Address: 39 Daryacha, Hauz Khas Villege, New Delhi, India. e-Mail: firstname.lastname@example.org , Website: www.ijcpgroup.com
Dr KK Aggarwal
Dr BC Roy Awardee
Sr Physician and Cardiologist,
President, Heart Care
Foundation of India
Delhi Medical Council
Director, IMA AKN Sinha Institute (08-09)
FIRST NATIONAL DAILY MEDICAL NEWSPAPER OF INDIA
5th December Saturday
HEPATITIS B UPDATE PART 2: TREATMENT
1. There is no specific treatment for acute hepatitis B
2. In 95 percent of adults, the immune system controls the infection and eliminates the virus within about six months.
3. Treatment with an antiviral medication may be considered in the rare patient with severe acute or prolonged acute hepatitis B.
4. In people who develop chronic hepatitis, an antiviral medication may be recommended to stop the virus from multiplying (to reduce or reverse liver damage), to prevent the spread of infection to others, and to prevent long-term complications of hepatitis B.
5. Several drugs are available to slow or stop the hepatitis B virus from multiplying
6. Lamivudine is effective in decreasing hepatitis B virus activity and ongoing liver inflammation. It is safe in patients with liver failure and long-term treatment can decrease the risk of liver failure and liver cancer. It is taken by mouth, usually at a dosage of 100 mg/day. The major problem is that a resistant form of hepatitis B virus (referred to as a YMDD mutant) frequently develops in people who take lamivudine for long-term treatment.
7. Adefovir is an alternative initial choice. Resistance to adefovir is less likely to develop. In addition, adefovir can suppress lamivudine-resistant HBV. It has been associated with kidney problems when used in high doses or for long durations. Adefovir is taken by mouth, at a dosage of 10 mg/day, for at least one year.
8. Entecavir is generally more potent than lamivudine and adefovir. Resistance to entecavir is uncommon in people who have never been treated with anti virals, but occurs in up to 50 percent of people who have used lamivudine. Entecavir is taken by mouth, at a dosage of 0.5 mg daily for patients who have no prior treatment and 1.0 mg daily for patients who have resistance to lamivudine for at least one year. Most patients will need long-term treatment.
9. INterfeorn- alpha: is an appropriate treatment for people with chronic hepatitis B infection who have detectable virus activity, ongoing liver inflammation, and no cirrhosis. Both conventional interferon (which is given by injection daily or three times a week) and pegylated interferon are approved. Interferon-alpha may be considered in young patients who do not have advanced liver disease and do not wish to be on long-term treatment. Interferon-alpha is not appropriate for people with cirrhosis who have liver failure or for people who have a recurrence of hepatitis after liver transplantation. It is given for a finite duration (4 to 12 months). This is in contrast to the oral HBV drugs, which are given for many years until a desired response is achieved. Drug resistance to interferon has not been reported.
10. Telbivudine is similar than lamivudine and is associated with a high rate of resistance, similar to lamivudine.
11. Tenofovir: is more potent than adefovir and is effective as a first line treatment in people who have not been treated with any antiviral drug and in patients who have -resistant hepatitis B virus. Tenofovir is not as effective in patients with adefovir resistant hepatitis B. Resistance to tenofovir has not been seen after one year of treatment.
12. Liver transplantation: may be the only option for people who have developed advanced cirrhosis.
13. Vaccinations: Every one with chronic hepatitis B should be vaccinated against hepatitis A unless they are known to be immune. Pneumococcal vaccine is recommended when HBV is diagnosed, and again at age 65. Influenza vaccination is recommended once per year, usually in the fall. Patients with liver disease should also receive standard immunizations, including a diphtheria and tetanus booster, every ten years.
14. Alcohol should be avoided since it can worsen liver damage. All types of alcoholic beverages can be harmful to the liver. People with hepatitis B may develop complications even with small amounts of alcohol.
15. As a general rule, unless the liver is already scarred, most drugs are safe for people with hepatitis B. An important possible exception is paracetamol, the maximum recommended dose in people with liver disease is no more than 2 grams (2000 mg) in 24 hours.
Dr KK Aggarwal
Moolchand may get new years gift well in advance?
Moolchand Medcity Delhi to be JCI accredited by this month. It will be the first hospital to get accreditation in first attempt.
The Joint Commission on Accreditation of Healthcare Organizations, known more commonly by its acronym, JCAHO or as The Joint Commission, is an independent, not-for-profit organization that evaluates and accredits healthcare organizations in the United States. JCAHO’s Joint Commission International (JCI) was founded in the late 1990s to survey hospitals outside of the United States. JCI, which is also not for profit, currently accredits facilities in Asia, Europe, the Middle East, and South America. JCI's standards and qualifications are derived from an international consensus of achievable expectations for structures, outcomes, and processes for medical facilities. The standards are designed to accommodate cultural, religious, and legal factors within specific countries and regions. Other JCI hospitals are Wockhardt, Apollo, Schroff eye Hospital, Asian heart institute etc.
(From Dr Maj Prachi Garg)
Experts say placebo effect accounts for one third of benefits from any treatment
According to Dr. Robert Ader, a psychologist at the University of Rochester, placebos can have real and beneficial effects. In fact, the placebo effect accounts for about a third of the benefits of any treatment, even carefully tested medicines.
Nearly one fourth of hospitalized heart failure patients readmitted within 30 days of discharge.
One fourth of patients hospitalized for heart failure in the US are readmitted within 30 days of discharge, according to an analysis of Medicare data published online November 10, 2009 in Circulation: Heart Failure.
Fasting prior to cholesterol test may not be necessary.
Measurement of either cholesterol levels or apolipoproteins does not require fasting according to research published in the Journal of the American Medical Association.
Exercise induced shortness of breath, asthma may be frequently misdiagnosed.
Investigators at the Colorado Allergy and Asthma Centers are saying that many people who are diagnosed with exercise induced shortness of breath and asthma frequently may be misdiagnosed.
Statin use may cut risk of gallstones, cholecystectomy.
Long term use of cholesterol lowering statins appears to reduce the incidence of gallstones and the need for surgery to prevent the excruciating pain they cause, according to findings published Nov. 11 in the Journal of the American Medical Association. Specifically, decreased risk of cholesterol type gallstones that required surgery was linked to one to 1.5 years of statin treatment, while no association was seen with shorter term use. In addition, the dose of the statin appeared to play a role, as patients who took high dose statins tended to have a lower risk of gallstone disease than those who took lower doses.
An investigational compound that combines an NSAID and a proton pump inhibitor in an enteric coated pill significantly reduced the rate of gastrointestinal ulcers in high risk patients with arthritis, even when the drug was taken on top of low dose aspirin, researchers reported here.
Snippets from Dr G M Singh
1. Regular physical activity is known to reduce blood pressure in 75% of individuals with hypertension and is a key component of lifestyle therapy for the prevention and management of hypertension. Aerobic activity is the preferred type of activity to lower blood pressure. Acute, moderate-intensity aerobic activity (40%-60% VO2max ) can decrease blood pressure by 5 to 7 mm Hg for up to 22 hours post exercise, so participation in aerobic activity is recommended on most, if not all, days of the week. The recommended duration for aerobic activity is 30 to 60 minutes of continuous or intermittent activity. Resistance activity results in a 3-mm Hg decrease in blood pressure and should supplement the aerobic activity. Low- to moderate-intensity resistance training (30%-40% of a 1—repetition maximum [1RM] for upper body exercises and 50%-60% 1RM for lower body exercises) is recommended 2 to 3 d/wk. The volume of resistance training for blood pressure reduction is 1 to 3 sets of 10 to 15 repetitions for 8 to 10 exercises that target large muscle groups (thighs, hips, back, chest, arms, and abdominals).
2. One of the greatest pieces of MEDICAL wisdom is to know what you do not know.
3. Recent publications of TRITON-TIMI (prasugrel) as well as PLATO (ticagrelor) have introduced new and potent anti platelet agents, but at the same time have left clinicians with multiple choices without clear direction regarding the most appropriate use of these agents.
There was once a very prim and proper older lady who had a problem with passing gas. Since she came from a generation when people didn't even talk about this kind of problem it took a long time for her to seek help. Finally, however, she was persuaded to consult her family doctor.
After she filled out all the proper forms and had waited about 20 minutes in the waiting room the doctor called her into his office, leaned back in his chair, folded his hands into a steeple and asked her how he could help.
"Doctor," she said, "I have a very bad gas problem. Yesterday afternoon I had lunch with the Secretary of State and his wife and had six, um, er, ahhh ... silent gas emissions. Last night I had dinner with the governor and his wife and had four silent gas emissions. Then, while sitting in your waiting room I had five silent gas emissions! Doctor, you've got to help me! What can we do?"
"Well," said the doctor raising his voice a little, "I think the first thing we're going to do is give you a hearing test."
Mini relaxations can help allay fear and reduce pain while you sit in the dentist’s chair or lie on an examining table. They’re equally helpful in thwarting stress before an important meeting, while stuck in traffic, or when faced with people or situations that annoy you. Here are a few quick relaxation techniques to try.
When you have got 1 minute. Place your hand just beneath your navel so you can feel the gentle rise and fall of your belly as you breathe. Breathe in slowly. Pause for a count of three. Breathe out. Pause for a count of three. Continue to breathe deeply for one minute, pausing for a count of three after each inhalation and exhalation.
When you have got 2 minutes. Count down slowly from 10 to zero. With each number, take one complete breath, inhaling and exhaling. For example, breathe in deeply saying 10 to yourself. Breathe out slowly. On your next breath, say nine, and so on. If you feel lightheaded, count down more slowly to space your breaths further apart. When you reach zero, you should feel more relaxed. If not, go through the exercise again.
When you have got 3 minutes. While sitting down, take a break from whatever you are doing and check your body for tension. Relax your facial muscles and allow your jaw to fall open slightly. Let your shoulders drop. Let your arms fall to your sides. Allow your hands to loosen so that there are spaces between your fingers. Uncross your legs or ankles. Feel your thighs sink into your chair, letting your legs fall comfortably apart. Feel your shins and calves become heavier and your feet grow roots into the floor. Now breathe in slowly and breathe out slowly. Each time you breathe out, try to relax even more.
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Letters to the editor
1. Thank you a lot for updating all of us with 'emedinews'. I am really addicted. I read/ study your daily writings. But I am astonished today as I have not received today's edition of emedinews which my PC receives regularly early in the morning. I hope I am not deleted from mail list. Please keep me on regular mail list. Thank you again, firstname.lastname@example.org
2. Dear Dr Aggarwal, First of all congratulations for this new venture, emedinews. I am sure it will be of a lot of help in educating the medical fraternity. I would like a clarification from you about the ownership of medical records about which you have in your bulletin dated 27 Nov 09 mentioned, Medical Records are the property of the patient: so far it has been the well accepted position, and rightly so, that medical records are the property of the hospital.
The hospital generating medical record is supposed to preserve the Records for a period of 3 years (Clause 1.3.1 IMC Reg. 2002). It is based on the following logic :
1. The records are generated by the hospital to preserve a record of the treatment given to the patient for any future reference ( for whatever reason ) as also for Medical education, Research and Medical audit , interalia.
2. The patient has not paid for the records and therefore cannot claim ownership of the records. The current normal practice of issue to the patient , on discharge, the discharge summary along with the investigation reports, including the X rays, ECG,C T Scan, and other images/ tracings etc is logical because the patient has paid for those investigations. Access to the case records or Issue of a copy of the records to the patient ( free-ex gracia / on payment of a reasonable amount )is not a disputed issue. Hospitals are required to issue to the patient a copy of the case record, on demand, within a period of 72 hours ( Clause 1.3.2 IMC Reg. 2002 and RTI Act )
In fact even the original record ( non-medico-legal case)can, in some odd case, be issued to the patient at the sole discretion of the hospital, if there is a justification. However, the patient cannot demand it as a right. In medico-legal cases , in any case, the original documents and the investigation reports/ films/ images etc have to be preserved by the hospital as evidence to be produced in the court subsequently. Even there, the copies / duplicates of the investigation reports can be issued to the patient, but not the originals. Implications of Treating Medical Records as The Patients’ Property: every patient will be entitled ( as his right )to take his original case record with him on discharge Being the patients’ property, the hospital will be required to hand over the original case records to the patients on discharge even if the patient does not demand it.
For its own requirement- the hospital will be forced to copy and preserve every patient’s record at a huge recurrent additional expenditure. In view of the above, I do not think that case records are / can be the property of the hospital. If you think your statement is right, and MCI is also of the view that Medical Records are the property of the hospital,
I would request you to kindly quote the exact authority. I would look forward to your reply. With best wishes: Dr S K Joshi, , email@example.com
Emedinews comments: I personally agree with you but the present law is that all records are to be preserved by the hospital for three years and a copy of the records needs to be given to the patient within 72 hours on demand. Most hospitals are charging some money for the case file and records. Also at the time of giving records the hospital may charge (and does charge money) for the same. The question was also discussed in DMC council meeting and the council was of the opinion that if the relations want original papers, the hospital will have to keep the certified copy and hand over the originals. No body stops the hospital from not charging for the medical records.
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