March 4  2015, Wedbesday
editorial
Managing diabetes
Dr KK Aggarwal
  • If no contraindications are present always start with metformin as initial therapy in most patients with type 2 diabetes. However, consider insulin as first–line drug in patients presenting with A1c >10%, fasting sugar >250 mg/dL, random sugar consistently >300 mg/dL, or ketonuria.
  • Start with metformin at the time of diabetes diagnosis, along with lifestyle interventions. Titrate dose to its maximally effective dose (2000–2500 mg/day) over 1 to 2 months.
  • If situations predisposing to lactic acidosis are present, avoid metformin and consider a shorter–duration sulfonylurea.
  • Star with lifestyle intervention first, at the time of diagnosis. If lifestyle interventions have not produced a significant reduction in symptoms of hyperglycemia or in sugar levels after 1 or 2 weeks, add the first drug.
  • Those who cannot be given metformin or sulfonylureas, repaglinide is an alternative, particularly in a patient with chronic kidney disease at risk for hypoglycemia.
  • Other alternative is a pioglitazone, which may be considered in patients with lower initial A1c values or if there are specific contraindications to sulfonylureas. There is a concern about atherogenic lipid profiles and a potential increased risk for cardiovascular events with rosiglitazone.
  • One can consider sitagliptin as monotherapy for those intolerant of or have contraindications to metformin, sulfonylureas, or thiazolidinediones. It is a drug of choice as initial therapy in a patient with chronic kidney disease at risk for hypoglycemia. It is however, less potent than repaglinide, which can also be used safely in patients with chronic kidney disease.
  • In patients in whom it is difficult to distinguish type 1 from type 2 diabetes, start with insulin.
  • Further adjustments of therapy should be made every three months based on the A1C result aiming it close to the non diabetic range. If A1c values >7%, one need to further adjust the diabetic regimen.
  • If A1c remains >7% another drug should be added within 2 to 3 months of initiation of the lifestyle intervention and metformin.
eMedipics

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News
  • Patients with recent-onset myalgic encephalomyelitis/chronic fatigue syndrome had distinct alterations in plasma immune signatures, reported an analysis of data and blood specimens from two large multicenter cohort studies. The data were published online in Scientific Advances.
  • Paracetamol, or acetaminophen, may have more risks than originally thought, particularly when it is taken at the higher end of standard therapeutic doses, suggests a new systematic review published online March 1 in BMJ.
  • Excess weight and smoking might each raise the likelihood of frequent heartburn or gastroesophageal reflux disease (GERD), suggests a new study published online in the American Journal of Gastroenterology.
  • The interim analysis of a phase 2 randomized trial revealed that the combination of the new antiangiogenic agent ramucirumab and docetaxel significantly increased progression-free survival (22 weeks) as compared with docetaxel alone (10.4 weeks) in advanced or metastatic urothelial carcinoma. The findings were presented at the Genitourinary Cancers Symposium (GUCS) 2015.
  • Preliminary studies suggest that a transurethral convective water vapor system may safely provide clinical benefit in patients with benign prostatic hyperplasia (BPH). The report is published online in Research and Reports in Urology.
Dr KK Spiritual Blog
Why do we apply holy ash?

Bhasma is the holy ash produced from the Homa, the sacrificial fire, wherein special wood along with ghee and other herbs are offered as a part of pooja. By the time a Bhasma is formed, no trace of original matter remains in the ash. Ash obtained from any burnt object is not bhasma.

The ritual involves worshipping the deity by pouring ash as abhishek and then distributing it as Bhasma, which is then applied on the forehead (usually), upper arms, chest, or rubbed all over the body. Some consume a pinch of Bhasma when they receive it.

The word Bhasma is derived from “bha” or "bhartsanam" ("to destroy") and "sma" or "smaranam" ("to remember"). It denotes "that by which our sins are destroyed and the Lord is remembered". Bhasma is also called vibhuti, which means glory. Bhasma is associated with Lord Shiva who applies it all over His body.

Spiritually, the Homa is the offering of oblations into the fire with sacred chants and signifies offering or surrender of the ego and egocentric desires into the fire of knowledge. The resultant ash signifies the purity of the mind. The fire of knowledge burns the oblation and wood signifying ignorance and inertia respectively.

The application of ash implies that one should burn false identification with the body.

Bhasma has medicinal values in Ayurveda. It is supposed to be the strongest of all Ayurveda preparations. According to Ayurveda, a Bhasma is formed when the matter is converted into non matter by the process of homa. The non matter is the spirit or the energy of the matter being processed with strong healing powers. It has the same significance as any ‘potentised’ medicine in homoeopathy.

It absorbs excess moisture from the body and prevents colds and headaches.

When applied with a red spot at the centre, the mark symbolizes Shiva–Shakti (the unity of energy and matter that creates the entire seen and unseen universe).

The Upanishads say that the famous Mrityunjaya Mantra should be chanted whilst applying ash on the forehead.
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Cardiology eMedinewS
  • For patients with paroxysmal and persistent atrial fibrillation (AF), losing weight may lead to a significant reduction in pericardial adipose tissue and favorable changes in cardiac structure, suggests a new study published online in the American Heart Journal.
  • About one-third of patients with nonischemic disease in a major cardiac resynchronization therapy (CRT) trial had cardiomyopathy related to premature ventricular contractions (PVCs) that might have been amenable to catheter ablation or other non-CRT therapy, suggests a new report published in the Annals of Noninvasive Electrocardiology.
Pediatrics eMedinewS
  • Sensitivity to cats and dust mites, identified on skin-prick testing in children up to 4 years of age, might predict the risk of developing asthma by age 7, suggests a new study presented at the American Academy of Allergy, Asthma & Immunology 2015.
  • Many children with neonatal encephalopathy have cognitive impairment that persists into the early school years, reported a new study of participants in an earlier hypothermia trial. The findings are published online in Pediatrics.
Event
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Make Sure
Situation: A patient with acute chest pain died before reaching the hospital.
Reaction: Oh my God! Why was water–soluble aspirin not given?
Lesson: Make sure that at the onset of acute heart attack and chest pain, water–soluble aspirin is chewed to reduce chances of sudden death.
Medicolegal
Dr Sudhir Gupta, Prof & Head, Forensic Medicine & Toxicology, AIIMS

What is The Medical Termination of Pregnancy Act, 1971?
  • It is an act to provide for the termination of certain pregnancies by registered medical practitioners.
  • Abortion or miscarriage is the premature expulsion of the fetus from the mother’s uterus at any time of the pregnancy before the full term pregnancy is complete.
  • Abortion may be i) Natural, i.e. spontaneous or accidental or ii) Artificial, i.e., therapeutic justifiable, eugenic, humanitarian or social grounds.
  • The Statement of Objects and reasons for introducing the Medical Termination of Pregnancy Bill, 2002 is as under: “The provisions regarding the termination of pregnancy in the Indian Penal Code which was enacted a century ago were drawn up in keeping with the then British Law on the subject. Abortion was made a crime for which the mother as well as the abortionist could be punished except where it had to be induced in order to save the life of the mother. It had been stated that this very strict law has been observed in the breach in very large number of cases all over the country. Furthermore, most of these mothers are married women, and are under no particular necessity to conceal their pregnancy.”
  • In recent years, when health services are expanded and hospitals availed to the fullest extent by all classes of the society doctors have often been confronted with gravely ill or dying pregnant women whose pregnant uterus have been tampered with a view to causing an abortion and consequently suffered very severely.
Dr Good Dr Bad
Situation: A patient with chest pain could pinpoint his pain.
Dr. Bad: It is a classical heart attack.
Dr. Good: It is non-cardiac chest pain.
Lesson: A cardiac chest pain can never be pinpointed by a finger.

(Copyright IJCP)
IJCP Book of Medical Records
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Quote of the Day
Determine what specific goal you want to achieve. Then dedicate yourself to its attainment with unswerving singleness of purpose, the trenchant zeal of a crusader. Paul J. Meyer
IMA,IJCP,HCFI
eMedi Quiz
Epidermodysplasia veruniciformis is caused by which of the following HPV serotypes:

a.1
b.3
c.5
d.11

Yesterday’s Mind Teaser: Presence of food might be expected to interfere with drug absorption by slowing gastric emptying, or by altering the degree of ionization of the drug in the stomach. Which of the following statements is not a correct example?

1. Absorption of digoxin is delayed by the presence of food.
2. Concurrent food intake may severely reduce the rate of absorption of phenytoin.
3. Presence of food enhances the absorption of hydrochlorothiazide.
4. Anitimalarial drug halofantrine is more extensively absorbed if taken with food.

Answer for yesterday’s Mind Teaser: 3. Presence of food enhances the absorption of hydrochlorothiazide.

Correct Answers received from: Dr KV Sarma, Dr Poonam Chablani, Raju Kuppusamy, Dr Jainendra Upadhyay.

Answer for 2nd March Mind Teaser: 3. Low oral bioavailability always and necessarily mean poor absorption.

Correct Answers receives: Dr Jainendra Upadhyay, Daivadheenam Jella, Dr Avtar Krishan.
Rabies News (Dr A K Gupta)
What is pre–exposure vaccination?

Pre–exposure (Prebite) vaccination means immunization before the bite.
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
IMA & UNICEF Pledge
Child Sexual Abuse: Prevention & Response

Grooming: It is method of building trust with a child and adults around the child in an effort to gain access to the child and increase the chances that the child will not consider the sexual advances of the perpetrator untoward or improper. However, in extreme cases, offenders may use threats and physical force to sexually assault or abuse a child.

Dr DS Bhullar, Asso Prof (D) Forensic Medicine & Toxicology, Patiala
Inspirational Story
This is Good!

The story is told of a king in Africa who had a close friend with whom he grew up. The friend had a habit of looking at every situation that ever occurred in his life (positive or negative) and remarking, "This is good!"

One day the king and his friend were out on a hunting expedition. The friend would load and prepare the guns for the king. The friend had apparently done something wrong in preparing one of the guns, for after taking the gun from his friend, the king fired it and his thumb was blown off.

Examining the situation the friend remarked as usual, "This is good!" To which the king replied, "No, this is NOT good!" and proceeded to send his friend to jail.

About a year later, the king was hunting in an area that he should have known to stay clear of. Cannibals captured him and took them to their village. They tied his hands, stacked some wood, set up a stake and bound him to the stake. As they came near to set fire to the wood, they noticed that the king was missing a thumb. Being superstitious, they never ate anyone that was less than whole. So untying the king, they sent him on his way.

As he returned home, he was reminded of the event that had taken his thumb and felt remorse for his treatment of his friend. He went immediately to the jail to speak with his friend. "You were right," he said, "it was good that my thumb was blown off." And he proceeded to tell the friend all that had just happened. "And so I am very sorry for sending you to jail for so long.

It was bad for me to do this." "No," his friend replied, "This is good!" "What do you mean, 'This is good'? How could it be good that I sent my friend to jail for a year?" "If I had NOT been in jail, I would have been with you."

Situations may not always seem pleasant while we are in them, but the promise of God is clear. If we love Him and live our lives according to His precepts, even that which seems to be bleak and hopeless will be turned by God for His glory and our benefit. Hold on, God is faithful! May God bless you this week as you seek His will in every situation.
Wellness Blog
Amiodarone linked to Cancer Risk in Men

The risk of cancer is increased in men taking amiodarone particularly in those with extensive exposure to the drug as per a retrospective study. Among men taking amiodarone, the risk for any cancer rose by almost 20% compared with the general population, according to Chia–Jen Liu, MD, of National Yang–Ming University Hospital in Yilan, Taiwan, and colleagues. And for men whose cumulative defined daily doses in a year exceeded 180, the risk was 46% higher the researchers reported online in the journal Cancer.
Media
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Was Govt prepared for swine flu?
Ritwika Mitra, March 2, 2015 DHNS

Could have been better handled if health dept planned ahead, say experts

With the capital witnessing at least 2,999 swine flu cases and 10 deaths this year, health experts say the situation could have been better handled here if the health department had planned ahead.

According to doctors, the season for swine flu cases will now be over with the temperature on the rise. However, panic has gripped the capital with the general public making a beeline for masks and going for tests for the H1N1 virus. Private chemists are seeing a sale of between 200-250 masks everyday. Commuters in public transport and crowded places are seen wearing masks.

The city is also reeling under the shortage of vaccines and Tamiflu syrups for children. Two weeks back, there was a shortage of Tamiflu capsules as well for two days before the government stepped up the stocks. The drug was not available at private chemist shops either.

With no government at the state before the Aam Aadmi Party came to power on February 14, there was a lack of coordination between the state and the Centre in handling the situation, say experts.

The lack of guidelines at an early stage triggered panic among the public who did not know for a significant period of time on the dos and don’ts of the infection or other necessary details like when to go for a swine flu test. Timely awareness could have helped avoid spreading panic among the public.

Recently, the government has taken innovative measures like booking announcement slots in the Metro discussing the “seasonal flu”.

Early intervention

“The regulations should have been in place from an early stage. The government should have issued guidelines on how people with suspected swine flu should not travel in public transport to avoid an outbreak of the infection. Mega events or gatherings should have been banned. But such instructions are still missing. The need of the hour is effective coordination between the Centre and the state and a clear cut policy for vaccination,” says Dr K K Aggarwal, Honourary Secretary General, Indian Medical Association (IMA).

The advertisements were issued once there was a spike in the number of cases in January. Since the beginning of the year, the capital has seen a total of 2,999 cases, according to figures by the Directorate of Health Services (DHS). Tests for swine flu were also carried out indiscriminately with the total number of tests conducted on a day even crossing 900.

The government had issued guidelines to private laboratories to test only Category C patients or those who are hospitalised and have shown severe manifestations of the flu. However, walk-in tests still continue, often adding to the panic. Category-B patients or those who are at a higher risk like pregnant women, children below the age of five, those above 60 years of age or those suffering from co-morbid conditions like diabetes, hypertension and showing signs of the flu also do not get tested. In this case, it is best to start treating them with Tamiflu drugs, said doctors.

“Panic-stricken people made a queue for the expensive swine flu tests even though they were suffering from seasonal flu. The labs also continued to overcharge them till the government put a ceiling on the price. Only high-risk people or those hospitalised need to get tested,” says Dr Naresh Chawla, member of the Delhi Medical Association (DMA).

Laboratories in city

The government put a sealing on the charges by private laboratories at Rs 4,500 after it was flooded with complaints of over-charging by the labs.

Currently, there are only three government laboratories which are authorised to carry out tests of swine flu. These include the National Centre for Disease Control, AIIMS and VP Patel?Chest Institute. Currently; AIIMS?is handling 80-100 samples everyday now, including samples from Safdarjung Hospital, Madan Mohan Malviya Hospital and Holy Family Hospital.

“Of the samples being tested, 30-35 per cent are testing positive. The test reports are being cleared in a day when we are updating the nodal officers of the respective hospitals on the results,” says Dr Lalit Dar, Associate Professor, Microbiology team, AIIMS.

VP Patel Chest Institute is handling between 20-30 samples everyday currently. However, if the institute sees an increase in number of samples, it will need an upgradation in infrastructure.

“The number of cases is likely to decline now. However, if the institute has to handle more number of samples, we will need more manpower and an upgradation in infrastructure to deal with the situation,” says Dr Rajendra Prasad, Director, VP Patel?Chest Institute.

The NCDC is testing between 200-250 samples everyday, say sources at the centre. The health department’s decision to open two more government laboratories at University College of Medical Sciences and Maulana Azad Medical College still remains pending.

“For testing samples for communicable diseases like H1N1, a bio-safety laboratory is required. The project to upgrade the two more labs is still in the pipeline,” says a senior DHS?official. SRL Diagnostics, which is one of the authorised private laboratories to conduct tests for swine flu, the incidence of positive cases of swine flu has consistently gone up from January’s 29.7 per cent to 34.7 per cent in the third week of February.

“According to the SRL data, Delhi-NCR has a high incidence of swine flu with 40 per cent of the cases reported positive, while Mumbai region reported 25 per cent of the cases positive,” says Sanjeev Vashishta, CEO, SRL Diagnostics.

Vaccination efforts

At a time when the virus is rapidly spreading, there is a shortage of vaccines in the city. The Centre had recommended the state health department to vaccinate healthcare workers who are at higher risk of contracting infection from the H1N1 virus.

“The vaccines will be free for doctors and paramedic staff who are directly dealing with patients admitted at hospitals for swine flu or in the OPD. These healthcare workers are most likely to be vaccinated from Monday,” Dr S K Sharma, Director, DHS, told Deccan Herald.

However, according to senior health officials, the vaccines will not be available by Monday as there is an acute shortage in the supply.

“It would not be possible to arrange for vaccines so early. Even though the health department was in touch with suppliers from the beginning of the season, there is not enough supply of vaccines,” says a senior health official.

The trivalent strain can give around 70 per cent protection against three prevalent virus strains. Even though experts have ruled out routine vaccination for the general public, it is important that healthcare workers get vaccinated. For the general public basic hygiene care is enough. There is no national policy on vaccination yet.

“It is also important that those in the high-risk groups get vaccinated once a year. Currently, there is less availability of the vaccines in the market. The spread of panic has also played havoc and contributed to the shortage. Those who do not need vaccination also are going for a shot,” says Dr Prasad.

It takes between one-two weeks for a person to develop immunity. “So when the virus is spreading fast, vaccination may not help. A person may be exposed to the infection before the antibodies develop,” says Dr Dar.

Shortage of medicines

For almost two days, government hospitals and private chemists saw a shortage in drugs before the government doubled its stocks.

“For a day, we had run out of Tamiflu drugs. There was a supply of around 5,000 capsules late the same night,” says a senior doctor at RML Hospital.

Krishna Medicos outside the hospital says private chemists around the hospital did not receive the supply for two days. “There was no supply of Tamiflu capsules for two days at the chemists. We had to turn away patients who were prescribed the drug,” says Dinesh Gupta of Krishna Medicos. The DHS?also said the capsules would be available at the 13 branches of DMA here.

However, currently the DMA branches are out of stock of Tamiflu capsules. “Each branch was given 50 capsules. In total, we received around 700 capsules which is not adequate. We are exhausted on the stocks now and will contact the DHS on Monday,” says Dr Anil Goyal, president, ?DMA.

There is still a shortage of Tamiflu syrups for children here with doctors giving a lesser dosage of the capsule crushed and dissolved in milk or warm water as a substitute to children. The DHS?has admitted to the shortage.

According to health experts, the government needs to foresee the condition in order to be prepared. “Swine flu is a seasonal flu and it should be anticipated that there will be an outbreak every alternate year,” says Dr Aggarwal.

More number of designated hospitals, better sensitisation of government doctors and clear-cut policies on vaccination for healthcare workers will help the government handle the situation effectively.

“There is definitely a need to take measures to curtail the number of infections and deaths in the city,” says a senior doctor.
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Reader Response
Congrats! You have done it. "If our aims & objectives are accepted at the time of registration, our actions also be accepted if we adhere to our objectives." Now can we endorse the products and procedures if we plough back those funds to meet our IMA's objectives? With best regards: Dr C Srinivasa Raju
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Anniversary Gift

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."
Delhi Medical Council still not Gazette Notified
Delhi Medical Council (DMC) 2009-2014 term expired on 20th December, 2014. In spite of having completed all formalities for elected and nominated members, the Gazette Notification still has not taken place.

Addressing a Press Conference, Padma Shri, Dr B C Roy National Awardee & DST National Science Communication Awardee, Dr KK Aggarwal, President Heart Care Foundation of India and Honorary Secretary General IMA and Dr Anil Goyal, President, Delhi Medical Association (DMA) said that today DMC is without any democratically elected body. The last DMC Body, whose term expired on 20th December 2014, by default, is still carrying out its functions.

There are 23 members in DMC; of these 8 members were elected on 16th November, 2014 and another DMA member was elected on 22nd November, 2014. The Lt. Governor, the then Govt., nominated 4 members on 22nd December, 2014 and 8 elected members from various medical colleges were elected before 20th December, 2014. Two are Director Health Services & Dean Universities as ex-officio members.

Since 22nd January, 2015, the file cleared by Lt. Governor for Gazette Notification is still pending with the new AAP Government.

IMA has written to the Chief Minister with no action so far. DMA representative also met the Chief Minister & Health Minister with no action.

IMA is seeking legal options also so that the democracy of DMC is maintained.

DMC performs both regulatory as well as educational functions for the medical profession in Delhi.