December 8   2015, Tuesday
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Dr KK AggarwalDr KK Aggarwal Statins and influenza vaccine

Statins, commonly used cholesterol-lowering drugs in the older adults, have immunomodulatory effects and may affect the response to a vaccine.

In an observational study conducted in the context of a randomized trial that evaluated influenza vaccines in the elderly, hemagglutination inhibition geometric mean titers to various influenza strains were markedly lower in subjects receiving chronic statin therapy than in those not receiving chronic statin therapy. This apparent immunosuppressive effect of statins on the vaccine immune response was most dramatic in individuals receiving synthetic statins. (1) In a large retrospective cohort study over nine influenza seasons using research databases of a large managed care organization in the US, statin therapy was associated with reduced influenza vaccine effectiveness against medically attended acute respiratory illness. (2)

Although these studies raise the possibility that older patients receiving statins are less likely to be protected by the influenza vaccine, but they should still be given statins if required as also an annual influenza vaccine.

1. Black S, et al. Influence of statins on influenza vaccine response in elderly individuals. J Infect Dis 2015

2. Omer SB, et al. Impact of statins on influenza vaccine effectiveness against medically attended acute respiratory illness. J Infect Dis 2015.

(Source: Uptodate)
Amit Sharma and Nilesh Aggarwal

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Breaking News
EMA OKs Nucala for severe refractory eosinophilic asthma

The European Medicines Agency (EMA) has approved mepolizumab (Nucala, GlaxoSmithKline), anti-interleukin-5 as an add-on treatment for severe refractory eosinophilic asthma in adults in the 31 European countries covered by the EMA. It is to be given as 100 mg subcutaneous injection every 4 weeks along with other usual medications such as high-dose inhaled corticosteroids and additional medicines that may include oral corticosteroids. (Medscape)

Centre to amend D&C Rules to bring all notified medical devices under Schedule M III

The Union health ministry will soon amend Schedule M III relating to requirements of factory premises for manufacture of medical devices and in-vitro diagnostic reagents or kits to bring all the notified medical devices under the ambit of Schedule M III which at present is being regulated under the provision of the Drugs and Cosmetics Rules, 1945. The present rule introduced in 1994 relates only to three medical devices namely sterile perfusion and blood collection sets, sterile hypodermic syringes and needles, while large number of devices has since been notified and is being regulated under the provision of the Drugs and Cosmetics Rules, 1945. The provisions of the revised Schedule M III will be applicable to manufacturers of finished devices, in-vitro diagnostics, mechanical contraceptives (condoms, intrauterine devices, tubal rings), surgical dressings, surgical bandages, surgical staplers, surgical sutures and ligatures, blood and blood components collection bags, intended for human or animal use that is manufactured in India… (Pharmabiz - Ramesh Shankar) 
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Specialty Updates
• MRI scans may be useful to detect childbirth injuries. Nearly 15% of women sustain pelvic injuries during childbirth that do not heal, suggested new research published in the American Journal of Obstetrics and Gynecology. About 25% of women showed fluid in the pubic bone marrow or sustained fractures similar to a sports-related stress fracture, and 66% showed excess fluid in the muscle, suggesting injury similar to a severe muscle strain; 41% sustained pelvic muscle tears, with the muscle detaching partially or fully from the pubic bone on MRI scans.

• Patients with epilepsy are more likely to commit suicide than the general population, reported new CDC data, presented at the American Epilepsy Society meeting.

• Reducing the size of large food portions, packaging and tableware could help to tackle obesity, suggested a report published in the BMJ

• Triple therapy consisting of methotrexate, sulfasalazine, and hydroxychloroquine has a favorable effect on the lipid profile over 2 years in patients with early rheumatoid arthritis when compared with methotrexate alone or methotrexate with a biologic agent, suggested a new study published online in Arthritis & Rheumatology.

• Among children with lactic acidosis due to severe anemia, transfusion of longer-storage red blood cells, compared with shorter-storage, resulted in a similar reduction of elevated blood lactate levels, a measure of tissue oxygenation, suggested a study published in JAMA.

• Intestinal bacteria change their composition and function when diabetic patients are treated with the drug metformin, suggested new research published in the journal Nature. Researchers noted that metformin causes favorable changes in the gut microbiota in patients with type 2 diabetes, which boosts the capability of the bacteria to produce certain types of short-chain fatty acids, such as butyric acid and propionic acid.

• Taking a deep breath might be a bit harder for children exposed early in life to a widely used class of pesticides in agriculture, suggested a new paper published in the journal Thorax. The research linked the levels of organophosphate pesticide metabolites in the urine of children with decreased lung function.

• Chimeric antigen receptor T cells targeting the B cell maturation antigen (BCMA) may completely eradicate or measurably decrease multiple myeloma, suggested the results of an ongoing pilot study presented at American Society of Hematology meeting.
Why don’t we touch papers, books and people with our feet?

In every traditional gurukul, no studies start without chanting the following

Saraswati namasthubhyam
Varade kaama roopini
Vidyaarambham karishyaami
Sidhirbhavatu me sadaa

“O Goddess Saraswati, the giver of Boons and fulfiller of wishes, I prostrate to You before starting my studies. May you always fulfill me” Indian Vedas consider knowledge about self as the supreme knowledge and all tools for the same are considered sacred and divine and must be given respect. The traditional custom is not to step on any sacred educational tool.
Legal Quote
Indraprastha Medical Corp. Ltd. vs State NCT of Delhi & Ors. Crl. M.C. No. 827/2010 on 2 August, 2010

The offence of criminal negligence requires a specific state of mind in respect of the person committing the offence. The offence of medical criminal negligence cannot be fastened on the company since the company can neither treat nor operate a patient of its own. It is the Doctor working in the company who treats & performs operations. It is the Doctor who examines the patients and prescribes medicines.”
Medical breakthroughs that were initially ridiculed or rejected

Though Gregor Mendel established the laws of inheritance through plant experiments and, to a lesser degree, with mice and bees, his contributions to science are included not only because of their far-reaching effects on medicine but because he experienced so many varieties of ridicule and rejection of his work. The scientific community initially rejected his theories because in their eyes he was a simple monk from a provincial town and so was not expected to address such weighty scientific questions. Also, his work combined mathematics with botany, two disciplines that were regarded as separate. The use of what are now considered simple statistical techniques was then seen as strange and obtuse to mid-19th century botanists and zoologists. His theories were not accepted until after he died, when the results were duplicated in papers published in 1900, some 35 years after he initially presented his ideas … (Medscape)
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IMA National Health Scheme (Contd.)

Appellate Body: If any member is aggrieved by the decision of the scrutinizing committee he can appeal to the managing committee.
a. In any eventuality there should not be any liability to IMA.
b. If it becomes impossible to carry out the objectives of the scheme, the scheme can be dissolved by a decision of the CWC and Central council.
c. Any remaining asset shall be transferred to National IMA to be used for charitable purposes.
22nd MTNL Perfect Health Mela, the annual flagship event of the Heart Care Foundation of India
Drug price cut yielded Rs 2,772 crore benefit to public

The government's decision to reduce prices of drugs, including those of cancer, cardiovascular diseases, AIDs/HIV and diabetes, has benefited the public to the amount of Rs 2,772 crore. Out of a total of 680 under the National List of Essential Medicines (NLEM) under the scheduled category of DPCO, 2013, the National Pharmaceutical pricing Authority (NPPA) has already fixed the ceiling prices in respect of 530 medicines. This includes 47 formulations for cancer, 53 for cardiovascular diseases, 20 for AIDS/HIV and 6 for diabetes. In addition, maximum retail has been capped in respect of 106, non-scheduled medicines, under para 19, of the Drug Price Control Order (DPCO) 2013. NPPA has also fixed the retail price of 247 new drugs under para 5 of DPCO, 2013… (ET Healthworld)
PCI envisages PPR 2015 to transform role of community pharmacist role in healthcare

According to the Pharmacy Council of India (PCI), the Pharmacy Practice Regulations 2015 would transform the community pharmacist's role in healthcare in the country. The regulation mandates B Pharm as the minimum qualification for a candidate to be employed as a pharmacist in chemists and druggist outlets and even pharmacy counters at hospitals. The two-year bridge course referred to as the Bachelor Degree In Pharmacy Practice (B Pharm Practice) designed by PCI to upgrade the qualified Diploma in Pharmacy (D Pharm) candidates is scheduled to take-off in the academic year 2016... (Pharmabiz - Nandita Vijay)
The Biggest Medical Stories of 2015 as rated by Medscape readers

The second biggest medical story of 2015 for Medscape readers (28%) was the approval of physician-assisted suicide (also called assisted dying) in California, making it the fifth state in the country where this practice is legal. California's new law, based on Oregon's trailblazing Death with Dignity Act, could create momentum for similar legislation to pass in more states.
MRI shows joints recover even under extreme duress

A study of ultramarathoners who ran the whole of Europe demonstrated that critical leg joints seemed to self-heal even as the runners covered about 70 km (42 miles) a day. In the study presented at the Radiological Society of North America (RSNA) meeting, nearly all cartilage segments of knee, ankle, and hindfoot joints, except patellar joint, showed a significant degradation within the first 1,500 to 2,500 km of the race. But the deficits resolved with continued running… (Medpage Today) .
Medical litigation cases have increased in the last decade

Statistics show that the cases of medical negligence in the country have gone up by 400% in the last decade. A recent survey carried out by National Law School of India University (NLSIU), Bengaluru, has pointed out four reasons for the rise in medical litigation in India namely greater consumer awareness, flexible consumer forums, cost involved in medical services, and litigant mindset among the populace… (ET Healthworld) .
UNOS approves child priority policy for lung transplant

The US Organ Procurement and Transplantation Network (OPTN) and the United Network for Organ Sharing (UNOS) Board of Directors have revised their pediatric lung allocation policy. The child priority policy will provide broader geographic sharing of lungs from child and adolescent donors younger than age 18 first to medically compatible candidates up to age 11, then to adolescents age 12 to 17. Lungs not accepted for these candidates will then be offered to adult candidates. Under prior allocation rules, donor lungs were first offered to candidates living near the donor hospital. If none were identified, the donor lungs were offered to those living farther away in 500-mile radius increments. Pediatric candidates received priority for child donor lungs within a 1,000-mile radius of the donor (followed by adolescents, then adults), and adolescent candidates received priority for adolescent donor lungs (followed by children, then adults). The new child priority policy also allows lung candidates listed before age two to be considered for donor lungs of any blood type, if their transplant program chooses to do so… (Medscape)
Focus on the whole diet and not just certain foods

A study published in the medical journal Diabetes Care has highlighted the importance of the whole diet rather than focusing on certain foods or food groups that might be beneficial. A diet rich in whole grains, fruits and vegetables (leafy green), nuts, and low–fat dairy may help people lower their risk of type 2 diabetes by 15% over 5 years than those who ate the lowest amounts of these foods. Also, a diet which contains high amounts of red meat, high–fat dairy and refined grains like white bread may boost the odds of diabetes development by 18%. In contrast, adults whose diets were high in red meat, high–fat dairy, refined grains like white bread, plus beans and tomatoes, saw their diabetes risk go up by 18% as a group.

Type 2 diabetes is closely linked to obesity and it is well–known that maintaining a healthy weight through diet and exercise reduces the risk of developing the disease. Diet affects diabetes risk independent of a person’s weight

USV Advts2
WP(C) No.8706/2015 titled “Indian Medical Association Vs. Union of India & Anr (NCERT)” Delhi High Court, New Delhi

Click here to read the proposed changes
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Bioethical issues in medical practice
Protecting the privacy and confidentiality of patients

Smita N Deshpande
Head, Dept. of Psychiatry, De-addiction Services
PGIMER-Dr. Ram Manohar Lohia Hospital
Park Street, New Delhi
You are a member of an informal discussion group of doctors who meet regularly to discuss difficult cases. At all these discussions, the conversation is frank and detailed, with all details of the patients, social situation, family issues etc. are discussed threadbare. Sometimes this discussion spills over into the hospital lifts, corridors and canteens. When these issues are really interesting, you discuss them at home with your spouse- a doctor- as well. Many times the name, address, and other details of patients are discussed as well.

a) Do such discussions breach medical confidentiality?
b) At which places should medical cases be discussed?
c) Should interesting medical cases be discussed at home?

Any suggestions? Do write in!

Adapted from: Bioethics Case Studies (AUSN and EEI, November 2013):
Inspirational Story
The lucky starfish

Once a man was walking along a beach. The sun was shining and it was a beautiful day. Off in the distance he could see a person going back and forth between the surf's edge and the beach. Back and forth this person went. As the man approached, he could see that there were hundreds of starfish stranded on the sand as the result of the natural action of the tide. The man was stuck by the apparent futility of the task. There were far too many starfish. Many of them were sure to perish. As he approached, the person continued the task of picking up starfish one by one and throwing them into the surf. As he came up to the person, he said: "You must be crazy. There are thousands of miles of beach covered with starfish. You can't possibly make a difference." The person looked at the man. He then stooped down and picked up one more starfish and threw it back into the ocean. He turned back to the man and said: “It sure made a difference to that one!”
eMedi Quiz
Low serum iron, low total iron binding capacity (transferrin), a normal to increased serum ferritin concentration; what is the diagnosis?

1. Anemia of inflammation
2. Iron deficiency anemia
3. Wrong report
4. Folic acid deficiency

Yesterday’s Mind Teaser: Which of the following are true regarding anemia?

1. Hb <13.5 g/dL or hematocrit (HCT) <41.0% represents anemia in men
2. Hb <12.0 g/dL or <36.0%, respectively, represents anemia in women.
3. Differences may also exist between races, in older adults, and in athletes.
4. All of the above

Answer for Yesterday’s Mind Teaser: 4. All of the above

Answers received from: Dr Jainendra Upadhyay, Dr Kailash Chandra Sharma, Dr Rajesh S Joshi, Daivadheenam Jella, Dr Avtar Krishan

Answer for 6th December Mind Teaser: 1. 1.5 to 3 days

Answers received from: Daivadheenam Jella
A kangaroo kept getting out of his enclosure at the zoo. Knowing that he could hop high, the zoo officials put up a 10-foot fence. He was out the next morning, just sauntering around the zoo. A 20-foot fence was put up. Again he got out. When the fence was 40 feet high, a camel in the next enclosure asked the kangaroo, “How high do you think they’ll go?” The kangaroo said, “About a thousand feet, unless somebody locks the gate at night!”
Reader’s column
• It is really the need of the hour. Unfortunately majority of blood banks do not get activated. Hundreds and thousands of wrongs go unnoticed all over leading to fatal outcomes or problems. God bless. Dr NK Bhatia

• Dear Dr Agarwal, I have to bring to your kind notice that at present there are about 18000 to 20000 medicines being manufactured and marketed by about 300 pharmaceuticals companies. This is not only inconvenient for the doctors to remember and is also impossible for any chemist to keep them. I request you to kindly look into the matter. My suggestion is that there should be only 2000 medicines and only 200 pharmaceuticals companies. This will not only convenient to all but also eradicate adulteration, which is quite heavy these days. Dr BR Bhatnagar
Press Release
Guide to protecting yourself from winter diseases

Awareness must be generated about how the sudden change in weather can cause health complications for the elderly, children and people with existing lifestyle diseases

New Delhi, December 7th, 2015: While the coming of the winter months and subsequent festivities are eagerly awaited by many; it also brings with it health implications especially for those suffering from pre-existing lifestyle diseases, the elderly and young children. It is essential that special care is taken during this time to be able to enjoy properly the winter season.

It is a known fact that the number of hospital admissions rise during the winter months. There are several reasons for this. Firstly the reduction in the daylight hours affects the hormonal balance of the body and causes Vitamin D deficiency a common trigger for heart attacks and strokes. The cold weather also triggers bouts of depression especially amongst the elderly population causing an increase in stress levels and hypertension. People suffering from winter depression are also seen indulging in high sugar, trans fat and sodium comfort food, which can be extremely dangerous for the diabetic and hypertensive population. Pneumonia is also extremely common during this period. Speaking about this, Padma Shri Awardee, Dr. A Marthanda Pillai – National President IMA and Padma Shri Awardee Dr. K K Aggarwal, President HCFi and Honorary Secretary General IMA said, “The risks of developing winter diseases like pneumonia, depression, hypothermia, fluctuating blood pressure amongst others can be prevented and easily managed by making some habitual changes to one’s lifestyle. It is advised that patients with pre-existing lifestyle diseases shouldn’t consume alcohol quantities during in winter months as it can cause complications. A healthy diet must be consumed, and binge eating should be avoided. Eating small and frequent meals is ideal”.

Below are some precautions each one of us must take to stay healthy during the winter months

• To prevent winter depression, one should either sit in the sunlight for long or stay in indoor spaces with illuminated light.
• Early morning blood pressure is higher in winter than in the summer months. Therefore, people with high blood pressure should ask their doctor to increase their blood pressure medicine during the winters.
• There are more heart attacks in the winter months than in the summer months and therefore, any chest pain especially in the morning in winter should not be ignored.
• During the winter season, one should avoid food that is excessively sweet, sour or salty
• Everyone should ask their doctor for pneumonia and flu vaccine.
• Pneumonia during the winters can be deadly in very young and old people. The flu vaccine should be given to all those who are at high risk, especially, people with asthma, diabetes and heart diseases.
• During the winters, one should avoid sleeping in closed rooms with electric gadgets like heaters on
• One should check the earthing of all the electric devices especially the geyser
• One should avoid using sugar while preparing sweets; instead one can use either Stevia or jaggery especially in Gajar Ka Halwa.
• One should avoid switching from one temperature to another without giving their body time for adjustment.
• Vitamin D is essential for good health. Each person should spend 40 minutes in the sunlight each day, especially before 10 am and after4 pm.

Prevention is always better than cure. A little extra care can help make the holiday months, more enjoyable and heart healthy. .