March 31  2015, Tuesday
editorial
High fat diet is prostate cancer prone
Dr KK AggarwalDiets high in saturated fat increases the risk of prostate cancer, according to a report from University of Texas M. D. Anderson Cancer Center in Houston published in the International Journal of Cancer.
  • Men who consume high saturated animal fat diet are two times more likely to experience disease progression after prostate cancer surgery than men with lower saturated fat intake.
  • There is also shorter "disease–free" survival time among obese men who eat high saturated fat diet compared with non–obese men consuming diets low in saturated fat.
  • Men with a high saturated fat intake had the shortest survival time free of prostate cancer (19 months)
  • Non–obese men with low fat intake survived the longest time free of the disease (46 months).
  • Non–obese men with high intake and obese men with low intake had "disease–free" survival of 29 and 42 months, respectively.
Take home messages
  • High saturated fat diet has been linked to cancer of the prostate
  • Reducing saturated fat in the diet after prostate cancer surgery can help reduce the cancer progression.
  • Cancer prostate has the same risk factors as that of heart blockages and both are linked to high saturated fat intake.
  • With the increase of heart patients, a corresponding increase in prostate cancer patients is also seen in the society
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IMA-GFATM RNTCP PPM Annual Review National Workshop (29th March 2015)
News
  • A new study has stated that being male is associated with worse memory and lower hippocampal volume throughout middle and old age in cognitively normal individuals. The findings are published online in JAMA Neurology.
  • Screening for prostate cancer using MRI and a lower prostate-specific antigen (PSA) threshold could result in fewer men needing biopsies with no compromise to cancer detection rates, suggests a pilot study presented at the European Association of Urology 30th Annual Congress.
  • Among patients with symptomatic intracranial arterial stenosis, the use of a balloon-expandable stent was associated with worse outcomes than medical therapy alone, reported the VISSIT (Vitesse Intracranial Stent Study for Ischemic Stroke Therapy) study. The study results were published in JAMA.
  • Most patients with lumbosacral radiculopathy have gluteal trigger points (GTrP), suggests a new study. The findings suggest that treating these trigger points could help ease pain in these patients. The findings are published in the American Journal of Physical Medicine & Rehabilitation.
  • Natamycin treatment of mycotic corneal ulcers improves vision-related quality of life, compared with voriconazole treatment, suggests the Mycotic Ulcer Treatment Trial I (MUTT I). The data are published online in JAMA Ophthalmology.
Dr KK Spiritual Blog
The Main Principle of Knowing the Truth

The main figure in the Upanishads is sage Yajnavalkya, known as one of the greatest philosophers. Most of the great teachings of later Hindu or Buddhist philosophy are derived from him. He taught the great doctrine of neti-neti, the view that truth can be found only through the negation of all thoughts about it.

Brhadaranyaka Upanishad is the oldest and the most important of all the Upanishads. Its name actually means the great forest-book.

Sage Yajnavalkya’s dialogues with his wife, Maitreyi are featured in the Muni Kanda or Yajnavalkya Kanda. The doctrine of neti-neti suggests the indescribability of the Brahman, the Absolute. Yajnavalkaya attempts to define Brahman.

Atman is described “neither this, nor this” neti-neti. The Self cannot be described in any way. Na-iti - that is Neti. Through this process of neti-neti you give up everything - the cosmos, the body, the mind and everything - to realize the Self.

Once the Atman is defined in this manner are you become familiar with it, a transformation takes place as realization dawns that the phenomenal world and all its creatures are made up of the same essence of bliss.

Brahman is infinite, amorphous, colorless, characterless and formless Universal Spirit, which is omnipresent and omnipotent, and like cosmic energy, is pervasive, unseen and indescribable.
  • Neti-neti Meditation: The principle of neti-neti has been used in meditation involving gnana yoga. Whenever a thought or feeling comes to mind that is not the goal of the meditation, or is not the soul or the inner self, the meditator simply has to say, “Not this, not this,” and dismiss the thought, image, concept, sound, or sense distraction. Any thought, any feeling, is patiently discarded — again and again if necessary, until the mind is clear and the soul/or the self is revealed.
  • Neti-neti and the mind: When you get into the habit of neti-neti, you can also discard thoughts of worry, doubt, or fear, and become established in the light of your inner self. You can, then, look back at worries and fears with deep insight and handle them.
  • Neti-neti and the medical profession: One of the basic medical teachings is to diagnose a condition by way of excluding other similar conditions. This is called differential diagnosis and this is the mainstay of allopathy. This also makes one investigative-oriented but is the only scientific way of knowing the truth.
  • Neti-neti and multiple choice questions: In any modern exam today, the principle of neti-neti is used. A question has four nearly similar answers and the student has to answer the correct one. He can only answer by the principle of negation.
  • Neti-neti and police investigations: This principle is also used while handling a criminal case. Everyone is a suspect in the crime initially, till a process of elimination clears them.
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Cardiology eMedinewS
  • Adding two non-invasive imaging tests to traditional cardiovascular disease risk factor assessment more precisely predicts a healthy patient's future risk of heart attack, stroke, or premature death, suggests a study published in the Journal of the American College of Cardiology (JACC).
  • The US Food and Drug Administration has approved the Impella 2.5 System, a miniature blood pump system designed to help certain patients maintain stable heart function and circulation during certain high-risk percutaneous coronary intervention (HRPCI) procedures, such as balloon angioplasty and stenting, which re-open coronary arteries that are narrowed or blocked due to severe coronary artery disease (CAD).
Pediatrics eMedinewS
  • Children whose early childhood is spent in a home with siblings, which serves as a marker for exposure to microbes early in life, tend to be at lower risk of developing juvenile idiopathic arthritis (JIA), suggests an Australian study published online in Arthritis and Rheumatology.
  • Adolescent patients who need scoliosis surgery may benefit most from going to a hospital that performs a high volume of the procedures, suggests new research from NYU Langone spine surgeons presented at the American Academy of Orthopaedic Surgeons 2015 Annual Meeting.
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Make Sure
Situation: A patient was brought to the ICU in cardiogenic shock.
Reaction: Oh my God! Why didn’t you take him for emergency angiography and subsequent PTCA?
Lesson: Make Sure to perform an emergency diagnostic angiography and mechanical revascularization with PTCA in patients of cardiogenic shock. Results of NRMI–2 suggest that this intervention is much better than thrombolytic therapy in such patients.
Dr Good Dr Bad
Situation: A patient with Mediclaim was advised MRI post discharge.
Dr. Bad: It will not be covered.
Dr. Good: It will be covered.
Lesson: Post hospitalization related medical expenses incurred during period upto 60 days after hospitalization of disease/illness/injury sustained are covered as part of claim.
(Copyright IJCP)
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eMedi Quiz
A 30-year-old man came to the outpatient department because he had suddenly developed double vision. On examination, it was found that his right eye, when at rest, was turned medially. The most likely anatomical structures involved are:

1. Medial rectus and superior division of oculmotor nerve.
2. Inferior oblique and inferior division of oculomotor nerve.
3. Lateral rectus and abducent nerve.
4. Superior rectus and trochlear nerve.

Yesterday’s Mind Teaser: A lesion of ventrolateral part of spinal cord will lead to loss (below the level of lesion) of:

1. Pain sensation on the ipsilateral side.
2. Proprioception on the contralateral side.
3. Pain sensation on the contralateral side.
4. Propriception on the ipsilateral side.

Answer for yesterday’s Mind Teaser: 3.Pain sensation on the contralateral side.
Correct Answers received from: Dr Madhusudhan G, Daivadheenam Jella, Dr Avtar Krishan, Dr K Raju, Dr KV Sarma, Dr Jainendra Upadhyay.
Answer for 29th March Mind Teaser: 2. Hypovolemia.
Correct Answers receives: Dr Jainendra Upadhyay, Dr Poonam Chablani, Dr Amit Desai, Dr Avtar Krishan, Daivadheenam Jella.
Rabies News (Dr A K Gupta)
Can all available anti–rabies vaccines be used by intradermal route?

Not all vaccines produced in India are at present fit for intradermal usage. The following vaccines have been approved by DCGI for use by intradermal route.
  • Purified chick embryo cell vaccine (PCEC): Rabipur and Vaxirab–N
  • PVRV (Purified verocell rabies vaccine): Verorab vial of 0.5 ml
  • PVRV: Abhayrab – vial of 0.5 ml, Human Biological Institute
  • PVRV: Indirab, vial of 0.5 ml/1.0 ml, Bharath Biotech, Hyderabad.
PDEV (Vaxirab) and HDCV (Rabivax) are approved for IM use only and not for IDRV.

Rabies vaccines formulated with an adjuvant should not be administered intradermally.
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
IMA NEWS
Sonal Namaste
When decontaminating hands with an alcohol-based hand rub, apply product to palm of one hand and rub hands together, covering all surfaces of hands and fingers, until hands are dry.
Move on pictorial warning criticized
SHANKAR BENNUR: The Hindu

Even as the anti-tobacco groups are pitching in for a bigger pictorial/graphical health warning on tobacco products to educate tobacco users on the dangers of its use, the Federation of Karnataka Virginia Tobacco Growers’ Association has opposed the recommendation and urged the Centre not to include this suggestion in the proposed amendment to the Cigarettes and Other Tobacco Products Act, 2003. “There is a move to increase the size of the statutory health warning either pictorially or graphically on tobacco products to 85 per cent from the current 40 per cent on both sides of the pack. This step will pose hurdles in identifying genuine and fake/illegal cigarette packs, leading to spurt in the sale of banned cigarettes in the market,” said association president B.V. Javare Gowda.

Addressing presspersons here, he claimed that India is the 5th biggest market for contraband cigarettes and said the move on the size of statutory warning on cigarette packs could boost their sales. Accusing the NGOs of carrying misleading campaigns against Indian tobacco farmers, he said some Indian NGOs, with the support of global anti-tobacco foundations, were pushing for policies which, Mr. Gowda termed “illogical, irrational and that which cannot be implemented.”

The campaigners, who operate from cities and metros, do not have the understanding of rural India and the impact of their campaigns on the livelihood of growers.

Note: IMA opposes the move by the Federation of Karnataka Virginia Tobacco Growers’ Association. The move is not scientific and needs to be condemned by all state and local IMA branches.
Facts about Tuberculosis (TB)
Is MDR TB treatable?
  • MDR TB requires extensive chemotherapy (24 months or more of treatment) with second-line anti-TB drugs like fluoroquinolones, kanamycin, ethionamide, cycloserine.
  • The second-line drugs are more costly and toxic than the first-line drugs.
  • The treatment success for MDR TB is only about 60-70% in comparison to 90%-95% for drug sensitive TB.
Conference Update
Have we conquered very late stent thrombosis?
Dr Tan Huay Cheem,
Singapore
  • Very late stent thrombosis (VLST) is defined as stent thrombosis occurring more than 1 year after implantation.
  • Its occurrence is rare but catastrophic with death of 20-40%, MI 50 -70% and frequently results in repeat intervention.
  • Mechanism of VLST differs from early ST in that it is mainly due to incomplete or delayed re-endothelialization, neoatherosclerosis, late stent malapposition and chronic inflammation.
  • Prevention includes better patient selection, better stent selection and deployment and better peri-and post-procedure care.
  • Significant reduction of VLST has been achieved with newer, more biocompatible polymeric second generation DES. Everolimus-eluting stent has the most robust and extensive clinical evidence of improved outcomes (0.5% VLST at 2 years) and should serve as the benchmark for any new device comparison.
The Killer Air
Dr Balaji P,
Chennai
  • Coronary air embolism is still a part of the inevitable complications of coronary angiography and angioplasty.
  • Heart can tolerate large quantities of air if entrainment occurs over a prolonged period.
  • Taking care during every step by DE-AIRING can avoid this simple but potentially fatal complication
  • Aggressive efforts to re-establish the coronary blood flow as soon as possible are essential to reduce injury to the myocardium and for speedy recovery from the hemodynamic crisis.
Drug eluting balloon Vs stenting for SFA disease Dr Max Amor, France
  • SFA is an extremely complex artery to treat: more than 20cm lesions, frequent occlusion, heterogeneous and extremely calcified atheroma and tapering sizes.
  • It often requires several tools to treat: tools to recanalize, to enlarge, to scaffold and to avoid acute and delayed occlusion and restenosis.
  • The armamentarium of treatment of SFA diseases has evolved in the last 20 years from plain balloon angioplasty to debulking (atherectomy) and balloon angioplastya and then to self-expandable nitinol stents with or without drug elution; now we have the drug-coated balloons (DCBs).
  • The latest results about self-expandable stents have shown a primary patency of around 30-50% at 5 years equivalent to femoropopliteal prosthetic bypass grafts. Several factors influence this disappointing result viz. length of the lesion, mechanical stress of SFA, stent fracture etc.
  • Several self-expandable stents are available that differ in geometry, nitinol characteristics and paclitaxel coating, but they all at some point are equivalent at very long term. Even the company players are numerous; the technology has plateaued in the last years.
  • DCBs, after their introduction in coronary angioplasty, have been proposed as an alternative to solve part of these limitations in SFA angioplasty. There is no risk of fracture because of no metal is left behind, there is healing and partial restoration of the artery even under mechanical stress, it can be used at bifurcation and joint area, in small arteries = 4mm and for the treatment of instent restenosis.
  • Not all DCBs are equivalent; they all use paclitaxel as a drug, over a semi-compliant balloon but with different coating.
  • These paclitaxel DCBs differ in drug-delivery technology and the excipients used, thereby resulting in tissue retention. These mechanistic differences are not well known as well as the side effects of extremely long (>10cm requiring 2-3 long DCB) lesions treated (wash-off of the drug, distal embolization of paclitaxel).
  • Several studies have confirmed the superiority of DCBs over simple balloon angioplasty in SFA disease.
  • The studies are insufficient to conclude about long lesions treated either by Nitinol Stents or DCBs.
  • The cost of several DCB balloons during a unique procedure is a major limitation today, which justifies their use only in cases of re-stenosis.
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Inspirational Story
Don’t Give Up

I had competed in Speech competitions for two years. This was my graduating year but it looked as though I may not go. Because of the small school that I attend we could only take 12 competitors. As the state meet approached, I felt relieved that I did not have to prepare.

Then two weeks before the meet, I was told that I was going. I began to practice living the roles I was playing. I was to compete in three events, Solo Acting, Pantomime and Readers Theatre. I felt overwhelmed; I had to learn new events and parts with only two weeks to prepare. At the state meet, we are not allowed to compete with scripts, so all my parts had to be memorized. I felt that I could not do it. There was no way.

With the help of my parents and my school teachers I was somehow able to prepare. It was finally the day. I competed and did well. I took First place in Solo Acting, Second in Readers Theatre and Third in Pantomime.

As I looked back on the preparation and the end result, I realized how close I had come to giving up. I learned never to give up. I also learned that for every bit of preparation, there is a reward.
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.
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Reader Response
When cross-Pathy is banned and is unlawful, how come Govt. Health officials distribute homeopathy medicines to public to prevent Swine flu. I feel it is illegal to recommend them. Kindly clarify. Regards: Dr B Srinivasulu, Aditya Nursing home, Adoni, Andhra Pradesh.
Wellness Blog
Diet is linked to the diabetes epidemic

A study published in the journal Diabetes Care, has highlighted the importance of the whole diet rather than focusing on certain foods or food groups that might be beneficial.

A diet rich in whole grains, fruits and vegetables (leafy green), nuts and low-fat dairy may help people lower their risk of type 2 diabetes by 15% over 5 years than those who ate the lowest amounts of these foods.

Also, a diet which contains high amounts of red meat, high-fat dairy and refined grains like white bread may boost the odds of diabetes development by 18%.

Type 2 diabetes is closely linked to obesity and it is well-known that maintaining a healthy weight through diet and exercise reduces the risk of developing the disease. Diet affects diabetes risk independent of a person’s weight.
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IMA Humor
Dream of a necklace

After she woke up, a woman told her husband, "I just dreamed that you gave me a pearl necklace for our anniversary. What do you think it means?"

"You’ll know tonight." he said.

That evening, the man came home with a small package and gave it to his wife.

Delighted, she opened it to find a book entitled "The Meaning of Dreams."
All patients with TB should be tested for HIV as a routine
The Indian Medical Association (IMA) recommends HIV screening for all TB patients after the patient is notified unless the patient declines (opt-out screening), said Padma Shri Awardee Dr A Marthanda Pillai National President IMA and Padma Shri Awardee Dr KK Aggarwal Honorary Secretary General IMA. This includes persons with TB disease and persons with latent TB infection.

Routine HIV testing is also recommended for persons suspected of having TB disease, persons diagnosed with latent TB infection, and contacts to TB patients. Prevention counseling and separate written consent for HIV testing should no longer be required.

A resolution was passed by IMA during their annual national review meeting on TB held in the city here today. Additional DDG, Central TB Division, Ministry of health, Dr Niraj Kulshreshtha and Dr K S Sachdeva, present on the occasion as Guests of Honor, said this is as per Govt of India guidelines.

Following were the main points of the discussion.
  • HIV infection is the most important known risk factor for progression from latent TB infection to TB disease.
  • Progression to TB disease is often rapid among people infected with HIV and can be deadly.
  • TB outbreaks can rapidly expand in patient groups infected with HIV.
  • Targeted HIV testing based on provider assessment of patient risk behaviors fails to identify a substantial number of people who are infected with HIV.
  • Many individuals may not perceive themselves to be at risk for HIV or do not disclose their risks.
  • Routine HIV testing reduces the stigma associated with testing.
  • When HIV is diagnosed early, appropriately timed interventions can lead to improved health outcomes, including slower progression and reduced mortality.
  • Identifying TB patients, suspects and contacts infected with HIV allows for optimal TB testing of these groups and provides opportunities to prevent TB in those without disease.
  • Both TB and HIV treatments are available free from the government under one window.
  • HIV testing can be done using the rapid card tests.