December 31   2015, Thursday
Dr KK AggarwalDr KK Aggarwal Game-Changers in Cardiology: A diabetes drug that benefits the heart

That glucose-lowering drug could benefit the heart was included as one of the top five "game-changers" in cardiology and endocrinology in 2015.

The EMPA-REG study of empagliflozin, a once-daily SGLT2 inhibitor used to treat type 2 diabetes, found that the drug cut the rate of cardiovascular death, nonfatal MI, and nonfatal stroke in type 2 diabetics.

The results were initially reported by Yale's Silvio Inzucchi, MD, at the European Association for the Study of Diabetes meeting (and simultaneously in the New England Journal of Medicine), and then Inzucchi followed up with additional analysis of the data at the American Heart Association scientific conference last month.
Breaking News

Health Min, IMA to set up working group

Health Ministry in collaboration with the Indian Medical Association (IMA) will form a first of its kind working group to evaluate and address the major healthcare problems in the country. This was announced by Health Minister J P Nadda, who also sought help of IMA members to fight the major health battles being faced by the Indian population, during his address at IMA's annual Central Council meeting the NATCON 2015, an IMA statement said. "Never in the history of the IMA has a joint committee of this nature been formed between the IMA and Government of India. We are extremely hopeful that together we will be able to find effective solutions to major healthcare issues being faced in our country. "Some of these include the high prevalence of water and food-borne diseases, increase in percentage of women smokers, epidemics nature of diseases such as dengue and swine flu as well as the incidence of lifestyle diseases in people as early as in their late twenties and thirties," the statement said.

"This will be a great boon for the Indian consumer at large for now medical devices will become more affordable and accessible even to the lower strata of the society. We believe that access to healthcare is a basic fundamental right of each and every Indian citizen under article 21 of the Indian constitution and no person must die of disease just because they cannot afford treatment," Dr KK Aggarwal, Secretary General of IMA, said. The IMA Central Council meeting was attended by over 1000 doctors who, over a two day period, discussed issues affecting the Indian medical community, including the increased cases of violence against doctors, un-warranted media trials, redundant laws that need urgent amendments and the commercialization of the medical practice by its inclusion under the Consumer Protection Act. (PTI)

New ACOG & SMFM recommendations say short-term magnesium sulfate use appropriate

Short-term (usually less than 48 hours) use of magnesium sulfate in obstetric care is appropriate for certain conditions and durations of treatment, according to a committee opinion from the American College of Obstetricians and Gynecologists and the Society for Maternal-Fetal Medicine. The new recommendations, which update the previous opinion from September 2013, are published in the January issue of the journal Obstetrics and Gynecology. Appropriate indications for magnesium sulfate use in obstetric care are: (Medscape)

• Prevention and treatment of seizures in women with preeclampsia or eclampsia,

• Fetal neuroprotection before anticipated early preterm (less than 32 weeks of gestation) delivery, and

• Short-term prolongation of pregnancy (up to 48 hours) to allow antenatal corticosteroid administration to pregnant women at risk for preterm delivery within 7 days.
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Specialty Updates
• Levels of high-sensitivity (hs) cardiac troponin I may help clinicians detect exercise-induced myocardial ischemia in patients suspected of having the condition, suggests new research published online in the American Heart Journal.

• New research finds that even before a diabetes diagnosis, higher-than-normal blood sugar levels could cause kidney damage. The findings are published in the American Journal of Kidney Disease. Researchers noted that both fasting glucose and HbA1c levels that are consistent with prediabetes are independent risk factors for kidney hyperfiltration and high albumin in the urine, suggesting that prediabetes may be a precursor to kidney disease.

• A new study, published in the Journal of Allergy and Clinical Immunology, finds that having asthma may increase the risk of developing shingles.

• Hyperbaric oxygen therapy does not benefit patients with radiation-induced chronic gastrointestinal (GI) symptoms in the long term, suggests new research published online in the Lancet Oncology.

• Standard antibiotic prophylaxis for pancreaticoduodenectomy (PD) may miss important pathogens, suggests new research published online December 23 in JAMA Surgery.

• The presence of myopia, or nearsightedness, significantly affects the muscles used in focusing the lens of the eye-a finding that has potential implications for the development of "accommodating" implanted intraocular lenses (IOLs) that can adjust to different visual distances, suggests a study published in Optometry and Vision Science.

• Adverse pregnancy outcomes are more prevalent among women with ankylosing spondylitis (AS) than those without AS, suggests new research published in Annals of the Rheumatic Diseases. Researchers noted that emergency and elective cesarean section deliveries were significantly more common among mothers with AS compared with population controls, and offspring of women with AS were more often preterm and small for gestational age (SGA).

• The risk of developing nonfatal cardiovascular disease (CVD) is almost twice as high in patients who develop type 2 diabetes before the age of 40 compared with those who develop later-onset disease; however, the risk is attenuated when adjusted for disease duration, reported a large cross-sectional survey published online in The Lancet Diabetes Endocrinology.

• The "sliding" technique of penile length restoration, combined with a penile prosthesis implant, can help some patients who have penile deformity and shortness resulting from Peyronie's disease (PD), suggests a study published online December 21 in BJU International.

• Central venous pressure (CVP)–guided fluid administration before, during, and after coronary angiography can significantly reduce the risk of contrast-induced nephropathy (CIN) and major adverse clinical events compared with standard protocols, suggests a new study published online in JACC: Cardiovascular interventions.
How to Remove Negative Thoughts

Darkness is absence of light and similarly negative thoughts are absence of positive thoughts. The answer to negative thoughts is to bring back positive thoughts. An ideal mind is a devil’s workshop and will always think negative. Here are some ways by which you can remove negative thoughts.

• Think differently as taught by Adi Shankaracharya. Once Menaka approached Arjuna with lust and said that she wanted to have a son like him with him. Arjuna said why wait for 25 years consider me as you son from today.

• Think opposite as taught by Patanjali. For example, if you are having a though to steal, silently start thinking of charity.

• Think positive as taught by Buddha. Make a list of positive actions to be done today as the first thing in the morning and concentrate on that list. Divert your mind to the pending works. It’s a type of behavioral therapy.
The Year in Medicine 2015: News That Made a Difference
New Program Improves Outcomes in Early Psychosis

A new program that takes a "real-world" approach to first-episode psychosis shows significant improvement in young patients. Investigators at the Albert Einstein School of Medicine in New York City found that patients who underwent the NAVIGATE program experienced greater improvement in quality of life and psychopathology, according to a report published online October 20 in the American Journal of Psychiatry. Patients who received the intervention were more involved in work and school than those who received standard community care. The study combined different aspects of treatment that have been studied elsewhere and can be easily implemented in community clinics. They included personalized medication management, family education, individual therapy focused on resilience, and supported employment and education. (Medscape)
The switch from trivalent to bivalent oral polio vaccine

18th December, 2015

Role of Partners (WHO, UNICEF, Rotary)

• Support Govt. in implementation of switch

• Independent monitoring of switch implementation and feedback to Govt. of India for any corrective measures

Role of IMA / IAP

• Communication about the switch date to its members nationwide

• Ensure availability of bOPV 2 week prior to switch date and not be used before switch.

• Ensure tOPV not used after switch date and disposal & destruction of tOPV stock after switch.

• Participation and cooperation of private sector in switch validation
Legal Quote
Samira Kohli vs Dr. Prabha Manchanda and Anr, SCI, Civil Appeal No. 1949 of 2004, 16.01.2008

“The basic principle in regard to patient’s consent may be traced to the following classic statement by Justice Cardozo in Schoendorff vs. Society of New York Hospital - (1914) 211 NY 125: ’Every human being of adult years and sound mind has a right to determine what should be done with his body; and a surgeon who performs the operation without his patient’s consent, commits an assault for which he is liable in damages."
Digital IMA
IMA Satyagraha
IMA Poll
Free diagnostics tests at govt healthcare centres in the New Year

The government is set to roll out the 'free diagnostics' scheme from January 1. The health ministry has written to all states asking them to start providing a basket of essential services for free to patients visiting public healthcare facilities. The diagnostic services offered under the scheme would include blood and urine tests for chronic diseases like diabetes, for tropical diseases like malaria and dengue, HIV tests, as well as essential imaging and radiology services like X-ray, CT scan and ultrasound… (ET Healthworld)
Rights of Transgender Persons Bill, 2015
The 'Rights of Transgender Persons Bill, 2015' prescribes that no child, who is born a transgender, shall be separated from his parents. Only a court order can take the child away from the parents, and courts too can intervene only in the interest of the child, like in cases where the immediate family is unable to care for a transgender child. The court would however have to try to place the child with his "extended family" which includes those related by blood, marriage or adoption. Besides ensuring a family life for transgenders, the bill enjoins upon local governments to provide them admission in educational institutions starting with schools, without discrimination, and with financial help. A transgender, if eligible, can also appear for any job in sectors identified in the bill… (Times of India – Subodh Ghildiyal)
DHR begins process for establishment of Medical Technology Assessment Board
The Department of Health Research (DHR) has started the process for the establishment of the Medical Technology Assessment Board (MTAB) which will carry out the review of different medical technologies including instrumentation on a continued basis in the country. The MTAB aims to encourage the process and finalise the development of standardized cost effective interventions that will reduce the cost and variations in patient care, expenditure on medical equipment indirectly affecting the cost of patient care, overall cost of medical treatment, reduction in out of pocket expenditure of patients and streamline the medical reimbursement procedures… (Pharmabiz - Ramesh Shankar)
Union Health Minister reviews preparedness on Seasonal Influenza (H1N1)

Union Health and Family Welfare Minister Shri J P Nadda issued necessary directions related to procurement, training, issuing of advisories and guidelines for the state governments in a high level meeting which took place today to review the preparedness to tackle seasonal Influenza (H1N1). Sufficient advisories have already been issued to the States and, if required, more will be issued. The Ministry has also undertaken adequate steps to augment capacity of health facilities to manage cases of Influenza (H1N1) and have further strengthened its testing facilities. The Ministry has also ensured availability of PPE Kits and N95 Masks for healthcare workers dealing with the cases. The officials also informed that there are sufficient tablets of Oseltamivir for early treatment of Influenza (H1N1) cases... (PIB)
Do You Know?

Non-vitamin K antagonist oral anticoagulants (NOACs), are also named direct oral anticoagulants (DOACs) or target-specific oral anticoagulants (TSOACs). For patients who require long-term anticoagulation, NOACs (such as apixaban, dabigatran, edoxaban and rivaroxaban) are convenient, dismissing the need of regular checking of hemostatic parameters, unlike the vitamin K antagonists (VKA). NOACs have been shown to reduce the risk of major bleeding in comparison with VKA, in particular intracranial hemorrhage.
IPC Code to know

IPC 320

Grievous hurt: Only the following kinds of hurt are designated as “grievous”:

1. Emasculation
2. Permanent privation of the sight of either eye
3. Permanent privation of the hearing of either ear
4. Privation of any member or joint
5. Destruction or permanent impairing of the powers of any member or joint
6. Permanent disfiguration of the head or face
7. Fracture or dislocation of a bone or tooth
8. Any hurt which endangers life or which causes the sufferer to be during the space of 20 days in severe bodily pain, or unable to follow his ordinary pursuits.
Bioethical issues in medical practice
Protecting the privacy and confidentiality of patients

Smita N Deshpande
Head, Dept. of Psychiatry, De–addiction Services
PGIMER-Dr. Ram Manohar Lohia Hospital
Park Street, New Delhi

You are a member of an informal discussion group of doctors who meet regularly to discuss difficult cases. At all these discussions, the conversation is frank and detailed, with all details of the patients, social situation, family issues etc. are discussed threadbare. Sometimes this discussion spills over into the hospital lifts, corridors and canteens. When these issues are really interesting, you discuss them at home with your spouse– a doctor– as well. Many times the name, address, and other details of patients are discussed as well.

a) Do such discussions breach medical confidentiality?
b) At which places should medical cases be discussed?
c) Should interesting medical cases be discussed at home?

Any suggestions? Do write in!

Adapted from: Bioethics Case Studies (AUSN and EEI, November 2013):

Responses received

• Medical discussions of difficult cases are very important from the doctor’s point of view and also from the patient’s point of view. They should definitely be discussed at home, in medical get-togethers, but not in lifts, hotels and public places. Medical science is based on discussions and exploration of the knowledge what one has. Dr BR Bhatnagar

• As regards Bioethical issues as deliberated above, may I suggest to keep discussion anonymous, important material for discussion are clinical facts and not the identification of the patient. This way perhaps we may not breach the confidentiality issues. Dr VJ Mahhadik
Lowering BP of No Help in Acute Stroke

According to findings from China Antihypertensive Trial in Acute Ischemic Stroke (CATIS) published in the Journal of the American Medical Association, use of antihypertensive drugs to lower systolic blood pressure by close to 13% as part of acute treatment of ischemic stroke did not reduce early mortality or disability compared with patients who did not receive antihypertensive therapy. At 14 days after randomization, there were 683 events among patients who received early aggressive antihypertensive therapy versus 681 events in the control group and at 3 months, there were 500 additional events in the treatment arm versus 502 among controls, said Jiang He, MD, PhD, of Tulane University School of Public Health in New Orleans. (MedPage)
WP(C) No.8706/2015 titled “Indian Medical Association Vs. Union of India & Anr (NCERT)” Delhi High Court, New Delhi

Click here to read the proposed changes
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Inspirational Story
Charles Plumb was a US Navy jet pilot in Vietnam. After 75 combat missions, his plane as destroyed by a surface-to-air missile. Plumb ejected and parachuted into enemy hands. He was captured and spent 6 years in a communist Vietnamese prison. He survived the ordeal and now lectures on lessons learned from that experience. One day, when Plumb and his wife were sitting in a restaurant, a man at another table came up and said, “You’re Plumb! You flew jet fighters in Vietnam from the aircraft carrier Kitty Hawk. You were shot down!” “How in the world did you know that?” asked Plumb.

“I packed your parachute,” the man replied. Plumb gasped in surprise and gratitude. The man pumped his hand and said, “I guess it worked!” Plumb assured him, “It sure did. If your chute hadn’t worked, I wouldn’t be here today.” Plumb couldn’t sleep that night, thinking about that man. Plumb says, “I kept wondering what he might have looked like in a Navy uniform: a white hat, a bib in the back, and bell-bottom trousers. I wonder how many times I might have seen him and not even said Good morning, how are you?’ or anything because, you see, I was a fighter pilot and he was just a sailor.” Plumb thought of the man hours the sailor had spent on a long wooden table in the bowels of the ship, carefully weaving the shrouds and folding the silks of each chute, holding in his hands each time the fate of someone he didn’t know.

Now, Plumb asks his audience, “Who’s packing your parachute?” Everyone has someone who provides what they need to make it through the day. Plumb also points out that he needed many kinds of parachutes when his plane was shot down over enemy territory-he needed his physical parachute, his mental parachute, his emotional parachute, and his spiritual parachute. He called on all these supports before reaching safety.

Sometimes in the daily challenges that life gives us, we miss what is really important. We may fail to say hello, please, or thank you, congratulate someone on something wonderful that has happened to them, give a compliment, or just do something nice for no reason. As you go through this week, this month, and step into the New Year, recognize people who pack your parachute…

Have a great year ahead. Cheers!

(Sent by Dr Ajay Kumar Singh)
A 20-year-old man complains of difficulty in reading the newspaper with his right eye. Three weeks after sustaining a gunshot injury to his left eye. The most likely diagnosis is:

1. Macular edema.
2. Sympathetic ophthalmia.
3. Optic nerve avulsion.
4. Delayed vitreous hemorrhage.

Yesterday’s Mind Teaser: A vitreous aspirate has been collected in an emergency at 9 pm what advice you like to give to the staff on duty regarding the overnight storage of the sample.

1. The sample should be kept at 4°C.
2. The sample should be incubated at 37°C.
3. The sample should be refrigerated deep freezer.
4. The sample should be refrigerated for the initial 3 hours and then incubated at 37°C.

Answer for Yesterday’s Mind Teaser:. 1. The sample should be kept at 4°C.

Answers received from: Dr Jainendra Upadhyay, Dr K V Sarma, Dr Avtar Krishan, Daivadheenam Jella.

Answer for 29th December Mind Teaser: 4. Superior vena caval obstruction

Answers received from: Dr Bitaan Sen & Dr Jayashree Sen, Dr Poonam Chablani.
Readers column
Dear Sir, very informative news. Regards: Dr Kripa
The Leave Application

A leave letter to the headmaster: "As I am studying in this school I am suffering from headache. I request you to leave me today."
Press Release
This New Year, say no to self- medication

• Paracetamol is one of the most commonly self-prescribed OTC drugs in India

• Majority of the population remains unaware of the dangers of Paracetamol poisoning

Suffering from a headache or a mild fever? Did you just self-medicate yourself and pop a Paracetamol available over the counter? Think again, for some over the counter drugs may actually be dangerous for you if consumed in the wrong quantities or with add-ons such as alcohol.

Paracetamol is the most widely used pain killer and anti-fever drug in the country. It is an integral component of hundreds of over the counter and prescription medications available in the market. Though remarkably safe when taken in medically prescribed dose, an overdose of Paracetamol can cause fatal and non-fatal liver damage. So much so that in consumers who drink alcohol on a regular basis, even a medically prescribed dose of Paracetamol can prove fatal if taken for a longer period of time. For instance as little as 6gms of Paracetamol consumed in 24 hours taken by women who regularly consume alcohol can cause acute liver injury. Children and pregnant women too remain at a high risk.

Speaking about the dangers of self-medication, Dr S S Agarwal – National President and Padma Shri Awardee Dr KK Aggarwal – Honorary Secretary General IMA in a joint statement said, ”With the age of the internet and easily available OTC medicines, self-medication has become a common practice each one of us indulge in. Paracetamol is one of the most commonly self-prescribed OTC drugs in India. However what most people remain unaware of is that when consumed in excess quantities, and along with substances such as alcohol and other drugs, even Paracetamol can be life-threatening. It is thus important that each one of us consult our physicians before popping bills.”

Paracetamol poisoning is the most common cause of acute liver failure in the United States and is becoming a major cause of concern in India too. The drug in India is available in two variants; one for instant relief and the other for sustained relief over a period of time in compositions of 125, 500, 650 mg. So the question remains is how much Paracetamol is safe to consume and what are the triggers for Paracetamol poisoning.

The therapeutic dose of Paracetamol is 10-15 mg per kg body weight for children below the age of 12 and 325-1000 mg per kg body weight for adults and can be given every 4-6 hours. The maximum recommended daily dose of Paracetamol in a day is 70 mg per kg in children or 4 grams in adults. Toxicity is unlikely to result from a single dose of less than 150 mg/kg in a child or 7.5 to 10 grams in an adult. However toxicity is likely to occur with a single dose of more than 250 mg per kg or more than 12grams for adults in a period of 24 hours.

Specific signs of Paracetamol poisoning include:

• Yellowing of the skin and the whites of the eyes (jaundice)
• Loss of co-ordination
• Low blood sugar (hypoglycaemia), which can cause symptoms including sweating, trembling, nausea and irritability

If anyone notices any signs of Paracetamol poisoning they must consult their doctor immediately. In addition to this people who consume alcohol on a regular basis, pregnant women and parents of young children must never self-prescribe medicines. They must always consult their family doctor.

The whole idea of writing this article is to emphasize that just because several drugs are available over the counter does not mean that they are all safe and can be self prescribed. It only means they can be procured from the market without a medical prescription. It is extremely important that they are taken under medical guidance. In addition to this, it is also important to note that often people try and deliberately take their life by consuming large number of painkillers in a go. To avoid any such case it is important that we raise awareness about this topic and never keep over a strip of Paracetamol at our home at a time. Prevention is key to living a healthy and disease free life.