October 5   2015, Monday
EDITORIAL
Dr KK AggarwalDr KK Aggarwal Hospital attack in Afghanistan

The World Medical Association has joined in the condemnation of the latest air strikes on a hospital in Afghanistan.

Dr. Xavier Deau, President of the WMA, said: ‘This latest tragedy strengthens our determination to ensure the safety of hospitals, health care facilities, patients and healthcare personnel during armed conflicts.

It underlines the importance of our work with the International Committee of the Red Cross to urge all governments to do more to ensure the safety of health care in situations of violence. Tragedies such as this shame us all'.

IMA also condemns the attack.
Breaking news
A new meta-analyses challenges calcium guidelines

The bulk of the evidence does not support guidelines that recommend a minimum calcium intake, including those from the Institute of Medicine. Most people don't need to worry about their calcium at all as per Mark Bolland, MBChB, PhD, an associate professor of medicine at the University of Auckland in New Zealand. Randomized controlled trials show calcium supplementation provides only a modest reduction in the risk for fractures, and the benefit may be outweighed by adverse reactions, he said. Yet fractures are the primary reason cited for minimum calcium intake. In the two meta-analyses, both published in the September 29 issue of BMJ, Dr Bolland and colleagues found that neither calcium supplements nor dietary calcium significantly reduced the risk of fractures or improved bone mineral density. (Medscape)
Dr Good Dr Bad
Situation: A patient who tested positive for malaria came with severe thrombocytopenia.
Dr Bad: This is classical malaria.
Dr Good: Also look for dengue.
Lesson: Malaria and dengue may coexist in the same patient.

(Copyright IJCP)
Specialty Updates
  • Alendronate may have a beneficial effect on muscle mass in addition to its well-known positive effect on bone mass, suggests a new study published in Osteoporosis and Sarcopenia.
  • How well a patient with heart failure responds to cardiac resynchronization therapy (CRT) over the long term could partly depend on their body-mass index (BMI) when the device is implanted, suggests a small cohort study, presented at the Heart Failure Society of America 2015 Scientific Meeting. Researchers found significantly greater 10-year survival on CRT for patients who were obese, compared with those of normal weight.
  • All people infected with HIV should receive antiretroviral therapy (ART) as soon as possible, and those at "substantial" risk should be offered pre-exposure prophylaxis (PrEP), according to new guidelines by the World Health Organization, published online September 30.
  • Treatment with prednisone among patients with rheumatoid arthritis was associated with increased mortality risk, although concomitant methotrexate attenuated this risk, reported a long-term study published online in Arthritis Care & Research.
  • Inflammatory bowel disease (IBD) patients who achieve remission on treatment may want to go off their IBD medications. But half or more of those who do will have a relapse. (Gastroenterology online September 14)
  • Subclinical brain infarcts and white matter hyperintensities on MRI of stroke-free patients are associated with double the rate of functional decline. (Mandip S. Dhamoon, MD, MPH, an assistant professor of neurology at the Icahn School of Medicine at Mount Sinai, in New York)
  • A new study showed a "significant decrease" in the erectile function score of most men after prostate biopsy, and the drop was independent of age, cancer diagnosis, and previous biopsy status, report the study authors, led by Katie Murray, MD, from the University of Kansas Medical Center in Kansas City.
  • People with a recently identified genetic variant associated with vitamin D metabolism may lower their risk for type 2 diabetes by eating a high protein diet, suggests new research published in the journal Diabetologia.
  • Although urinary tract infections (UTIs) appear to be uncommon during hospital admissions for suspected multiple sclerosis exacerbations, physicians may consider screening for UTIs in MS patients who are female, older, have a history of UTIs, or have severe walking impairment, suggests new research presented at the American Neurological Association meeting.
  • A new study, presented at the 2015 Annual Meeting of The North American Menopause Society (NAMS), suggests that vitamin D supplementation can significantly increase muscle strength and reduce the loss of body muscle mass in women as late as 12+ years after menopause.
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Media
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eSPIRITUAL
Do what you do to God
  • There are two types of people who believe in either Dvaita or Advaita philosophy.
  • People who believe in Dvaita philosophy, for them God and human being are different.
  • The people who believe in Advaita philosophy believe that God is within them.
  • In Hinduism, the first group believes in Sanatan Dharma and does Moorti pooja (idol worship) and the second Arya Samaj, which does not believe in Moorti pooja.
  • In both situations, medically the message is one.
  • If God is different than you, then you try to be like Him and if God is in within you, then you are Him.
  • In both situations, we should deal with our body the same way as we deal with God.
  • Anything which is not offered to God should not be offered to our body such as cigarettes, drugs etc or such things should be consumed in less quantity (onion, garlic, radish etc.).
  • We never worship God with hydrogenated oil; we always worship him either with oil or with Desi Ghee. The message is we should not consume trans fats.
  • "Bhagwan ko bhog lagate hain"; we never feed God. The message is, we should eat less.
  • Amongst all Gods, only Lord Shiva is said to consume bhang and alcohol that too only in his incarnation of Bhairon, which indicates that both alcohol and bhang can be consumed in some quantity only in special situations meaning that they cannot be consumed without medical supervision.
  • Anything grown under the ground is not offered to God, thus, these items should not be eaten or eaten in moderation.
  • We never offer white salt and white rice to God. They are also bad for human beings.
  • Gur, shakkar, brown rice and puffed rice are offered to God. They can be consumed by human beings.
Medicofinance
Importance of financial goals
  • A cash flow plan functions best if it reflects a doctor’s goals, whether long-term or short-term. The purchase of a luxury sedan in three years or the decision to remodel your basement next winter should influence one’s cash flow plans.
  • The goals that one has already set will help one shape the personal version of this system. These should often be referred.
  • As a doctor achieves some short-term goals, or begins to see significant progress towards long-term goals, his enthusiasm for this process will increase and that will make the system even more effective for him.
(Source: IJCP)
Industry News
  • Digital tech to provide synergies for startups: The next wave of startups will happen in the areas of fintech, health tech, eComm tech, IoT and clean tech, and everything will be led by digital technologies, said Russ Shaw, Founder of Tech London Advocates (TLA). In an interaction with Deccan Herald as part of the formation of London-Bangalore community of technology leaders — TLA Bangalore Working Group — Shaw said digital technologies are bringing a shift in the way businesses are running globally. (Deccan Herald- N V Vijayakumar)
  • Report: Medical app market worth $489M in 2015: The medical app market was worth $489 million in 2015 and nearly 40 percent of sales came from health monitoring apps, according to a report from research firm Kalorama Information. Kalorama includes telemedicine and monitoring apps in this app category. “Involvement in this care segment has several benefits and hospitals, care givers, device manufacturers, and patients are continuing to jump on board with acceptance and using this technology,” Bruce Carlson, publisher of Kalorama Information, said in a statement. (Mobihealthnews.com- Aditi Pai)
  • 70% of startup founders aged less than 30 years: Hyderabad: The third edition of Manthan Samvaad held in the city on October 2 at JRC Convention Centre opened to an overwhelming response with over 1500 members participating in the event. The event was organised by Manthan Foundation in association with Dr. Reddy’s Laboratories. It was indeed a feast of fresh thoughts, ideas and intelligent conversations. R Chandrasekhar, President of NASSCOM, was one of the guest speakers at the event who spoke at length on the ‘Start up Revolution’ in the country. (The hansindia.com)
  • Sequoia capital puts Rs 40 crore in Backwater Technologies, the startup behind Chillr app: Mumbai: Silicon Valley-headquartered venture capital firm Sequoia is investing Rs 40 crore in Backwater Technologies, the startup behind Chillr app which allows users to transfer money to any contact in their phone book. The Mumbai-based startup, which has tied up with HDFC Bank and Bank of Baroda till date, will use the funding for customer acquisition as technology increasingly disrupts the financial services industry. Chillr had earlier raised around Rs 6 crore from MobMe Wireless and plans to raise another Rs 10 crore as a part of its Series-A round. (The Economic Times- Madhav Chanchani)
eMEDIPICS
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Cardiology - Yesterday, Today & Tomorrow - A CME was organized by IMA HQs on World Heart Day at IMA House, New Delhi
Humor
Customer: I have a huge problem. A friend has placed a screensaver on my computer, but every time I move the mouse, it disappears.
Medicolegal
Achieving Privacy and confidentiality in day to day practice- an ethical dilemma

Pragya Sharma
Lecturer, Dept. of Clinical Psychology
Smita N Deshpande
Head, Dept. of Psychiatry,
De-addiction Services
PGIMER- Dr. Ram Manohar Lohia
Hospital, New Delhi

Doctors in busy settings face an ethical dilemma. Maintenance of confidentiality and privacy becomes problematic due to the use of shared rooms. At times, the patient hesitates to share medical information due to this fact. More funds and better infrastructure may not always be possible. What is your preferred solution in such circumstances?

a) Ignore the issue as sharing information is culturally acceptable in India

b) Acknowledge overcrowding, try to make the patient comfortable within the shared setting

c) Extend work hours, push back appointments to ensure one patient per room at a time

d) Whisper/ talk in low voices

Do write in with your views and solutions.

Here are the responses received
  • I will go for a) Ignore the issue, as sharing information is culturally acceptable in India unless someone specifically asks for not sharing a small part of information. Saranya Devanathan, Psychiatrist
  • I think we cannot see 2 or 3 patients in one room. The patient’s right of privacy cannot be compromised for any reason. Each patient should be interviewed in a single room, and the patient and the family members should also be seen separately at least once and as and when needed. Infrastructural issues cannot be the excuse for inefficient treatment. Prof. Anil Agarwal, Psychiatrist
  • Lack of infrastructure is not an excuse for not observing privacy and confidentiality Patients should be seen alone as well as with family members. Prof. Satish Malik
  • Explain that the other person too is a doctor like me and assure that she would maintain confidentiality. Sudhakar Bhat, Psychiatrist
  • It is very difficult to provide a separate place and extending work hours may not be possible for doctors. They can talk in low voices and make the patient as comfortable as possible. If the issue really demands confidentiality like HIV or any other which patient is not at all confident to discuss in overcrowded situations, then extra time can be given after the crowding hours. Respecting the privacy of the patient is very important. Triptish Bhatia, Principal Investigator, GRIP-NIH, USA Project, Dept. of Psychiatry, Dr Ram Manohar Lohia Hospital, New Delhi
  • Firstly, we can have cabins or space with glass partitions, which prevent the sound from reaching other places. Secondly, if we are to be economical then probably the patients, of course depending upon their problem and certainly alongside giving him assurance and confidence about confidentiality, can be asked to record their voices in their phones and then ear phones can be used as a medium to listen to the voice recorded by the patient. These ear phones shall be inserted/worn by both - the patient as well as the client so that they are on the same track of conversation. But, this can be done only at the time of case history taking. If the client is educated, he can write and the doctor can ask and clarify. Enquiry questionnaires could be used. Structuring the room accordingly can help. I don't know how much do we support online counselling and case history taking. However, people (doctors and patients) who are ready for the online case history-taking, shall be taken separately by doctors at say a particular day and they must be given facility and services of the same with helpers available around in a particular room Or can be done in a booth placed to be able to communicate with the doctors in any given area within the compound. Parul
  • Lack of rooms is a fact in mental health care. But mental health service cannot and should not be stopped due to this fact only. Privacy is definitely an important issue but when infrastructure is not adequate then also treatment means a lot. When any country does not have adequate infrastructure then decision should be taken according to what is available in nearby surrounding. So treatment comes first as per hierarchy of decision criteria. So the clinician should explore the possibility of privacy if possible. S/he may evaluate himself/herself, the nature of information forthcoming during the interview and take decision accordingly whether to ensure privacy or not. However privacy of any nature should be given due respect. But this suggestion is for setting where rooms are not available in adequate number. So the clinician may also ask the patient and family about their comfort level. However it has been observed that people do not care that much in a hospital outpatient department as they have their mind made up for such crowded places. And again people feel a kind of security being stranger in the crowd. If there are not too many patients then privacy must be secured for the patient. But during a rush this issue should be dealt by considering the nature of the problem and the sensitivity of the patient and the family. Ranjita Thakur
  • Having interned at Sion Hospital in Dept of psychiatry department, this dilemma was an everyday problem. However, practitioner skills made huge difference. Doctors who were able to successfully get history and provide details at the same time respecting confidentiality showed the following:
    • Apologize to the patient for the overcrowding but saying at the same time that all these people require a doctor so we have to work with this.
    • Telling that other professionals in this room are competent and caring doctors and will not make fun of (most men who were hesitant came with premature ejaculation issues); instead can actually assist in solving the problem.
    • Allowing them to speak softly if it is a sensitive detail.
Therefore if we really want to keep patient’s interest at the fore, a way can always be found to do so. Sadaf Vidha
Breaking news
Mid-day meal rules linked with FSA now

The Centre on Thursday notified the Mid-Day Meal Rules, 2015 linking them to the provisions under the Food Security Act 2013, which entitles the citizens to food allowance in case the State is unable or fails to provide food grains. The new Mid-Day Meal scheme by HRD Ministry seeks to fix responsibility on persons for non-supply of food for three consecutive school days or five days in a month. It also seeks to improve efficiency in implementation by plugging loopholes, checking irregularities and ensuring quality of food served. On the Food Security Allowance, it says, “If mid-day meal is not provided in school on any school day due to non-availability of food grains, cooking cost, fuel or absence of cook-cum-helper or any other reason, the State Government shall pay Food Security Allowance by 15th of the succeeding month.” The allowance will be fixed based on quantity of food grain supplied as per entitlement of a child and the cooking cost prevailing in the State. (The Pioneer)
MAKE SURE
Situation: A foreigner with a single loose stool developed sepsis.
Reaction: Oh my God! Why were antibiotics not started in time?
Lesson: Make sure that all foreigners are diagnosed to be suffering from Traveler’s diarrhea even if there is one single loose motion.
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Updates
Leadership & Detox Meeting of the Presidents and Secretaries of all States

IMA for the first time is organizing a Leadership & Detox Meeting of the Presidents and Secretaries of all States and Local Branches on 10th & 11th October, 2015 (Saturday & Sunday) at Om Shanti Retreat Centre, Pataudi Road, Near Manesar, Gurgaon. The meeting will start on Saturday, the 10th October at 2 PM and end on Sunday, 11th October, 2015.

IMA has made arrangements for stay and hospitality of first 800 persons at twin sharing basis. All State branches are requested to spread this message in the local branches so that their Presidents/Secretaries can participate in the meeting. Kindly be informed that all the States and Branches may kindly get their travel reimbursed from their own state/local branch funds.
90% of doctors rely on online search engines to aid clinical decisions: Survey

New Delhi: Call it digital penetration or lack of clinical sources for information but as many as 90% of doctors rely on online search engines to aid their clinical decisions with Google being the most popular and frequently used non-evidence based search engine, showed a latest survey conducted in the Asia Pacific region, reports TOI dated Oct 3, 2015. Highlighting the existing gap between what physicians are really looking for and the information sources they use to achieve that, the findings showed top reasons for the search of clinical information on web was to "stay abreast of latest developments in their field" followed by "reference during treatment and surgery." Doctors perform an average of six professional searches a day during their course of work, it said. (Times of India - Sushmi Dey)
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Safety Alerts List of Drugs, Medical Devices and Cosmetics declared as Not of Standard Quality/Spurious/Adulterated/Misbranded for the Month of August 2015

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Metformin-related vitamin B12 deficiency might contribute to clinically significant peripheral neuropathy in diabetes patients [Mattijs Out, MD, an internist of vascular medicine at Bethesda Diabetes Research Center, Hoogeveen, the Netherlands)
GP Tip: Heeding a clue to possible dementia

Formal mental status testing is time-consuming and often unnecessary for general medical evaluations. If a patient with reasonable hearing acuity looks at his or her companion more than twice before answering when directly questioned during history taking, there is a strong likelihood of incipient dementia.
CDC Unveils Redesigned Healthy Pets Healthy People Website

CDC today launched its redesigned Healthy Pets Healthy People website, with expanded information about diseases people can catch from pets, farm animals, and wildlife. Users can now search alphabetically by animal and learn which zoonotic diseases they may carry. It is a unique “one-stop shop” where people can learn simple actions to protect themselves – and their pets. The redesigned website offers:
  • An alphabetized list and description of diseases that can spread from animals to humans.
  • A list of animal species with the description of diseases associated with the animal.
  • Specific groups of people that may be more susceptible to diseases from animals.
  • Tips for preventing illnesses acquired from pets and other animals.
  • Detailed information about the health benefits of owning a pet.
(Source: CDC)
Safe, easy access to public spaces for poor citizens vital to achieving equality, ending discrimination, says UN Secretary-General in Message on World Habitat Day

In his message on World Habitat Day, on 5 October, the UN Secretary-General Ban Ki-moon’s said, “Each year on World Habitat Day, we reflect on the state of human settlements and on what we want the cities of the future to look like. This year’s observance follows the adoption of the 2030 Agenda for Sustainable Development — an inspiring new framework that will guide our efforts to end poverty and ensure prosperity for all on a healthy planet. The new Sustainable Development Goals — which include SDG 11 to “make cities and human settlements inclusive, safe, resilient and sustainable” — represent a broad international consensus that recognizes sustainable urban development as a transformational approach. As part of an integrated agenda, cities and human settlements have an important role to play across the entire spectrum of the 2030 Agenda. The theme of World Habitat Day 2015 is “Public Spaces for All”. Frequently overlooked and undervalued, public spaces are increasingly being recognized as the vibrant, beating hearts of the world’s towns and cities, which are today home to half of humanity….(Source: http://www.un.org/press/en/2015/sgsm17182.doc.htm/)
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eWELLNESS
Alcohol: Benefits Vs Risk
  • There is consensus that non drinkers should not start and the ones who drink can continue provided they do so in moderation and in absence of contraindications. People tend to consume more alcohol in winter and near the New Year.
  • Persons who have been lifelong abstainers cannot be easily compared with moderate or even rare drinkers. Recommending alcohol intake to them even if they would agree to drink is not justified.
  • The diseases that moderate alcohol use prevents (such as coronary heart disease, ischemic stroke, and diabetes) are most prevalent in the elderly, men, and people with coronary heart disease risk factors. For these groups, moderate alcohol use is associated with a substantial mortality benefit relative to abstention or rare drinking.
  • For young to middle–aged adults, especially women, moderate alcohol use increases the risk of the most common causes of death (such as trauma and breast cancer).
  • Women who drink alcohol should take supplemental folate to help decrease the risk of breast cancer.
  • Men under the age of 45 may also experience more harm than benefit from alcohol consumption. In this age group, moderate alcohol use is unlikely to provide any mortality benefit, but consumption of less than one drink daily appears to be safe if temporally removed from operation of dangerous equipment. For individuals with established contraindications to alcohol use, even this level of alcohol use is dangerous.
  • Men can tolerate more alcohol than women. The ideal therapeutic dose of alcohol is around 6 grams per day. Medically safe limits are 10 grams in one hour, 20 grams in a day and 70 grams in a week. (50% for the women).
Inspirational Story
Nature’s lessons

Why don’t you and your friend get together and play the game?

One of you say the name of any bird, animal, worm or plant and guess what you can learn from it. There usually is something so do not give up too easily. And if you stumped you can always ask the grown up to help you out. Take, for instance, ants. Are they not a model of hard work? How busily and tirelessly they ferret for food all day. They are excellent at team work too. It is wonderful to see six or seven of them haul away a tiny shred of coconut or grain of sugar.

And what about the crow? Most people don’t like crows but I think they are admirable. Do you know that they are nature's garbage disposers? Give them anything, even rotten food, and they will gratefully gobble it up. Another remarkable trait is that when one of them spies food, they generously call out to their fellows, even if it is just a mite, so go ahead and see what our animal friends have to teach us.
eMEDI QUIZ
All of the following are examples of traction epiphysis, except:

1. Mastoid process.

2. Tubercles of humerus.

3. Trochanters of femur.

4. Condyles of tibia.

Yesterday’s Mind Teaser: The nerve commonly damaged during McBurney's incision is:

1. Subcostal

2. Iliohypogastric.

3. 11th Thoracic.

4. 10th thoracic.

Answer for Yesterday’s Mind Teaser: 2. Iliohypogastric.

Answers received from: Dr Poonam Chablani, Dr Jainendra Upadhyay, Daivadheenam Jella, Dr.B.R.Bhatnagar, Dr Avtar Krishan,

Answer for 3rd October Mind Teaser: 4. Inferior mesenteric vein.

Correct Answers received from: Dr Bitan Sen & Dr Jayashree Sen.
Press Release
Create simplified and indiscriminate organ donation regulations in India

Issues such as traffic congestion and discrimination between Indian patients and patients from other nationalities have made organ transplantation a difficulty in India.

New Delhi, 4th October 2015: The mechanism of organ transplants in India has been going through a rough phase for quite a long time now. Adding to the existing roadblocks is the government’s new ruling that gives preference for organ transplants to people depending on their nationality and place of living rather than on merit or the need for transplant.

The Transplantation of Human Organs and Tissues Rules, 2014 has now been implemented and the rule 31 (4e) is a violation of MCI act.

According to Rule 31: Manner of establishing National or Regional or State Human Organs and Tissues Removal and Storage Networks and their functions. — (4) The broad principles of organ allocation and sharing shall be as under, — (e) sequence of allocation of organs shall be in following order: State list/ Regional List/ National List/ Person of Indian Origin/ Foreigner.

There will be a violation of MCI act if doctors follow this as at the time of registration, each applicant shall be given a copy of the following declaration by the Registrar concerned and the applicant shall read and agree to abide by the same: (d): I will not permit considerations of religion, Nationality, race, party politics or social standing to intervene between my duty and my patient.

Speaking on the issue, Padma Shri Awardee, Dr A Marthanda Pillai National President and Padma Shri Awardee Dr. K K Aggarwal – Honorary Secretary General IMA and President HCFI in a joint statement said, “The government’s ruling has given rise to an uproar in the Indian medical fraternity. The judgment forces doctors to differentiate between patients. Additionally, decisions will now be made on the basis of region and nationality of the patients instead of their needs, which is a violation of Medical Council of India (MCI) Act. Two main areas of “illegal organ trade” and “deceased donation program” still offer a lot of scope, which the Indian government needs to focus on instead of encouraging disparities. The illegal organ trade practices are giving rise to the already widening gap between the number of organs available and number of organs required. In short, the difference between the demand and supply of organs has led to their commodification in India.”
Digital IMA