February 4  2015, Wednesday
IMA SLIM Initiative
Dr KK Aggarwal;
Choose Wisely: SLIM
S. No
Rajesh Malhotra
G Karthikeyan
Internal Medicine
Praveen Agarwal
Rajendra Prasad
Neerja Bhatla
Rakesh Lodha
Rajesh Thakkar
Lalit Kumar
Achal Srivastava
S Mahajan
Promod Garg
Amlesh Seth
Radhika Tandon
Raju Sharma
Draft for cardiology

Five practices that should be avoided by cardiologists

1. Coronary CT angiography should NOT be used as a “screening” test in asymptomatic individuals without clinical suspicion of CAD

2. Cardiac stress testing is NOT indicated in asymptomatic individuals at low risk of coronary events.

Non-invasive testing in patients with suspected coronary artery disease (CAD) should be based on the assessment of their pre-test probability of having disease determined from clinical evaluation (e.g., presence of symptoms and risk factors). Patients with an intermediate pre-test probability (15- 85%) of having CAD should undergo stress testing.1 Coronary CTA may sometimes be considered as an alternative to rule out significant CAD in patients in the lower range of intermediate pre-test probability.1 Neither stress testing nor coronary CTA is useful in patients with a low pre-test probability of CAD.1,2

Asymptomatic patients may be further stratified by the risk of future CAD events using either the QRISK2, ASCVD, or other validated scores. Patients who are categorized as having a 10-year risk <10% will not benefit from stress testing or coronary CTA.3

Indiscriminate use of stress testing with imaging and coronary CTA expose patients to the risk of radiation and iodinated contrast, and the anxiety, costs and harms of the resulting downstream invasive testing and interventions, which may not be indicated.

3. Annual cardiac stress testing should NOT be performed as part of routine follow-up evaluation of asymptomatic individuals or those with stable symptoms

Periodic stress testing in asymptomatic individuals or patients with stable disease (i.e., testing not prompted by changes in symptom status) are considered inappropriate.3 The widely prevalent annual health check-ups involving stress testing should be discouraged.

4. Patients undergoing non-cardiac surgery, who have moderate to good functional capacity (=4 METs), OR have no risk factors for CAD, should NOT undergo echocardiography or stress testing as part of routine pre-operative evaluation

Patients who are active and have moderate to good functional capacity (i.e., they can exercise =4 METs) and those without risk factors for CAD are unlikely to benefit from routine assessment of left ventricular or function stress testing.3 On the contrary, such an approach may cause more harm by delaying elective surgery.

5. Patients presenting late (>72 hours) after STEMI should NOT have angioplasty for an occluded infarct related artery without evidence of ischemia or viability

Patients with an occluded infarct related artery do not benefit from a strategy of systematic percutaneous coronary angioplasty performed after 72 hours of an ST elevation MI.2 Decisions about revascularization should be made based on the presence of symptoms, evidence of ischemia/viability in the infarcted territory.

  1. Task Force M, Montalescot G, Sechtem U, et al. 2013 ESC guidelines on the management of stable coronary artery disease: the Task Force on the management of stable coronary artery disease of the European Society of Cardiology. Eur Heart J 2013;34:2949-3003.
  2. Authors/Task Force m, Windecker S, Kolh P, et al. 2014 ESC/EACTS Guidelines on myocardial revascularization: The Task Force on Myocardial Revascularization of the European Society of Cardiology (ESC) and the European Association for Cardio-Thoracic Surgery (EACTS)Developed with the special contribution of the European Association of Percutaneous Cardiovascular Interventions (EAPCI). Eur Heart J 2014;35:2541-619.
  3. Wolk MJ, Bailey SR, Doherty JU, et al. ACCF/AHA/ASE/ASNC/HFSA/HRS/SCAI/SCCT/SCMR/STS 2013 multimodality appropriate use criteria for the detection and risk assessment of stable ischemic heart disease: a report of the American College of Cardiology Foundation Appropriate Use Criteria Task Force, American Heart Association, American Society of Echocardiography, American Society of Nuclear Cardiology, Heart Failure Society of America, Heart Rhythm Society, Society for Cardiovascular Angiography and Interventions, Society of Cardiovascular Computed Tomography, Society for Cardiovascular Magnetic Resonance, and Society of Thoracic Surgeons. J Am Coll Cardiol 2014;63:380-406.
CPR10 Camp at Bal Bharti Public School Dwarka 8th December 2013
News Around the Globe
  • Two-thirds of medication-related visits (MRVs) to the emergency room by pediatric patients were deemed preventable, and the most common reason for those MRVs was an adverse drug reaction in a prospective observational study. Peter Zed, BSc, PharmD, of the University of British Columbia in Vancouver, and colleagues, reported that 65% of pediatric ER visits were defined as preventable "if drug treatment or lack thereof was inconsistent with current best practice." Medication-related visits were most frequently associated with adverse drug reactions (26.4%) followed by sub-therapeutic dosage (19.0%) and nonadherence (17.2%). (Medpage)
  • Ebola vaccine trial opens in Liberia: A large clinical trial to assess the safety and efficacy of two experimental vaccines to prevent Ebola virus infection is now open to volunteers in Liberia. The trial is being led by a recently formed Liberia-U.S. clinical research partnership and is sponsored by the National Institute of Allergy and Infectious Diseases (NIAID), part of the National Institutes of Health. The Partnership for Research on Ebola Vaccines in Liberia or PREVAIL, a Phase 2/3 study, is designed to enroll approximately 27,000 healthy men and women aged 18 years and older.
  • A new study shows how lurking pools of dormant HIV may hold the secret to curing the disease. Researchers, in their report published in the journal Cell, state that HIV cure possibly lies in targeting dormant virus reserves.
  • All adults aged 65 and above should now have the 13-valent pneumococcal conjugate vaccine (PCV13) in addition to the 23-valent pneumococcal polysaccharide vaccine (PPSV23) to protect against pneumococcal infection, suggests the 2015 Advisory Committee on Immunization Practices (ACIP) Recommended Immunization Schedule for adults being published in Annals of Internal Medicine.
  • An oral supplement containing arginine, zinc, and antioxidants seems to improve healing of mild to severe pressure ulcers in malnourished patients, suggests an article published in Annals of Internal Medicine.
  • The US Food and Drug Administration (FDA) has approved a new formulation of hydrocodone with abuse-deterrent properties. The product will be formulated with BeadTek, a technology designed to provide abuse-deterrent properties without changing the release properties of hydrocodone.
  • A new report published in Mayo Clinic Proceedings advises people to replace processed foods containing high levels of added sugars and fructose with whole foods such as fruit and vegetables. Added fructose has been identified as major driver of type 2 diabetes 'epidemic'.
Dr KK Spiritual Blog
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 positive thoughts back. Ideal mind is devils workshop and will always think negative.

Here are the 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 that why wait for 25 years consider me as you son from today.
  • Think opposite as taught by Patanjali. For example if you are thinking of stealing, then silently start thinking of charity.
  • Think positive as taught by Buddha. Make a list of positive actions to be done today the first thing in the morning and concentrate on that list. Divert your mind to the pending works. This is a type of behavioral therapy.
Cardiology eMedinewS
  • A new compound, called AP39, which generates minute quantities of the gas hydrogen sulfide inside cells, could be beneficial in cases of high blood pressure and diseases of the blood vessels that occur with ageing and diabetes, suggests a new report published in the Nitric Oxide Journal.
  • A minimally invasive procedure to repair severe mitral valve regurgitation by clipping together the valve's leaflets can improve function and quality of life and reduce the risk of hospitalization, suggests new research presented at the 27th annual International Symposium on Endovascular Therapy (ISET).
Pediatrics eMedinewS
  • A new study from the Centers for Disease Control and Prevention finds the majority of pre-packaged meals and snacks for toddlers contain high levels of salt or sugar, putting children's health at risk. The study is published in the journal Pediatrics.
  • Overweight children are just as likely as thin children to have celiac disease, reveals a new study published in the Journal of Pediatric Gastroenterology and Nutrition.
Make Sure
Situation: A patient on amlodipine developed severe gum hypertrophy.
Reaction: Oh my God! Why was amlodipine not stopped?
Lesson: Make sure that all patients on amlodipine are observed for gum hypertrophy, which is a side effect of amlodipine.
Beneficiaries of Heart Care Foundation Fund
(Contributed by Dr MC Gupta, Advocate)

Q. A patient was advised admission but he declined to be admitted. His condition deteriorates. He files a complaint against the doctor alleging negligence, saying that the doctor should have advised admission but he never did so. The doctor has a carbon copy of the prescription given to the patient where he has written that "Advised admission. Refused". It does not bear the signature of the patient. What is its legal validity?

It may have some validity but the patient is likely to say that:
  • He was not given any prescription slip at all. OR
  • He has lost the slip but it did not contain the words "Advised admission. Refused" and that these words have been added later on.
It is advisable that the refusal should be signed by the patient. If he refuses to sign, this fact should be testified by somebody else such as another doctor or staff member.
Dr Good Dr Bad
Situation: A patient with hypertension had non–responding cough.
Dr. Bad: Take an X–ray.
Dr. Good: Stop ACE inhibitors.
Lesson: The commonest cause of cough in a patient with high blood pressure is the intake of ACE inhibitors.

(Copyright IJCP)
IJCP Book of Medical Records
IJCP’s ejournals
Twitter of the Day
Dr KK Aggarwal: Inhaling diesel exhaust Fumes causes heart attack or stroke http://bit.ly/15QdVeB #Health
Dr Deepak Chopra: Fear is the memory of pain. Addiction is the memory of pleasure. Freedom is beyond both. http://bit.ly/15QdVeB #Health
CPR 10
Total CPR since 1st November 2012 – 101090 trained
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,
Rabies News (Dr A K Gupta)
Can IDRV be given in private hospital?
The ID route has been permitted to be used in selected anti–rabies clinics (ARCs) having an adequate number of patients (at least 5/day) seeking post–exposure prophylaxis against rabies every day to make IDRV viable and cost–effective.
About the Editor
Padma Shri, National Science Communication and Dr B C Roy National Awardee, Honorary Secretary General IMA, Immediate Past Senior National Vice President IMA, Professor of Bioethics SRM University, Sr. Consultant Medicine & Cardiology, Dean Board of Medical Education, Moolchand, President Heart Care Foundation of India, Chairman Legal Cell Indian Academy of Echocardiography, Editor in Chief IJCP Group of Publications & eMedinewS, Member Ethics Committee Medical Council of India (2013-14), Chairman Ethical Committee Delhi Medical Council (2009-14), Elected Member Delhi Medical Council (2004-2009), Chairman IMSA Delhi Chapter (March 10- March13), Director IMA AKN Sinha Institute (08-09), Finance Secretary IMA (07-08), Chairman IMAAMS (06-07), President Delhi Medical Association (05-06)
Govt to sell 504 drugs under 'Jan Aushadhi'

Sushmi Dey, TNN | Feb 3, 2015, 12.54 AM IST

NEW DELHI: From July 1, you can walk up to a chemist and ask for a 'Jan Aushadhi' brand for your medicine, with the government set to launch its own brand to sell low cost generic medicines. The Centre will procure medicines in bulk from public as well as private drug manufacturing firms and rebrand them under 'Jan Aushadhi'. These will be sold in the retail market at a competitive price, allowing consumers to buy a cheaper yet quality product from the government, official sources said.

To start with, the government has identified 504 essential medicines, which include antibiotics, painkillers, vitamins and medicines used in treatment of cardiovascular, respiratory, diabetes and gastroenterology diseases. "In the first phase, we have mostly identified medicines from the top 100 drugs based on their sales. More medicines as well as medical devices will be included in the second phase," an official in the know of developments told TOI.

In the first phase, these drugs will be made available to 800 select chemists, mostly across Delhi. However, the government plans to expand the reach to most metros by the end of the year.

The Bureau of Pharma Public Sector Undertakings of India (BPPI), the nodal agency under the department of pharmaceuticals (DoP) for implementing this project, has already floated the tender seeking application for supply of medicines for the programme.

The Indian pharmaceutical retail market, pegged at Rs 87,000 crore annually, is dominated by branded generic products, unlike developed markets like the US and Europe. In other words, while there are very few patented medicines sold in India, most of the medicines available in the market are branded products sold by private firms.

Pharmaceutical firms spend huge amounts in creating these brands. However, since prescription-based medicines cannot be promoted through advertisements, companies often push these brands through doctors and chemists. Consumers, who are often unable to make an informed choice for purchasing medicines, have to rely on the doctor's prescription or on chemists. The government's latest move providing an umbrella brand for generic drugs is aimed at enabling consumers to make that choice.

However, there are concerns on whether the government will be able to maintain and monitor quality of all products sold under this brand since they will be procured from different firms. Government officials say procurement norms and sampling will ensure quality control.

The government, along with BPPI, has held consultations with various stakeholders including pharmaceutical firms to ensure there is regular and adequate supply of medicines. The proposal has also been vetted by the doctor fraternity, bringing on board the Medical Council of India as well as the Indian Medical Association to ensure doctors prescribe Jan Aushadhi drugs.

"Initially, the government had apprehensions that doctors would not support such a move because it may hurt the private sector. However, we have ensured them full support if the quality of products is maintained," IMA secretary general K K Aggarwal said. Once the brand is rolled out, the government also plans to make it mandatory for public hospitals to prescribe it wherever possible, an official said.


Child Sexual Abuse: Prevention & Response

Sexual offences under the POCSO (Protection of Children from Sexual Offences) Act 2012
  • Actual or attempted penetrative sexual intercourse with a child;
  • Non-penetrative sexual activity e.g. rubbing the penis between the child’s thighs or genitals;
  • Fondling a child’s sexual parts, i.e. genitals, breasts or buttocks;
  • Oral sex with a child, i.e. mouth to sexual parts;
  • Forcing a child to masturbate another person;
  • Masturbating a child;
  • The adult showing his or her private parts to the child
  • Inappropriately watching the child undress or using the bathroom;
  • Photographing a child in sexual poses;
  • The exploitative use of a child in prostitution or any other unlawful sexual practice;
  • The exploitative use f children in pornography;
  • Showing pornography or any pictures of a sexual nature to the child that he or she does not want to see ; and
  • Letting the child watch or hear a act of sexual intercourse.
Dr DS Bhullar

NABH Update

Wellness is a state of optimal health covering physical, mental, social aspects of an individual.

Tip of the day for safe and effective strength training

Use proper form to avoid injuries and maximize gains.

10 Worst Medical Treatment Dangers 2015

Patient-Handling Device Errors

A survey of 1000 hospitals found that patient-handling injuries, often caused by improper use of devices to move patients, accounted for 25% of all workers' compensation claims for the healthcare industry in 2011. For example: With patient lift devices, a sling was not attached properly or the lift was overloaded. ECRI's testing of mobile patient lifts found that some could deform when overloaded. FDA has noted that tipping of the lift is a concern if the patient's weight shifts or if the lift is not positioned correctly underneath the bed. When using transfer boards, caregivers should avoid shearing forces when inserting the board under the patient, particularly for those with pressure ulcers or burns.

(Source: Medscape)

Medscape Family Physician Lifestyle Report 2015

What are the Family Physicians’ favorite pastimes?

When asked about favorite pastimes, burned-out family physicians and their less stressed peers tended to like the same ones to the same degree. Percentages were nearly identical for all, with about 79% of family physicians in both groups preferring to spend time with family. However, this was lower than the percentage reported in 2013 (86% of burned-out family physicians and 89% of non–burned-out peers). About two thirds of all family physicians like travel and exercise. Both non–burned-out and burned-out family physicians far preferred reading (57%, 56%) and cultural events (47%, 45%) to outdoor sports such as golf (12%, 11%) and hunting or fishing (11%, 10%).


Inspirational Story
The Lesson of the Homeless

It was a cold winter's day that Sunday. The parking lot to the church was filling up quickly. I noticed as I got out of my car fellow church members were whispering among themselves as they walked in the church.

As I got closer I saw a man leaned up against the wall outside the church. He was almost lying down as if he was asleep. He had on a long trench coat that was almost in shreds and a hat topped his head, pulled down so you could not see his face. He wore shoes that looked 30 years old, too small for his feet, with holes all over them, his toes stuck out.

I assumed this man was homeless, and asleep, so I walked on by through the doors of the church.

We all fellowshipped for a few minutes, and someone brought up the man lying outside. People snickered and gossiped but no one bothered to ask him to come in, including me.

A few moments later church began. We all waited for the Preacher to take his place and to give us the Word, when the doors to the church opened.

In came the homeless man walking down the aisle with his head down. People gasped and whispered and made faces.

He made his way down the aisle and up onto the pulpit where he took off his hat and coat. My heart sank.

There stood our preacher...he was the "homeless man." No one said a word. The preacher took his Bible and laid it on his stand.

"Folks, I don't think I have to tell you what I am preaching about today. If you judge people, you have no time to love them."
Quote of the Day
Nothing ever comes to one that is worth having, except as a result of hard work. Booker T. Washington
IMA in the News
  • Govt. to sell 504 drugs under Jan Aushadi: TOI
  • 200 hundred cases Swine Flu - Panic created: Navodaya Times
  • IMA Flu Update on Antiviral Drug Oseltamivir: Hari Bhoomi
  • Anti viral medicine is not needed for normal flu: Virat Vaibhav
  • Anti viral medicine is not needed for normal flu: Mahamedha
  • Mild to moderate flu requires no antiviral drugs: IMA: India Medical Times
IMA in Social Media
https://www.facebook.com/ima.national 28036 likes
https://www.facebook.com/imsaindia 46044 likes
https://www.facebook.com/imayoungdoctorswing 378 likes
Twitter @IndianMedAssn 767 followers
http://imahq.blogspot.com/ www.ima-ams.org
Reader Response
Dear Sir, Very informative newspaper. Regards: Dr Kalpana
Wellness Blog
Skin care
  • Clean with soap and water.
  • Moisturizers can make the skin dirty.
  • Dryness is better than being dirty.
  • No soap is a better soap.
  • Glycerin is the safest moisturizer.
  • Rub hard but take care to not cause bruises.
  • Soap emulsifies, therefore, one should remove 100% of surface part.
  • Killing the normal flora of the skin is a bad idea. Therefore, do not use antiseptic soaps.
  • Remember, Dettol does not kill pseudomonas infection.
Can creams and oils penetrate skin?
  • The answer is no.
  • Oil cannot be absorbed.
  • Nutrition cannot be absorbed from the skin.
  • Almond cannot be absorbed from the skin.
  • Unless the skin is damaged, nothing can be absorbed.
  • For absorption, an occlusive dressing has to be used over a patch with a bandage, only then the drug can be absorbed. The bandage damages the skin because of preparation of moisturizer and heat. Any agent, which is irritating, can cause inflammation, erosion and then only a drug can be absorbed.
  • If the skin is damaged, it can cause inflammation and can cause dermal pigmentation.
  • Ultrasound techniques can be used to increase absorption.
  • Newer drugs are getting absorbed through nano techniques.
eMedi Quiz
Raised serum level of lipoprotein (a) is a predictor of:

1. Cirrhosis of liver.
2. Rheumatic arthritis.
3. Atherosclerosis.
4. Cervical cancer.

Yesterday’s Mind Teaser: Commonest cause of sporadic encephalitis is:

1. Japanese B virus
2. Herpes simplex virus.
3. Human Immunodeficiency virus.
4. Rubeola virus.

Answer for yesterday’s Mind Teaser: 2. Herpes simplex virus.

Correct Answers received from: Dr Poonam Chablani, Dr. Jainendra Upadhyay, Dr Avtar Krishan, Daivadheenam Jella

Answer for 2nd Feb Mind Teaser: 3. No surgery for gallbladder stones.

Correct Answers receives: Daivadheenam Jella, Tukaram Pagad, Dr Avtar Krishan, Dr M Mahesh, Dr Jainendra Upadhyay.
IMA Videos
News on Maps
The Year in Medicine 2014: News That Made a Difference
Readers Respond: The Biggest Medical News of the Year

In a Medscape survey of our members in November, the Ebola outbreak was the biggest medical news of the year. Sixty-eight percent of respondents picked Ebola compared with 8% for the maintenance of certification debate, 7% for the first birth by a woman with a uterine transplant, and 5% for new guidelines expanding the use of statins. Nearly 5% of respondents wrote in other suggestions, including new drugs to cure hepatitis C without interferon; the effects of the Affordable Care Act/Obamacare; improved outcomes in early non-small-cell lung cancer detected with CT scans; and the morcellation debate. (Source: Medscape)
Video of the Day
Press Release of the Day
Drinking Coffee Prevents Parkinson’s disease

Nicotine in tobacco has been used for its medicinal value for quite some time for diseases like Parkinson’s disease and ulcerative colitis. A study from University of Miami School of Medicine, USA, has shown that people from families prone to Parkinson’s disease are less likely to develop the disease if they drink coffee on a regular basis, 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

IMA, commenting on the study said that both coffee and nicotine have a link with dopamine in the brain. Dopamine is a chemical that decreases in patients with Parkinson’s disease.

It is possible that people who are going to have Parkinson's disease have lower levels of dopamine. Those with low levels of dopamine may be more likely to enjoy caffeine.

Parkinson's disease is caused when brain cells that produce dopamine die. The disease is progressive, affecting about one percent of people older than 65.

Symptoms begin with shaking and can progress to paralysis. There is no cure, although a number of drugs can make symptoms better for a time.
IMA Humor
Cab Drivers
Two cab drivers met. "Hey," asked one, "why did you paint one side of your cab red and the other side blue?"

"Well," the other responded, "when I get into an accident, you should see how all the witnesses contradict each other.