxygen levels dip and the brain sends an urgent "Breathe now!" signal, which briefly wakes the sleeper and makes him or her gasp for air. That signal also jolts the same stress hormone and nerve pathways that are stimulated when you are angry or frightened. As a result, the heart beats faster and blood pressure rises — along with other things that can threaten heart health such as inflammation and an increase in blood clotting ability. (Source Harvard)
Events
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Make Sure
Situation: A patient on ACE inhibitor developed angioneurotic edema.
Reaction: Oh my God! Why did you continue with the ACE inhibitor?
Lesson: Make sure that patients on ACE inhibitors are advised to watch for symptoms of urticaria and stop the drug immediately, if swelling of lip, face or tongue develops (Br J Clin Pharmacol 1999;48(6):861–5).
Dr Good Dr Bad
Situation: A patient presented with subclinical hyperfunctioning thyroid gland.
Dr. Bad: No treatment is needed.
Dr. Good: You need to be on treatment.
Lesson: A study published in the journal Archives of Internal Medicine has shown that subclinical hyperthyroidism is associated with higher risks of overall mortality, cardiovascular mortality and atrial fibrillation (Arch Intern Med. 2012 May 28;172(10):799-809).

(Copyright IJCP)
eMedi Quiz
A 70-year-old male patient presented with history of chest pain and was diagnosed to have coronary artery disease. During routine evaluation, an ultrasound of the abdomen showed presence of gallbladder stones. There was no past history of biliary colic or jaundice. What is the best treatment advice for such a patient for his gallbladder stones?

1. Open cholecystectomy.
2. Laparoscopic cholecystectomy.
3. No surgery for gallbladder stones.
4. ERCP and removal of gallbladder stones.

Yesterday’s Mind Teaser: The correct sequence of cell cycle is:

1. G0-G1-S-G2-M.
2 .G0-G1-G2-S-M.
3 .G0-M-G2-S-G1.
4 .G0-G1-S-M-G2.

Answer for yesterday’s Mind Teaser: 1. G0-G1-S-G2-M.

Correct Answers received from: Dr Jainendra Upadhyay, Dr Poonam Chablani, Dr K V Sarma, Dr Sharavana.

Answer for 30th June Mind Teaser: 2. Presence of U waves.

Correct Answers received: Dr Sharavana.
eMedinewS Humor
The phone bill was exceptionally high. Man called a family meeting to discuss.

Dad: This is unacceptable. I don't use home phone, I use my work phone.

Mum: Me too. I hardly use home phone. I use my company phone.

Son: I use my office mobile, I never use the home phone.
All of them shocked and together look at the maid who's patiently listening to them.

Maid: "What? So we all use our work phones. What's the big deal??
IMA,IJCP,HCFI
Rabies News (Dr A K Gupta)
Is it essential to perform skin sensitivity test prior to the administration of ERIG?

Majority of reactions to ERIG result from complement activation and are not IgE-mediated and will not be predicted by skin testing.

The recent WHO recommendation states that there are no scientific grounds for performing a skin test prior to the administration of ERIG, because testing does not predict reactions and ERIG should be given whatever the result of the test.

However, skin test is mandatory to avoid any possible litigation under Consumer Protection Act in India.
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
  • Alcohol consumption, particularly in moderation, has consistently been linked to a lower risk of cardiovascular disease and type 2 diabetes (Medscape)
  • There is an increased risk of serious infections associated with use of TNF-α inhibitors within the first 90 days of starting treatment and a subsequent decline in risk. This calls for increased clinical awareness of potential infectious complications among people with inflammatory bowel disease using these drugs, especially early in the course of treatment (Medscape).
Why should the Indian Govt. not allow online pharmacies in India?
An online pharmacy sounds convenient; no waiting in queues, no rushing to the pharmacy before it shuts shop for the day, placing the order is easy, moreover, the order can be placed any time of the day and the medicines are conveniently delivered via courier at your doorstep. Yet, this convenience comes at a price. Not only there may be financial implications for the patients, their safety may even be endangered at times.

The online pharmacy may have its own cancellation policy and may not refund or only partly refund the amount paid upon cancellation of the order or even non-delivery of an order. Unlike the local neighborhood pharmacy or the hospital pharmacy, the patient does not have access to a pharmacist if he/she has any questions about a medicine.
  • There are no well-defined dedicated laws for online pharmacies. Pharmacies in India are governed by the Drug and Cosmetics Act 1940, Drugs and Cosmetic Rules 1945, Pharmacy Act 1948 and Indian Medical Act 1956.

    Laws related to ecommerce are defined under the Information Technology Act, 2000.

    According to Indian laws, a chemist can dispense prescription drugs only on the prescription of doctor. A prescription requires the name of the doctor, his /her address and registration number besides the name/s of the drug/s, their potency, dosage, and duration for which the drugs are to be supplied. The chemist cannot dispense quantity in excess of what has been prescribed by the doctor. Before dispensing the drugs, the pharmacist is expected to verify the completeness, authenticity and legality of the prescription.

    Even over-the-counter (OTC) drugs can be sold only by licensed retailers.
  • The major issue of concern is that prescription drugs cannot be sold online. There are provisions in the various acts mentioned above regarding the same.
    • According to Subsection 1 of section 42 of Indian Pharmacy Act 1948, “….no person other than a registered pharmacist shall compound, prepare, mix, or dispense any medicine on the prescription of a medical practitioner.” Section 42 (2) also states, “whoever contravenes the provisions of sub-section (1) shall be punishable with imprisonment for a term which may extend to six months, or with fine not exceeding one thousand rupees or with both.”
  • Online availability of prescription drugs will violate provisions of various acts like Pharmacy Act, Drugs & Cosmetics Act.
    • Section 10 of the Drugs & Cosmetics Act prohibits import of any drug that is not of standard quality, any misbranded, adulterated or spurious drug or any drug for requires a license for import. It also does not permit import of “any drug which by means of any statement, design or device accompanying it or by any other means, purports or claims to cure or alleviate any disease.” Imported medicines may be fake, mislabeled and unsafe.
    • Likewise, Section 18c of the Drugs & Cosmetics Act prohibits manufacture and sale of any drug without a license.
    • Section 27 of Drugs and Cosmetics Act has provisions for penalty for manufacture, sale, etc., of drugs in the form of imprisonment and monetary fine. It very clearly states in subsection “b(ii) without a valid licence as required under clause (c) of section 18.”

      Recently, an FIR was filed against Snapdeal.com by Maharashtra FDA for allegedly selling drugs, including prescription drugs, online for violating provisions of the Drugs and Magic Remedies (Objectionable Advertisements) Act, 1954 and directly contravening Section 18 (c) of the Drugs and Cosmetics Act, 1940, which prohibits manufacture and sale of certain drugs.
    • The Drugs and Cosmetics Act, 1940, and the Drugs and Cosmetics Rules, 1945, have clear guidelines on the sale of Schedule H and Schedule X drugs, which are ‘restrictive drugs’ and can be sold only on the prescription of a registered medication practitioner. Schedule X drugs include narcotics and psychotropic substances. Chances of drug abuse and addiction are higher with these drugs. They also require meticulous storage and dispensing records. The prescription has to be in duplicate, one copy of which is to be retained by the licensed pharmacist for 2 years.
    • Schedule H1 of the Drugs & Cosmetic Act 1945 mandates a licensed pharmacist to maintain a separate register for sale of drugs that are specified in Schedule H1 with details of the patient, doctor and the name of the drug/s including quantity; it is to be kept for three years and is open to inspection by regulatory authorities. Schedule H1 mainly includes potent antibiotics (like anti-tuberculosis drugs), habit forming painkillers like Tramadol and anti-anxiety drugs that induce sleep.

      Schedule H1 drugs are also required to have special labeling, with symbol Rx in red to be clearly displayed on the left top corner of the label and a box warning with a red border - “It is dangerous to take this preparation except in accordance with the medical advice. Not to be sold by retail without the prescription of a registered medical practitioner.”

      Online pharmacies may not abide by these regulations and bypass them.

      The objective of Schedule H1 was primarily to check the indiscriminate use of antibiotics in India, in view of the rising incidence of multi-drug resistant bacteria, a serious public health issue worldwide. Easy access to antibiotics via online pharmacies will defeat this very purpose.
    • The Drugs and Cosmetics Act has no provisions for online sale of medicines, or home delivery of medicines. Hence, online sale of medicines cannot be legally permitted.
  • The prescriptions submitted via fax/email may be fake and it could be difficult to verify their authenticity. Online correspondence and/or scanned copies are legally not permitted.
  • Online pharmacies will promote drug abuse, drug misuse, self-medication etc. Any mediation taken without the supervision of doctors may be dangerous and even potentially life-threatening.
  • Pharmacists are not allowed to accept and dispense prescriptions that are brought in by children. Online pharmacies will provide easy access to controlled drugs or even street drugs to this vulnerable group.
  • Regulation 5.3 of MCI Code of Ethics stipulates that pharmacists and doctors should work together. If online pharmacies are allowed, then this relationship will be lost.
  • Many online pharmacies may be operating without the appropriate license. This increases the chances that drugs sold by such unlicensed pharmacies maybe counterfeit, substandard, or adulterated and therefore risky to the patient. There are no checks in place to make sure that the drugs sold by online pharmacies are not spurious.
  • If online pharmacies are allowed, the National Pharmacovigilance Program, initiated by Central Drugs Standard Control Organisation (CDSCO) under the Ministry of Health and Family Welfare, will become a futile exercise. This program is not only meant for doctors but also for pharmacists. In March this year, the Health Ministry approved a Materio Vigilance Programme of India to monitor adverse events associated with medical devices. If there is no system in place to monitor and analyze adverse drug reactions, this will directly affect the health of the patients.
  • Medicines have to be stored properly as recommended by the manufacture. Exposure of medicines to high temperatures in storage or in transit could diminish their efficacy and are a potential health risk. There is no way to check the storage conditions of the drugs sold by the online pharmacies.
  • Regulatory authorities continue to monitor a drug for any adverse effect even after it has been on the market. If the safety/quality of the medicine comes under question or, if it is potentially contaminated, mislabeled or is improperly packaged, then they may recall or withdraw a prescription or OTC drug from the market even after it has been approved. Sometimes, the manufacturer may voluntarily recall a drug. If online pharmacies are permitted, the drug recalls become very, very difficult, almost next to impossible.
  • Breach of confidentiality is another major concern. Online pharmacies may misuse personal and financial information of the patient as well as of doctors leading to cases of identity thefts and fraud.

    The WMA 2005 Declaration of Lisbon on the Rights of the Patient gives them the right to confidentiality, which states that all identifiable patient data must be protected. Regulation 7.14 of MCI Code of Ethics 2002, also does not allow a registered medical practitioner to disclose the secrets of a patient that he/she may have been learnt in the exercise of his / her profession. Declaration (g) given to doctors at the time of registration states: I will respect the secrets which are confined in me.

    There is no legislation specific to data privacy in India as yet. The laws that deal with data protection or privacy in India are Section 43A of the Information Technology Act, 2000 and the Information Technology (Reasonable Security Practices and Procedures and Sensitive Personal Data or Information) Rules 2011.

    There is a proposed Privacy (Protection) Bill, 2013 (“Bill”), which focuses on the protection of personal and sensitive personal data of persons. If passed and enacted, it will override all existing provisions directly or remotely related to privacy under section 3, which provides that “no person shall collect, store, process, disclose or otherwise handle any personal data of another person except in accordance with the provisions of this Act and any rules made thereunder.”
  • Online pharmacies offer drugs at low cost or at discounted prices to lure customers. If the online pharmacy gives cheaper alternatives of drug/s prescribed, this violates the doctor- patient-pharmacist relationship, which is based on trust.
  • Pharmacy laws in India do not allow a pharmacist to substitute a brand written by a doctor.
  • Pharmacists are also not authorized to change potency of the prescribed drug, even if the patient asks for it.
  • Refilling of a prescription is not allowed by pharmacists unless authorized by the doctor. If the doctor has prescribed a drug, e.g., 3 days, the pharmacist cannot dispense drugs for more than this duration.
  • Online pharmacies may provide rebates and commissions to doctors to provide prescriptions on the basis of online information that has been filled by the patient. This way doctors will be vulnerable to malpractice suits. Regulation 6.4 of MCI Code of Ethics prohibits doctors from giving or receiving any rebates or commissions.
  • Similar to the online search service Justdial.com, online pharmacies may also promote doctor substitution, which is unethical.
  • Ultimately online pharmacies will be taken over by MNCs and Indian laws are not applicable to MNCs.
Indian Medical Association is against online pharmacies in India. This will encourage substitution of cheaper and spurious drugs by the online stores and the doctor-patient confidentiality will be affected. And, will be a violation of all the laws quoted above. It will deny the patient the supervision of the Doctors in the use of medicines. This will encourage patient to use one prescription repeatedly without the supervision of the Doctor. This can cause many adverse drug related reactions, it will encourage drug abuse and overuse of habit-forming drugs. The medicolegal liability will still fall on the doctor, when a patient misuses this facility. The service of online pharmacy will be utilized by affluent and educated people. Hence online pharmacy has no public health benefits or implications; but at the same time it is loaded with scope for misuse, drug abuse, dependence and adverse reactions.

Prof.Dr A Marthanda Pillai    Dr K K Aggarwal
National President, IMA       Honorary Secretary General, IMA
IMA,IJCP,HCFI
Quote of the Day
It is wise to direct your anger towards problems – not people; to focus your energies on answers – not excuses. William Ward
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Reader Response
Dear Sir, very informative news. Regards: Dr Kalpana
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Press Release
Indian Medical Association celebrates Doctor’s Day across all its state branches

Raises awareness about how people should approach their doctors for advice on disease prevention as opposed to just cure

Also, stress on the important principles that govern a healthy doctor-patient relationship


On the occasion of Doctors Day, large-scale celebrations took place across all the State branches of the Indian Medical Association. In parallel press events held across 30 IMA branches, senior doctors were honored for their contribution in the field of medicine. Key principles that should govern the crucial doctor-patient relationship were also discussed. In addition to the doctors and their families, social organizations and the general public joined the celebrations. Blood donation camps were also organized in each State and awareness was raised about how each healthy individual must donate blood regularly. July 1st is observed as 'Doctors Day' every year in memory of Bharat Ratna Awardee late Dr. B C Roy who was the doyen of the medical profession.

“Doctors in India have since the very onset been bestowed the status of God. However with the recent inclusion of medical services under the Consumer Protection Act, the integrity and trust in the doctor-patient relationship has been threatened“, said Padma Shri Awardee Prof (Dr) A Marthanda Pillai, National President & Padma Shri Awardee, Dr K K Aggarwal, Honorary Secretary General, IMA, in a joint statement.

The Indian Medical Association expressed its concern over the drastic increase in the cases of violence against doctors and medical establishments. It was discussed that the need of the hour was for the society to create an atmosphere where doctors can practice with peace and dignity. This in turn would allow the medical fraternity to put its best foot forward towards providing the best possible healthcare services to the society at large without the fear of assault and harassment. The urgent need for a Central Act to protect doctors while on duty and medical establishments against public outrage was also voiced.

Another important concern raised was regarding common healthcare issues, which continue to plague our society such as a high maternal mortality and infant mortality rate and the inability of the government to stop the spread of communicable diseases (India fares lower than even Nepal, Bangladesh & Sri Lanka in this regard). With the gradual increase in treatment costs, IMA

also urged the government to roll out a realistic health policy aimed at the overall benefit of the Indian population and to increase the health allocation in the union budget to at least 2.5% of the GDP.

Voicing a unanimous plea, Dr Ajay Lekhi, President & Dr Alok Bhandari, Honorary Secretary of the Delhi State Branch, IMA said, “IMA demands that the right to health be made a fundamental right. To achieve this goal, the government should strengthen the public healthcare delivery system and promote and support the private health sector which caters to 70% of the healthcare demands of our country”,

All 2.5 lakh members of the Indian Medical Association were asked to take a pledge re-instating their commitment towards the overall healthcare benefit of the nation and working while upholding the highest standards of ethics. While a doctor saves the lives of a majority of his patients, there are some cases, which are beyond his control. In such scenarios, the doctor must maintain an empathetic approach towards the family of the patient.

IMA directed doctors to follow several practices in public interest including devoting one hour in a week towards promoting the idea of swachch bharat - swasth bharat; providing medical concessions to the elderly; working towards eradicating any discrimination against girl children; offering special privileges to women delivering a girl child; providing free heart surgeries to girl children suffering from complex congenital heart disease and cannot otherwise afford the surgery cost; adopting villages under the IMA Aao Gaon Chalen initiative; starting adolescent clinics; starting meditation cells; and notifying every case of TB.