July 5  2015, Sunday
eMedinewS
editorial
Passive smoking can cause dementia
Dr KK AggarwalPeople exposed to secondhand smoke may face as much as a 44 percent increased risk of developing dementia.

Smoking is already known to increase the risk for dementia and Alzheimer’s disease.

A study from Peninsula Medical School in Exeter, England published in the journal BMJ has shown that there is an association between cognitive function and exposure to passive smoking. The risk increases with the amount of exposure to secondhand smoke. For people at the highest levels of exposure, the risk is probably higher.

The study collected data on more than 4,800 nonsmokers who were over 50 years old and tested saliva samples from these people for levels of cotinine, a product of nicotine that can be found in saliva for about 25 hours after exposure to smoke. The researchers found that people with the highest cotinine levels had a 44 percent increased risk of cognitive impairment, compared with people with the lowest cotinine levels. And, while the risk of impairment was lower in people with lower cotinine levels, the risk was still significant.

Passive smoking is also associated with an increased risk of stroke and heart disease
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23 doctors attend the IMA Rise & Shine CME on Vitamin D deficiency in Palakkad
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TRENDO 2015
The 3rd Annual meeting of the Endocrine Society of Tamil Nadu and Puducherry will be held in Kodaikanal on 11th and 12th of July 2015. TRENDO 2015 is proposed to address latest updates, emerging concepts, clinical applications and controversies in diabetes, thyroid disorders, gonadal problems, pituitary disorders, metabolic bone disease and adrenal diseases.
News
  • Hema Malini sustained a nose fracture in the car accident. She was sitting on the rear seat of her car. This has again led to a deep concern over the need to wear back-seat safety belts, something that's neither legally mandatory nor advocated through any awareness program. The recent death of Gopinath Munde in a car accident had also created similar debate. But with no action at the government level. Most people think back-seat belts is not necessary. But wearing them is as essential as wearing front-seat belts.
Seat Belt Rule
  1. Wearing seat belts while driving reduces fatalities by about 60% and injuries by nearly 50% during mishaps.
  2. It doubles the chances of survival in a serious accident and prevents occupants from being ejected out from the vehicle in case of an impact.
  3. The driver and co-passengers in four wheelers must wear seat belts as it is mandatory under the Indian Motor Vehicles Act.
  4. The penalty for not wearing a seat belt is Rs. 100/- for the first offence and Rs. 300/- for repeat offences. (138(3) CMVR 177 MVA)
  5. As per sub-rule (2) of the 138 of Central Motor Vehicle Rules, the driver and the person seated on the front seat of the motor vehicle are by law required to wear the seat belts, while the vehicle is in motion.
  6. As per the provisions of sub-rule (3) of Rule 138 of the Central Motor Vehicle Rules, 1989 in a motor vehicle, in which seat-belts have been provided under sub-rule (1) or sub-rule (1A) of rule 125 or rule 125A, as the case may be, it shall be ensured that the driver, and the person seated in the front seat or the persons occupying front facing rear seats, as the case may be, wear the seat belts while the vehicle is in motion.
  7. Any person contravening these provisions of law and not wearing the seat belt as required shall be punished under Section 177 of the motor Vehicles Act, 1988.
  8. Rule 125 (1) requires the manufacturer of every motor vehicle other than motor cycles and three-wheelers of engine capacity not exceeding 500 cc, shall equip every such vehicle with a seat belt for the driver and for the person occupying the front seat.
  9. Rule 125 (1A) requires the manufacturer of every motor vehicle that is used for carriage of passengers and their luggage and comprising no more than 8 seats in addition to the driver's seat, shall equip it with a seat belt for a person occupying the front facing rear seat.
  10. The provisions in Sub-rule (1) of rule 125 of the Central Motor Vehicles Rules, 1989 stipulate that from 1994 onwards every manufacturer of Motor Vehicles other than Motor Cycles and 3-Wheelers of engine capacity not exceeding 500 CC shall equip every such vehicle with a seat belt for the driver and the person occupying the front seat.
  11. In US: In 1983, front seat belt wearing regulations for drivers and passengers (both adult and children) came into force. In 1989, wearing rear seat belts became compulsory for children under 14. In 1991, when it became compulsory for adults to wear seat belts in the back of a car, there was an immediate increase from 10 per cent to 40 per cent in observed rear seat belt wearing. For your own and others’ safety, the law requires you to use a seat belt in all motor vehicles if one is fitted and for children up to 135cms in height to use a child restraint.
  • A single-center study in JAMA Surgery that randomized 61 obese patients with type 2 diabetes to Roux-en-Y gastric bypass, laparoscopic adjustable gastric banding, or an intensive, 1-year lifestyle intervention found that up to 40% of patients who underwent the bariatric surgery had at least partial remission of diabetes at 3 years, compared with no one in the nonsurgical arm.
  • A Taiwanese study published in The Lancet is the first to link use of metformin to increased risk of death in patients with type 2 diabetes and advanced kidney disease.
  • A single-gene mutation has been identified that shuts down production of the carboxypeptidase-E (CPE) enzyme, and causes severe obesity and type 2 diabetes. The mutation affects insulin processing and appetite suppression and leads to intellectual disability and reproductive problems, reported new research published in PLoS One.
  • Midurethral sling operations for stress urinary incontinence in women have a good safety pro?le and are highly effective in the short and medium term, reported a systematic review published online July 1 in the Cochrane Database of Systematic Reviews.
  • New research, presented at the European League Against Rheumatism Congress 2015, suggests that in patients with symptomatic osteoarthritis of the hand, 24 weeks of treatment with hydroxychloroquine may not ease pain or improve function.
Cardiology eMedinewS
  • Appropriate (but not inappropriate) shocks from implantable cardioverter defibrillators (ICDs) may be a risk factor for increased CV mortality, new research suggests UMBRELLA registry,
  • New guidelines from the American Heart Association/American Stroke Association (AHA/ASA) recommend treatment with stent retrievers for carefully selected patients who are undergoing acute ischemic strokes. The guidelines are published in the journal Stroke.
Pediatrics eMedinewS
  • Central-line-associated bloodstream infections were reduced by 59% in a large pediatric hospital when children were bathed daily with disposable cloths containing 2% chlorhexidine gluconate, reported a study presented at the Association for Professionals in Infection Control and Epidemiology 2015 Annual Meeting.
  • The Committee on Genetics of the American College of Obstetricians and Gynecologists and the Society for Maternal-Fetal Medicine has released an opinion on the "advantages and limitations" of cell-free DNA screening for fetal aneuploidy in the general obstetric population, published online June 26.
Dr KK Spiritual Blog
Mindfulness meditation

Sit on a straight–backed chair or cross–legged on the floor.

Focus on an aspect of your breathing, such as the sensation of air flowing into your nostrils and out of your mouth, or your belly rising and falling as you inhale and exhale.

Once you've narrowed your concentration in this way, begin to widen your focus. Become aware of sounds, sensations, and ideas.

Embrace and consider each thought or sensation without judging it good or bad. If your mind starts to race, return your focus to your breathing. Then expand your awareness again.
Inspirational Story
Four Burning Candles

In a room there were four candles burning. The ambiance was so soft you could hear them talking. The first one said, "I am PEACE, however nobody can keep me lit. I believe I will go out."

Its flame rapidly diminishes and goes out completely. The second one says, "I am FAITH. Most of all I am no longer indispensable, so it does not make any sense that I stay lit any longer." When it finished talking a breeze softly blew on it putting it out.

Sadly, the third candle spoke in its turn. "I am LOVE. I have not gotten the strength to stay lit. People put me aside and don’t understand my importance. They even forget to love those who are nearest to them.” And waiting no longer it goes out.

Suddenly a child entered the room and saw three candles not burning. “Why are you not burning you are supposed to stay lit till the end." Saying this, the child began to cry. Then the fourth candle said, "Don’t be afraid, while I am still burning we can re–light the other candles, I am HOPE."

With shining eyes, the child took the candle of Hope and lit the other candles.

The flame of Hope should never go out from our life and that each of us can maintain HOPE, FAITH, PEACE and LOVE.

Hope never abandons you. You abandon hope. Consult not your fears but your hopes and your dreams. Think not about your frustrations, but about your unfulfilled potential. Concern yourself not with what you tried and failed in, but with what it is still possible for you to do.
Events
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Make Sure
Situation: A chronic smoker developed cancer of lung.
Reaction: Oh my God!! Why was he not screened earlier for cancer of lung?
Lesson: Make sure that all chronic smokers are given an option for lung cancer screening with low dose spiral CT.
Dr Good Dr Bad
Situation: A patient with positive malaria came with severe thrombocytopenia.
Dr Bad: This is classical malaria.
Dr Good: Also look for dengue.
Lesson: Malaria and dengue may co exist in the same patient.

(Copyright IJCP)
eMedi Quiz
Haemorrhage secondary to heparin administration can be best corrected by administration of:

1. Vitamin K.
2. Whole blood.
3. Protamine.
4. Ascorbic acid.

Yesterday’s Mind Teaser: Raised serum level of lipoprotein (a) is a predictor of:

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

Answer for yesterday’s Mind Teaser: 3. Atherosclerosis.

Correct Answers received from: Dr G Madhusudhan, Dr Bitaan Sen & Dr Jayashree Sen, Dr Poonam Chablani, Daivadheenam Jella, Dr K V Sarma.

Answer for 3rd July Mind Teaser: 2. Herpes simplex virus

Correct Answers received: Dr Sharavana, Dr Avtar Krishan.
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IJCP Book of Medical Records
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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
Press Release
Negative stress may lead to heart disease

Marital disharmony and job dissatisfaction are the two main mental risk factors for heart attack. Many studies in the past have found a strong correlation between a nagging wife and early heart attacks in men. Similarly, literature has shown that work–related stress is related to early onset of high blood pressure, diabetes, stroke and heart attacks, said Padma Shri, Dr. B C Roy & DST National Science Communication Awardee, Dr K K Aggarwal, President Heart Care Foundation of India and Hony. Secretary General, Indian Medical Association.

A study from University College, London has shown that chronically stressed workers have a 68% of higher risk of developing heart disease especially in people under the age of 50.

Whether stress–related chemical changes or stress-related behavior is linked to heart disease, is a question yet to be answered. Stress–related lifestyle involves eating unhealthy food, smoking, drinking and skipping exercises.

Chemical changes related to chronic stress are increased levels of cortisol, epinephrine and norepinephrine.

Amongst stress, negative stress is more dangerous than positive stress and amongst negative stress it is jealousy, anger and cynicism, which are associated with heart attack.

The answer lies in managing stress by acting on a personal situation and not reacting to it. In children the same type of stress, especially during exam days, can end up with anxiety, insomnia and suicidal attempts.
eIMA News
WHPA Campaign against Spurious Medicines in India – A Report
Pradeep Mishra, WHPA/FIP; Dr KK Aggarwal, IMA; Dr Lalit Kanodia, Apollo Hospitals; Ms Manjiri Gharat, IPA; Ms Jasu S Patidar, INC; Dr Mohanta, IPA

The World Health Professions Alliance WHPA brings together the global organizations representing the world’s dentists (FDI), nurses (ICN), pharmacists (FIP), physical therapists (WCPT) and physicians (WMA) and speaks for more than 26 million health care professionals in more than 130 countries. WHPA works to improve global health and the quality of patient care and facilitates collaboration among the health professions and major stakeholders.

WHPA has partnered with Pfizer to develop and deliver this campaign to tackle Spurious Medicines in India. The campaign was run in collaboration with the healthcare professionals associations in India, specifically Medical Doctors (through the Indian Medical Association, IMA), Nurses (through the Indian Nursing Council, INC) and Pharmacists (through the Indian Pharmaceutical Association, IPA), to help shape a campaign to raise awareness of the public health threat associated with spurious medicines in India.

Fine-tuning the scope and focus of the campaign

The first step of the campaign was to convene a meeting of an Advisory board so that the relevant Indian Healthcare Professionals Associations could benefit from the inputs of relevant stakeholders.

During this first meeting, the partners of the campaign agreed upon a Campaign Charter:

Campaign Charter: This campaign and meeting has been convened to address the issue of spurious medicines, in the context of the threat presented to patients in India. The definition of spurious drugs is provided in Section 17-B of the Drugs and Cosmetics Act, 1940 of Government of India.

Throughout the whole campaign, careful consideration will be given to specifics of India, recognising the use of both traditional (this was not considered due to non representation of any one professional association to represent traditional medicine) and ‘western medicines’ (generics or branded) medicines.

The original intention of the campaign was to raise awareness among patients in Indian on spurious medicines, qualitative research indicated that this would create a high level of anxiety among the population, as they would perceive that there was little they could do to prevent spurious medicines.

Further to a 2nd meeting where the conclusions of this qualitative research was presented, the campaign focus shift to raise awareness and educate healthcare professionals. During this meeting, the key messages were agreed, as well as the next steps for campaign development

WHPA campaign – India

The second step of the campaign was to sign the Memorandum of Understanding (MoU) between the three healthcare associations (IMA, IPA, INC). The signing of the MoU denoted the partnership and trust between the organisations as well as the shared recognition of the importance of the issue. The associations agreed that to ‘start small but think big’: a pilot intervention would allow testing of messaging and approach to support more successful roll-out. The first pilot was made in Apollo Hospitals among all three healthcare groups. Based on the feedback of this first pilot, minor adjustments were made and the three Indian professional associations conducted pilots on education and awareness amongst their members.

The campaign included training programs as education and awareness interventions on how to minimize this threat with the interest to increase knowledge as well as change behaviours.

Seven locations were chosen to conduct the training sessions for Doctors, Nurses and Pharmacists (community and hospital) respectively on spurious and counterfeit medicine. The content of training program, study material including the evaluation questionnaire was developed jointly by WHPA and stakeholder associations. The Sensitisation cum Training programme were conducted in sessions of two hours duration on an average.
  • Participants: Healthcare Professionals (Doctors, Nurses and Pharmacists)
  • Expected Sample size: 100 Doctors, 200 nurses and 100 Pharmacists
  • Actual Attendance: 677
    Doctors- 70 including senior and junior practicing medical doctors
    Nurses-252 including senior and junior practicing nurses
    Pharmacists-355 including community and hospital pharmacists
Assessing the campaign

The three healthcare professional group participants were subject to a pre-training test and post-training tests, in order to assess the interactive training cum awareness

Description of the Pre test evaluation:

The session was preceded with a pre test evaluation consisting of questions covering the prevalence, societal consequences and regulatory aspects of the spurious medicines. The participants were explained of answering them as true / false or tick the most appropriate answer. Some of the questions in the pre test questionnaire were left blank.

Scoring pattern: All questions were allotted equal marks (1 each) and every correct or partially correct entry in case of multi correct answer type questions was awarded a score of 1. All incorrect answers were marked as 0.

Description of the Post test evaluation:

The sensitisation cum training session was followed by a post test to calculate the gain from the training session. Many of the questions in pre-test which were observed having been left blank were answered for the post test. However, many of the participants marked only one or two of the correct answers in the multi answer type questions.

Training Impact: The training session caused an impact on the knowledge and perception about spurious medicines among the participants. Among the pharmacist groups the improvement in knowledge ranged from 14% (n-30) and 16.35% (n-51) to 21.43% (n-59). The pharmacists were convincingly conscious of spurious medicine prevalence and their consequences in public health. The sensitisation program increased their awareness about other factors relating to spurious drug such as their prevalence and the severity of the matter as is evident from the increased average scores in the post test.

A radical gain in knowledge was observed within the nursing fraternity with 9.33% (n-52) to 13.20% (n-191). A good number of conversions were observed with nurses for the knowledge about spurious drugs, their prevalence and societal consequences.

The knowledge gain in case of doctors (n-31) was not much of a difference so no significant results can be drawn. It remains as an area open to further investigation and improvements.

Results

The participants took active part in the pre test as well as the post test. Good gain of knowledge was observed in the groups. Maximum conversion was observed with the awareness of the broader definition, scope and the severity of the spurious medicines. Out of the 414 respondents, who participated in pre and post test 58% of the audience were nurses which will impact patient-drug-compliance greatly. Being aware makes them being conscious of the quality of drugs in use which would certainly increase their involvement in finding out the prevalence of such drugs in the healthcare setting and increase the level of quality and help them march towards the noble cause of healing. Similarly the pharmacists who play a key role in drug distribution can reduce the prevalence of spurious drugs and counterfeit medicines using the visual inspection tools and awareness.

Inference

The training session does bear an impact on enhancement of knowledge and perception about spurious drugs among healthcare professionals from Pharmacy and Nursing fraternity. The current understanding of spurious drugs seems to be low, especially among nursing professionals, as can be accessed from the queries raised. (Including an initial query about ‘What is spurious drug? We don’t know what spurious drugs are, how we’ll be able to take the pre test!’) Good conversion from incorrect to correct answers depicts good people engagements through interactive presentation – hints towards effectiveness of training module and session. Conceptual questions being answered correctly with good conversion, data based questions got negative conversion. The post training evaluation also allowed the participant to share their insights and suggestion on their contribution to control this menace. Maximum of the participants believed that drugs purchase source should be authentic and genuine and laid emphasis on the proof of purchase. The need to make healthcare professionals as well as consumers aware of the menace and the availability of visual inspection tools was felt by a large population amongst the participants. The mechanism to report suspects and motivating people to report suspects and ADRs preferably through a toll free number and handling the defaulters through fast track courts included other suggestions.

Conclusion

In all professional groups, the campaign enabled an improvement in knowledge and /or perception about spurious drugs and counterfeit medicines. The collaboration resulted in development of a handbook on spurious medicines in India, which can be used for education, awareness, detection and reporting of spurious medicines in India. This was probably a rare occasion that the three leading professionals associations in India have been involved in such a joint project and it was felt that this increased the trust among them, which may eventually lead to a formalised collaboration among these three professional associations.

Acknowledgement: Pfizer, Inc. USA
Clarification regarding procedures to be followed in case of short term demonstration/ display of Ultrasound/Imaging Machines m the workshops/CME-reg
No. V.11011/05/2013 -PNDT
Government of India
Ministry of Health & Family Welfare (PNDT Division)
Nirman Bhawan, New Delhi Dated the 14th May, 2015

To
The Principal Secretaries (Health & FW), All States/UTs,

Subject:-Clarification regarding procedures to be followed in case of short term demonstration/ display of Ultrasound/Imaging Machines m the workshops/CME-reg.

Sir,
I am directed to say that an Expert Committee was constituted to re-examine the provisions of the PC & PNDT Act, 1994 and rules framed thereunder. The expert committee had given clarifications regarding the powers of State Appropriate authorities and the closure of unused/idle/surrendered Ultrasound machines. The recommendations were placed in the 22nd Meeting of the Central Supervisory Board (CSB) [constituted under the Pre-conception and Pre-natal Diagnostics Techniques Act (PC & PNDT Act), 1994) held on 13th October, 2014 under the Chairmanship of Hon'ble HFM. The CSB has endorsed the following recommendations made by the Expert Committee:-

District Appropriate Authority may grant permission for education/training or display of diagnostic technologies as prescribed below.
  • For display at scientific exhibition, the organising body should take permission from the District Appropriate Authority for the display of diagnostic technologies/equipment specifying their details. DAA should ensure that these diagnostic technologies are not used for live demonstration and the organizing body has to take all responsibilities for the violations under the PC & PNDT Act, 1994, if any.
  • For live demonstration at workshops and conferences, permission should be granted only when these diagnostic technologies are demonstrated in registered facilities under the PC & PNDT Act, 1994 with transmission facility for viewing by the delegates. Along with the request by the organizing body the details of the diagnostic technologies/equipment used in the workshops/ conferences and list of experts/ professional demonstrating technologies along with qualifications must be submitted. The registered facility that provides its premises for same should also intimate to their respective District Appropriate Authority with all information pertaining to the equipment used and experts/professional demonstrating technologies. In all live demonstration and conferences Appropriate Authority should ensure that all the record under the provision of the PC & PNDT Act are maintained and preserved.
2. In view of above recommendations of CSB, you are requested to take further action and disseminate the same among all stakeholders.

Yours Faithfully

(Subhash Chandra)
Deputy Secretary to the Government of India Tel: 23061540
IMA NEWS
  • The Maharashtra State Aids Control Society (MSAC) has expressed fear in the run-up to the Kumbh Mela of unprotected sex and the possible spread of HIV and AIDS because of shortage of condoms. (TOI)
  • India, which is already is the third most obese country in the world, is showing increasing incidence of over-weight children and adolescents in urban areas. Latest estimates show prevalence of obesity among adolescents (13-18 years) has grown from 16% to 29% over the last five years. (TOI)
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The hardest battle you are ever going to fight is the battle to be just you. Dr. Felice Leonardo Buscaglia
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Reader Response
Dear Dr Aggarwal, I enjoy reading eMedinewS daily & also share it with others. Thank you very much. Dr. Vinod Reddy
Media
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Wellness Blog
Vegetarian diet and Soya Products help reduce BP

Ingestion of a vegetarian diet may reduce systolic blood pressure by 5 mmHg, which may reduce the risk of heart disease by 21%.

One major feature of a vegetarian diet that may affect blood pressure is the amount of dietary fiber; with an increased amount being associated with decreased systemic pressures. Multiple meta–analyses have shown benefits with dietary fiber intake on blood pressure.

Vegetarians, in general, have lower blood pressure levels and a lower incidence of hypertension and other cardiovascular diseases. Experts postulate that a typical vegetarian’s diet contains more potassium, complex carbohydrates, polyunsaturated fat, fiber, calcium, magnesium, vitamin C and vitamin A, all of which may have a favorable influence on blood pressure. More significant reductions were observed in older (greater than 40 years) and hypertensive individuals.

Soya is good for high blood pressure because it is naturally high in potassium and low in sodium. Potassium and sodium are electrolytes, and a high–potassium, low–sodium diet promotes a healthy blood pressure.

Soya can be good for high blood pressure when you eat it as an alternative protein source to unhealthy meats. Soya–based meat substitutes, such as veggie burgers, veggie bacon and meatless cold cuts, can be higher in fiber and lower in sodium than animal-based meat products. They can lower your risk for heart disease because they are lower in saturated fat. However, soya does not contain the long–chain omega–3 fatty acids that are found in fatty fish and shellfish; these may lower your blood pressure, according to the Linus Pauling Institute.

Even though soya is low in unhealthy saturated fat, some soya products are high in total fat and calories, and as a result will contribute to weight gain if you eat too much. Losing weight if you are overweight, or maintaining your current weight if you are already at a healthy weight, improves your chances of lowering your high blood pressure.
IMA Humor
High Blood Pressure

When a physician remarked on a new patient’s extraordinarily ruddy complexion, he said, "High blood pressure, Doc. It comes from my family."

"Your mother’s side or your father’s?" I asked.

"Neither," he replied. "It’s from my wife’s family."

"Oh, come now," I said. "How could your wife’s family give you high blood pressure?"

He sighed. "You oughta meet ’em sometime, Doc!
Rabies News (Dr A K Gupta)
What is the "furious form" of rabies in animals?

The excitative phase follows the prodromal phase in some animals. The animal becomes irrational and may aggressively use its teeth, claws, horns, or hooves. The expression is one of anxiety with dilated pupils. Noise invites attack. The rabid animal roams extensively and attacks other animals, including humans and any moving object. Cats usually manifest furious type of rabies.
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