Wednesday, August 31, 2011

Emedinews:Dr Good Dr Bad:A female with rheumatoid arthritis became pregnant while taking leflunomide.

Situation: A female with rheumatoid arthritis became pregnant while taking leflunomide.
Dr. Bad: Continue it.
Dr. Good: Stop it immediately
Lesson: In women with rheumatoid arthritis who become pregnant while taking leflunomide, healthy pregnancy outcomes usually occur, if the drug is discontinued at the earliest and a cholestyramine drug elimination procedure is done. (Arthritis Rheum 2010;62:1494)

Emedinews: Makesure:A 40-year-old male developed acute heart attack after playing squash.

Situation: A 40-year-old male developed acute heart attack after playing squash.
Reaction: Oh my God! Why was a cardiac test not done?
Lesson: Make sure that anybody taking up anaerobic games after the age of 40 should first get a cardiac clearance.

The Buddha Description of a Disease: Desire, Hatred and Ignorance




According to Buddhism, the three negative emotions that cause a disease are “desire, hatred and Ignorance”.

Accordingly physical sickness is classified into three main types.

1.         Disorders of desire (Ayurveda equivalent of Vata imbalance): These are due to disharmony of the wind or energy. The seed of these disorders are located in the lower part of the body. It has cold preferences and is affected by mental desires. In this, the person mainly suffers from the disorders of movement functions.
2.         Disorders of hatred (Ayurveda equivalent of Pitta imbalance): It is due to disharmony of the bile. The seed of these disorders is centered in the middle and upper part of the body and is caused by the mental emotion of hate. The person suffers from metabolic and digestive abnormalities.
3.         Disorders of ignorance (Ayurveda equivalent of Kapha imbalance): It is due to the disharmony of phlegm, the seed of which is generally centered in the chest or in the head and the disorder is cold in nature. It is caused by the mental emotion of ignorance.

Desire, hatred and ignorance, all are produced in the mind and behave like a slow poison. According to Udanavarga (a Sanskrit Buddhist text) from iron appears rust, and rust eats the iron”, “Likewise, the careless actions (karma) that we perform leads us to hellish lives.

According to the other scriptures, six afflictions are most troublesome, namely ignorance, hatred, desire, miserliness, jealousy and arrogance.

Patience is the most potent virtue a person can acquire. According to the Shanti Deva, “There is no evil like hatred, and there is no marriage like patience. Therefore, dedicate your life to the practice of patience.”

Bhagvad Gita classifies the enemies as Kama, Krodha, Lobha, Moha and Ahankara and out of them Kama, Lobha and Ahankara, are the three gateways to hell.

About the author: Dr K K Aggarwal is Padmashri and Dr B C Roy National Awardee, President Heart Care Foundation of India, Dean Board of Medical Education Moolchand Medcity, Sr. Physician & Cardiologist, Chairman Ethics Committee Delhi Medical Council, Visiting professor Clinical Research DIPSAR, Past President Delhi Medical Association and Past Academic and Research Wing Heads IMA.

Padma Shri Awardee Dr KK Aggarwal on Sudden Cardiac Death in Hindi

Padma Shri Awardee Dr KK Aggarwal on Sudden Cardiac Death in English

zSHARE - Padma Shri Dr KK Aggarwal on Air pollution is linked to heart disease. emedinews audio 1st September_1-2.mp3

zSHARE - Padma Shri Dr KK Aggarwal on Air pollution is linked to heart disease. emedinews audio 1st September_1-2.mp3

Tuesday, August 30, 2011

Emedinews:Makesure: A patient on 10 units of insulin developed hypoglycemia after taking a light breakfast.

Situation: A patient on 10 units of insulin developed hypoglycemia after taking a light breakfast.
Reaction: Oh my God! Why was the insulin dose not reduced?
Lesson: Make sure that insulin dose is correct. The formula is 500/total daily dose. The value will be the amount of sugar fluctuation with ten grams of carbohydrates.

Emedinews: Dr Good Dr Bad:A patient had LDLC of 100 mg/dL and HDLC 61 mg/dL.

Situation: A patient had LDLC of 100 mg/dL and HDLC 61 mg/dL.
Dr Bad: Start statins.
Dr Good: No treatment is required yet.
Lesson: HDL–C ≥60 mg/dL counts as a "negative" risk factor; its presence removes one risk factor from the total count.

zSHARE - Padma Shri Awardee Dr KK Aggarwal on Go wish you Muslim friend Eid Mubarak emedinews audio 31st August.mp3

zSHARE - Padma Shri Awardee Dr KK Aggarwal on Go wish you Muslim friend Eid Mubarak emedinews audio 31st August.mp3

Emedinews: Makesure: A patient missed his second dose of Hepatitis B vaccine and developed Hepatitis B.

Situation: A patient missed his second dose of Hepatitis B vaccine and developed Hepatitis B.
Reaction: Oh my God! Why was the vaccine not given between 1–2 months?
Lesson: Make sure that all patients who missed their second dose of vaccine at one month are given the same upto second month (1–2 months).

Emedinews: Dr Good Dr Bad: A patient was on rapid weight loss program.


Situation: A patient was on rapid weight loss program.
Dr Bad: Go ahead.
Dr Good: Add UDCA.
Lesson: As weight loss may increase the likelihood of gallstones, UDCA is often added when the weight loss is more than 1 – 1.5 kgs per week.

Monday, August 29, 2011

Stay Tuned with- Padma Shri Awardee Dr KK Aggarwal on Ganesha_ the Stress Management Guru_30th August-1-2.mp3

zSHARE - Padma Shri Awardee Dr KK Aggarwal on Ganesha_ the Stress Management Guru_30th August-1-2.mp3

Padma Shri Awardee Dr KK Aggarwal on When not to ignore consipation in Hindi

Padma Shri Awardee Dr KK Aggarwal on When not to ignore consipation in English

Emedinews: Makesure: A patient of pulmonary Koch’s taking ATT complains of numbness in fingers and toes.

Situation: A patient of pulmonary Koch’s taking ATT complains of numbness in fingers and toes.
Reaction: Oh my God! I forgot to prescribe vitamin B complex.
Lesson: Make sure that in patients talking ATT (including INH) B–complex vitamins (especially vitamin B6) are prescribed to prevent neuropathy. Addition of antioxidants and multivitamins also boost the immune system.

Emedinews: Dr Good Dr Bad: A female with past history of DVT needed an OC prescription.

Situation: A female with past history of DVT needed an OC prescription.
Dr Bad: Start OC patch (transdermal).
Dr Good: You cannot be on OCs.
Lesson: There is a possibility of an increased risk of venous thromboembolism in oral contraceptive patch users.

Sunday, August 28, 2011

HCFI Update: When not to ignore constipation

While most instances of constipation may not be serious, some cases of infrequent or difficult bowel movements need evaluation by a doctor said Padma Shri and Dr B C Roy National Awardee Dr K K Aggarwal, President Heart Care Foundation of India, and MTNL Perfect Health Mela.

Constipation is one of the most common gastrointestinal complaints. Those reporting constipation most often are women and adults ages 65 and older. Pregnant women may have constipation, and it is a common problem following childbirth or surgery.

Constipation occurs when the large colon absorbs too much water or if the colon's muscle contractions are slow or sluggish, causing the stool to move through the colon too slowly. As a result, stools can become hard and dry.

Common causes of constipation are:

1. Not enough fiber in the diet
2. Lack of physical activity
3. Some drugs
4. Pregnancy
5. Elderly
6. Abuse of laxative
7. Ignoring the urge to have a bowel movement
8. Dehydration
9. Underlying cancer
10. Depression

Heart Care Foundation of India offers this list of warning signs:

a. You’re constipated for the first time
b. You’ have been treating with house hold remedies for constipation for three weeks with no improvement.
c. You have associated abdominal pain.
d. You have associated bloody stools.
e. You have associated unexplained weight loss.


Ganesha, the Stress Management Guru

If Lord Krishna was the first counselor who taught the principles of counseling, Lord Ganesha taught us the principles of stress management. We should worship Lord Ganesha and follow his principles whenever we face any difficulty or are stressed out.

The elephant head of Ganesha represents that when in difficulty, use your wisdom, intelligence and think differently. It can be equated to the Third Eye of Lord Shiva. Elephant is the most intelligent animal in the kingdom. Here wisdom implies to thinking before speaking. Lord Buddha had also defined that one should not speak unless it is necessary, is based on truth and is kind.

The big elephant ears of Lord Ganesha signify listening to everybody (taking opinions) when in difficulty. Elephant ears are known to hear long distances.

Elephant can also see a long distance and in terms of mythology the elephant eyes of Ganesha represent acquiring the quality of foreseeing when in difficulty. The elephant mouth of Ganesha represents speaking less so that more time can be given to ears to listen

The big tummy of Ganesha represents retaining and digesting all information gathered by hearing to people in difficulty.

The trunk represents to use one’s power of discrimination to scrutinize gathered information. It also indicates to do both smaller and bigger things by oneself. Elephant trunk can pick up a needle as well as break a tree.

The broken and unbroken tooth of Ganesha represent being in balance both in loss and gain. One should not get upset if the task is not accomplished and also not get excited if the task is accomplished.

In times of difficulty, Ganesha also teaches us not to lose strength and control one’s attachments, desires and greed. The four arms of Ganesha represent strength. Ropes in two hands indicate attachments, Laddu or Sweet in one hand represent desires and mouse represents greed. Riding over the mouse indicates controlling one’s greed.

Ganesha is worshiped either when one’s task is not getting accomplished or when a new work is initiated. In both situations, these principles of Lord Ganesha need to be inculcated in one’s habits.

Saturday, August 27, 2011

HCFI Update: Risk of heart attack triples with pre-hypertension

A person with pre–hypertension, upper systolic blood pressure between 120–140 mmHg and lower diastolic pressure between 80–90 mmHg, is more than three times likely to have a heart attack and 1.7 times more likely to have heart disease than a person whose blood pressure is lower than 120/80 mmHg, said Padma Shri and Dr B C Roy National Awardee Dr K K Aggarwal, President Heart Care Foundation of India and MTNL Perfect Health Mela.

Normal blood pressure is lower than 120/80 mmHg and hypertension is a blood pressure more than 140/90 mmHg or higher.

If pre–hypertension is aggressively treated, 47% of all heart attacks can be prevented. Lifestyle modifications such as weight control, regular physical activity and changes in diet are recommended for people with pre–hypertension. The importance of pre–hypertension has been listed as one of the top 10 recent advances in cardiology. Every effort should be made to lower the blood pressure below 120/80 mmHg.

Emedinews:Makesure: A patient with fever and cough develops complications after he was given antibiotics.

Situation: A patient with fever and cough develops complications after he was given antibiotics.
Reaction: Oh my God! What was the need of giving the antibiotics?
Lesson: Make sure that a patient with fever and cough is not given antibiotics as presence of cough mostly signifies viral infection.

Emedinews: Dr Good Dr Bad: A patient with metabolic syndrome was found to have impaired kidney functions.

Situation: A patient with metabolic syndrome was found to have impaired kidney functions.
Dr Bad: They are not related.
Dr Good: They are related.
Lesson: People with metabolic syndrome are at 55% increased risk for kidney disease (reduced kidney functions), according to a study to appear in the Clinical Journal of the American Society of Nephrology.

(Ref: Thomas G, et al. Metabolic syndrome and kidney disease: a systematic review and meta-analysis. Clin J Am Soc Nephrol 2011 Aug 18. Epub ahead of print)

Emedinews:Inspiration: The Rock

An old farmer had plowed around a large rock in one of his fields for years. He had broken several plowshares and a cultivator on it and had grown rather morbid about the rock. After breaking another plowshare one day, and remembering all the trouble the rock had caused him through the years, he finally decided to do something about it.

When he put the crowbar under the rock, he was surprised to discover that it was only about six inches thick and that he could break it up easily with a sledgehammer. As he was carting the pieces away he had to smile, remembering all the trouble that the rock had caused him over the years and how easy it would have been to get rid of it sooner.

(Dr Anupam Sethi Malhotra)

Emedinews: Linagliptin new DPP-IV inhibitor

It is used as an adjunct to diet and exercise in adults with type 2 diabetes mellitus. It can be used as monotherapy or in combination with other oral agents. It lowers A1C by o.5% (1-4). Adverse reactions were uncommon, but include nasopharyngitis, hyperlipidemia, cough, hypertriglyceridemia, and weight gain (5).

As it is eliminated via the enterohepatic system, no dose adjustment is necessary in patients with renal or hepatic impairment.

References
1. Diabetes Obes Metab 2011;13:65.
2. Diabetes Obes Metab 2011;13:258.
3. Scott LJ. Linagliptin: in type 2 diabetes mellitus. Drugs 2011;71:611.
4. Diabetes Obes Metab 2011.
5. http://bidocs.boehringer-ingelheim.com/BIWebAccess/ViewServlet.ser?docBase=renetnt&folderPath=/Prescribing+Information/PIs/Tradjenta/Tradjenta.pdf

HCFI Update: Do not ignore 2nd attack of dengue

If you have suffered from dengue in the past be more careful as the second attack of dengue may be more dangerous than the first attack, said Padma Shri and Dr B C Roy National Awardee Dr K K Aggarwal, President Heart Care Foundation of India and MTNL Perfect Health Mela.

There are four different strains of dengue and one can, suffer with dengue four times during lifetime. Subsequent dengue infections are more likely to end up with deadly complications.

A person with dengue can also simultaneously suffer from malaria. Malaria and dengue together can lower platelet counts to a dangerous level leading to complications.

In a dengue season nobody should take aspirin for fever as it can precipitate bleeding, he added.

In dengue most complications occur within two days of subsiding of fever and most people are careless during this period. Any abdominal pain, giddiness or weakness after the fever has subsided should be attended to, by a doctor. Dengue complications during this period are due to shift of blood volume and patient requires rapid infusion of oral or intravenous fluids in large quantity.

There is no need for giving platelets unless the counts have fallen lower than 2% of original platelet counts.

Emedinews:Insights on Medicolegal issues:Medical literature must exist in the public domain to serve as legitimate evidence in court

• To constitute valid medical testimony, the witness must be identified
• For a document to serve as legitimate evidence in a trial it must exist in the public domain and the degree to which a medical document/literature/book validates the point you are making depends upon the reliability of the document. The author of a document is a witness and you are calling upon to testify.
• Conventions for citing sources are somewhat dynamic. However, at a minimum you should identify the individual, institution, or publication that authored the document and the publication date.
• When it is not otherwise evident, you ought to make quick reference to the qualifications of the author to lend an air of credibility to the document. Although it is not necessary to read additional information into the records, you must be prepared to provide a complete bibliographic citation if called upon to do so by the court of law or cross lawyer.

(Contributed by Dr Sudhir Gupta)


Emedinews: Makesure: A patient with fever and cough developed complications after he was given antibiotics.

Situation: A patient with fever and cough developed complications after he was given antibiotics.
Reaction: Oh my God! What was the need of giving the antibiotics?
Lesson: Make sure that a patient with fever and cough is not given antibiotics as presence of cough mostly signifies viral infection.

Emedinews: Dr Good Dr Bad: A patient at risk for stroke came for diet consult

Situation: A patient at risk for stroke came for diet consult
Dr Bad: Take normal diet
Dr Good: Take high potassium diet
Lesson: Individuals who eat a diet rich in potassium appear to have a lower risk for stroke than people with minimal potassium intake.

Source: Journal Stroke

Emedinews :Inspiration: The World is a Puzzle

There was a man who had a little boy that he loved very much. Everyday after work the man would come home and play with the little boy. He would always spend all of his extra time playing with the little boy. One night, while the man was at work, he realized that he had extra work to do for the evening, and that he wouldn’t be able to play with his little boy. But, he wanted to be able to give the boy something to keep him busy. So, looking around his office, he saw a magazine with a large map of the world on the cover. He got an idea. He removed the map, and then patiently tore it up into small pieces. Then he put all the pieces in his coat pocket.

When he got home, the little boy came running to him and was ready to play. The man explained that he had extra work to do and couldn’t play just now, but he led the little boy into the dining room, and taking out all the pieces of the map, he spread them on the table. He explained that it was a map of the world, and that by the time he could put it back together, his extra work would be finished, and they could both play. Surely this would keep the child busy for hours, he thought. About half an hour later the boy came to the man and said, "Okay, it’s finished. Can we play now?" The man was surprised, saying, "That’s impossible. Let’s go see." And sure enough, there was the picture of the world, all put together, every piece in its place.

The man said, "That’s amazing! How did you do that?" The boy said, "It was simple. On the back of the page was a picture of a man. When I put the man together the whole world fell into place."

(Contributed by Dr. Anupam Sethi Malhotra)



Emedinews : Metformin reduces A1C levels more than DPP-IV inhibitor monotherapy

Metformin as initial therapy is supported by a meta-analysis of 140 trials and 26 observational studies.
Older drugs (metformin and second generation sulfonylureas) had similar efficacy in reducing A1C values (1%) and other cardiovascular risk factors (blood pressure, lipids, body weight) compared with newer drugs (thiazolidinediones, meglitinides, and GLP-1 receptor agonists).

Source: Ann Intern Med 2011; 154:602.

Friday, August 26, 2011

Emedinews: Inspiration:A field mouse or an Osprey

Life offers two choices.

We can live scurrying for survival or soaring to the unlimited heights. The choices are modelled by two these two creatures.

A few months back while sitting in a boat fishing with a couple of friends, I noticed a field mouse on the river bank. He emerged out of his hole, darted in a couple of directions, and then scurried back. I thought of the existence of this little creature. His life is spent running around, frightened and frantic, following his nose. He darts here, scurries there, turns in circles, but never really sees much beyond his nose. He is trying to sniff his way to successful living, which defined, by a mouse's existence, is finding some daily morsel to consume, to sustain him, so that he can carry on for the rest of his life, frightened and frantic. Sound familiar.

A few minutes later I glanced up and noticed soaring high above was an Osprey.

Rather than a picture of a frightened and frantic existence, I saw a wide winged creature using the air currents to maneuver majestically in the unlimited heights. Rather than sniffing out a meager existence, this keen eyed hunter with a panoramic view of the river and lake beneath, was simply waiting for the appropriate time to swoop and capture his prey. The amazing creature, rather than return to some tiny hole in the river bank, glides toward a nest fashioned at the top of the tallest of trees.

The strength in his wings, the power in his talons, the amazing capacity of his vision, the effortless capacity to soar, It is the osprey, not the field mouse that models our human potential.

I don't know about you, but it is easy for me to decide which creature I want to exemplify my life. I want to soar. I want to explore. I want to see the big picture. I want to conquer. I want to climb higher, go farther, dive deeper, and experience more. I want my soul enlarged, my mind expanded, my heart enlivened and my spirit energized. I want the scurrying to stop. I want the frantic darting about following my nose, to end. I want new strength, fresh thinking, clear vision and resolved courage.

I want to be more and more like the osprey and less like the field mouse, for to live like this field mouse is to insult my creator and deny my true destiny.

(Contributed by Ms Ritu Sinha)

Emedinews: Makesure: A patient with dengue fever developed shock.

Situation: A patient with dengue fever developed shock.
Reaction: Oh my God! Why was the blood pressure 90/70 ignored?
Lesson: Make sure that a pulse pressure of less than 20 is not ignored, it is an impending sign that the patient is going into shock.

Emedinews:Insights on Medicolegal issues:Medical literature must exist in the public domain to serve as legitimate evidence in court

Do not misrepresent the document/medical literatures in the Court of Law; drawing a contrary conclusion from passages accurately interpreted does not constitute misrepresentation.

1. The electronic files to which other debaters would be denied access are not published. However, files and documents which other debaters may access, even if they have no subscribe to a commercial service to do so, satisfy the publication rule.

2. The advent of the Internet has created a new form of publication – electronic documents like this e-medinews. Electronic documents are accepted as published if they are accessible by the general public.

3. The portion of a document read as evidence cannot be taken out of context. When a document is cut in a manner which lends the quoted passage a meaning other than what would be derived from a more complete reading, you are misrepresenting the document. This does not mean, however, that you are responsible for drawing the same conclusions from information as the author of the document.

4. One paragraph or even one part of a paragraph may be all that is necessary to substantiate the point a doctor want to make in a court room. Reading the remainder of the document, even if it establishes a context for the evidence, is unnecessary and time consuming. The document must potentially be available to any debater researching the topic or lawyer/interested party of cross examination side

5. Drawing a contrary conclusion from passages accurately interpreted does not constitute misrepresentation. The fact that the author of the document reached a different conclusion from the information argues – perhaps persuasively – against your conclusion. However, you have not misused the evidence.

6. Read the used evidence literature verbatim in the court of law. Documents must be presented in the words of the author. When you paraphrase evidence, you argue in a circle. A document obviously will seem to support your point if you are allowed to read into the record only what you think it says.

HCFI Update: Walk at a pace of 4mph for 90 minutes a week

Physical activity involving moderate-intensity exercise for 15 minutes a day or 90 minutes a week can reduce deaths from any cause by 14% and increase life expectancy by three years said Padmashri and Dr B C Roy National Awardee Dr KK Aggarwal President Heart Care Foundation of India and MTNL Perfect Health Mela.

Quoting a study published in the August 16 in The Lancet, Dr Aggarwal said that beyond the minimal amount of 15 minutes of daily exercise, each additional 15 minutes was associated with a further reduction in all-cause mortality risk by 4% and in all-cancer mortality risk by 1%.

These benefits of exercise are seen in all age groups, in both sexes, and in persons at risk for cardiovascular disease.

The current guideline is to do 150 minutes of exercise per week.

Moderate intensity exercise refers to a level of exertion during exercise that raises your heart rate to a point where you sweat and feel you're working, yet you're able to carry on a conversation. You can talk, but you can't sing.

Example is walking at a pace of 4mph.

Thursday, August 25, 2011

Emedinews: Dr Good Dr Bad: A patient with diabetes was found to have high pesticide levels in the blood

Situation: A patient with diabetes was found to have high pesticide levels in the blood
Dr Bad: They are not related
Dr Good: They are related
Lesson: Individuals with moderately high blood levels of organ chlorine pesticides have a greater chance of developing type 2 diabetes.
Source: Aug. 4 in Diabetes Care

Emedinews: Was Lord Ganesha born of a stem cell transplant?

Today West claims that they can make human bladder tissue from the human skin cells. But was not lord Ganesha created by Parvati from the dirt of her body? The dirt from allopathic point of view would equate to the cells of her skin. In today’s terms Ganesha birth can be explained as the origin of stem cell baby birth in the literature. .

First identified in the hematopoietic blood system stem cells are present in many other tissues. All stem cells are capable of self-renewal and they can differentiate.

Self-renewal is the ability to proliferate without the loss of differentiation potential and without undergoing biologic aging. Stem cells can divide symmetrically (in which both daughter cells are either stem cells or differentiated cells) or asymmetrically (yielding both a stem cell and a more differentiated cell)

Stem cells can be either totipotent, pluripotent, multipotent, or unipotent. Totipotent cells can produce all cell types (embryonic and extra embryonic placenta). Pluripotent cells can only make cells of the embryo proper. Multipotent cells can only make cells within a given germ layer. Unipotent cells make cells of a single cell type.

In 2006 Shinya Yamanaka and colleagues introduced genes expressed in pluripotent cells into mature cells by a process, called reprogramming and induced a pluripotent state in a previously differentiated cell type. These cells are now called induced pluripotent cells (iPS).

iPS technology has revolutioned science today. A keratinocyte derived from the skin can be induced to become a pluripotent stem cell. Also a cell taken from an individual can be induced to become a cell type capable of forming any other cell type. A skin obtained from a patient with a degenerative brain disorder is now used as a drug after getting converted into a pluripotent cell.

Today the recognition that a cell taken from an individual can be induced to become pluripotent (a cell type capable of forming any other cell type in that individual's body) has provided unprecedented opportunities for regenerative medicine.

Today most easily accessible patient cell types, such as skin fibroblasts or blood cells are being reprogrammed to iPS.

Theoretically therefore it is possible to make any tissue from iPS. That means the skin cells can make liver, brain, heart or I fact the whole baby.

It looks that this technology claimed by the Western scientists of converting skin cell into iPS cell was available in our Vedic era and the birth of Ganesha by Parvati might have been an example of the first human baby made from the skin iPS.

Emedinews : Should we do routine HPV test in women?

Most doctors continue to recommend annual cervical cancer screening, despite guidelines recommending that low-risk women be tested every three years reports American Journal of Obstetrics and Gynecology on Aug. 18.

Centers for Disease Control and Prevention have mentioned three clinical situation in a woman between the ages of 30 and 60 years of age with a current normal Pap test:
• No current human papillomavirus (HPV) test results and history of 2 consecutive normal Pap test results,
• A current negative HPV test result and a history of 2 consecutive normal Pap test results
• A current negative HPV test result and no history of Pap tests.

In all three cases, guidelines would support extending the screening interval up to three years.

HCFI Update: NCR to benefit from MTNL Perfect Health Mela in October

The country’s popular “18th Perfect Health Mela 2011” will be held from 14th to 23rd October 2011 at NDMC Grounds Laxmi Bai Nagar, New Delhi.

The Mela is being organised by Heart Care Foundation of India jointly with Health Department, Govt. of Delhi, MTNL, NDMC, MCD, LIC, Dept. Of Science & Technology, Govt. of India, Coca Cola India Ltd., World Fellowship of Religions, etc.

18th in a row, the brainchild of Heart Care Foundation of India, the Mela attracts 3-5 lakh members of the public over a duration of 10 days.

The Mela is organised every year between Dusshehra and Diwali and creates health awareness about all aspects of health among people from all walks of life and all ages, incorporating all pathies under one roof through the medium of infotainment. The Mela is the right mix of health picnic, exhibition, competition and infotainment.

Addressing a press conference and releasing Mela Poster, Dr. K K Aggarwal, Padma Shri & Dr. B.C. Roy Awardee, President of Heart Care Foundation of India and MTNL Perfect Health Mela and Mr. Sandeep Marwah Director, Asian Academy of Film and Television said that the event will provide a unique opportunity for the NCR people to have their heart and general health check up done and know all about prevention.
Dr. P K Sharma, MHO, NDMC, Dr. N K Yadav, MHO, MCD , Dr K S Bhagotia CMO, DHS, Mr. Sunil Kumar PGM, MTNL, Dr Sadhna Ji Maharaj from World Fellowship of Religions in a joint statement said that the Mela will be a right place to know everything that is happening in medicine.

The Mela will be a mix of exhibitions, checkups, competitions, and infotainment under one roof and will be a perfect health picnic spot for the schools and families.


Emedinews:Insights on Medicolegal issues:Doctors should avoid special efforts to “cover up” any medical fact

The media and general public are vastly becoming informed and law conscious. There is awareness of modern diagnostic/therapeutic methods. The standard of doctors/hospital, its opinion and method of medical/surgical interventions are being scrutinized from time to time in public as well as Court of law and media. The doctor should not avoid talking to the media but definitely not too much and too soon.. Prejudicial and sensational statements should not be made by doctor prior to trial. It is incumbent upon doctors to have good knowledge of the law governing their profession, in order not to transgress the law.

• Doctors should totally avoid special efforts to “cover up” alleged medical negligence or unintentional wrong doing or inevitable medical accident.
• It is a standard accepted universal fact that “Medicine is not mathematics but is a science of uncertainty and an art of probability. One thing that makes medicine so difficult is that there is no such thing as the average man can understand the intricacies. We can only say the reading is ‘within the range of normal’. Medicine is a biological science with the variability inherent in body physiology with the variability inherent in biological matters.
• Forensic medicine is not an exact science as a mathematical calculation hence while making a forensic opinion it is required to deliberate that unexpected results are produced due to biological variations in case to case, there is an element of uncertainty and absolute proof is a rarity in any medical care delivery.
• Doctors should bear in mind the essential difference between probability and proof. They should be reasonable in their opinions and should not overstate the likelihood of a relationship between cause and effect.
• The doctor should be ready to defend every finding and conclusion on the report on clinical and scientific grounds in the court of law. He should be aware of professional and scientific viewpoints which might differ from his, and should be familiar with the latest scientific literature in relation to the subject involved.
• The doctor in the Court of law may clarifying his testimony by means of photographs, maps, diagrams, charts, X-rays, skeletons, models, slides, films, tapes, etc., when they are properly verified.

(Contributed by Dr Sudhir Gupta)

Emedinews:Makesure: A neonate in an ICU being administered IV calcium exhibits signs of inflammation and necrosis at injection site.


Situation: A neonate in an ICU being administered IV calcium exhibits signs of inflammation and necrosis at injection site.
Reaction: Oh my God! Why didn’t you observe the IV site carefully. 
Lasson: Make Sure that all hypocalcemic neonates are put on a cardiac monitor while receiving calcium infusions and the IV site is closely observed, because extravasation of calcium can produce severe interstitial necrosis.

Emedinews : Inspiration: 10 keys to bring more inspiration into your life

Have you ever asked yourself what is inspiration?

When the word inspiration is broken down into its component parts, it simply means "in - spirit". When you are living "in - spirit" You feel excited about yourself and your life. You have a special connection with all parts of your mind and body. The question is how can we connect to our spirit at all times to take that actions that make all things possible? Below are 10 keys to open your doors to your inspiration.

1. The first key to inspiration is enjoyment. It would take a spiritual master to get inspired about doing the dishes. So find something that really excites you. It can be anything that you really enjoy.

2. The second key is love. When you are actively pouring love into what you are doing, this will guarantee that you are opening yourself to experiencing more inspiration.

3. The third key is to trust yourself. Listen to that little voice inside yourself and know that this comes from heart. This is called intuition.

4. The fourth key is to follow what your intuition tells you. The more you listen to it, the stronger your intuition will become. If you don't pay attention, that little voice gets fainter and fainter until you can no longer hear it.

5. The fifth key is to keep telling yourself "I can". These are some of the most powerful words that you can ever use. When you say this to yourself often enough, you build abridge between yourself and your inspiration.

6. The sixth key is not to listen to anyone that says "no you can't". They might think that they may not be able to, and try to project this negative belief onto you, but remember to keep telling yourself that, "I can! "

7. The seventh key is to believe in yourself. When you are backed by a strong belief in yourself and your dreams, nothing is impossible.

8. The eighth key is to avoid negativity. Ask yourself, do you really need to read the newspaper or watch the news on TV everyday ? Nothing kills inspiration quicker than being surrounded by bad news.

9. The ninth key is acceptance. Accept that on some days you feel much more inspired than on others. This is normal, nobody can be completely inspired every minute of the day.

10. The tenth key is possibly the most important of all. Take action every day, no matter how small a step it seems. Action is the fuel to the fires of inspiration. Make it a daily practice to keep your fire burning. The taking of actions, no matter how small, will fill you with inspiration for taking the next step.

(Contributed by Dr Anupam Sethi Malhotra)



Wednesday, August 24, 2011

Emedinews: Dr Good Dr Bad: A woman between the ages of 30 and 60 years of age with a current normal Pap test

Situation: A woman between the ages of 30 and 60 years of age with a current normal Pap test came with a current negative HPV test result and a history of 2 consecutive normal Pap test results
Dr Bad: Go for annual pap smear test
Dr Good: get the pap smear every three years
Lesson: Low-risk women be tested every three years as per a report in American Journal of Obstetrics and Gynecology on Aug. 18.

HCFI Update: Do not eat curd in Bhadon month?

One should not take green leafy vegetables in the month of Shravan and curd (yogurt, dahi) in the month of Bhadon said Padma Shri and Dr B C Roy National Awardee Dr K K Aggarwal President heart Care Foundation of India and MTNL Perfect Health Mela.

One should also avoid milk in the month of Ashwin and butter milk (mahi, matha), pulses and oil in the month of Kartik.

Ayurveda defines the concepts of Vata, Pitta and Kapha. In terms of modern medicine, Vata represents movement; Pitta metabolism and Kapha structure and water.

As per Ritucharya (seasonal routine), Vata or movement functions in the body are aggravated in Varsha Ritu (rainy season) which coincides with Shravan and Bhado months. During these months, pitta starts accumulating.
Pitta or metabolism is aggravated in Sharad Ritu (Ashwin and Kartik months) and Kapha in the Vasant Ritu (Chaitra and Vaisakha). In Sharad Ritu when Pitta gets aggravated the Kapha is accumulating.

In the month of Shravan, as Vata or movement function is aggravated, any food item which aggravates Vata or movement will cause harm to the body. Ground leafy vegetables increase Vata, and therefore, are prohibited in the month of Shravan. According to modern medicine, during rainy season, most of the ground worms will also come to the surface and infect the leafy vegetables. This is another reason why leafy vegetables are harmful to the body in the month of Shravan.

In Varsha Ritu (Rainy season), Vata is aggravated but Pita has stated accumulating which gets aggravated in Sharad Ritu. Therefore in the month of Bhadon, it is advised to eat less yogurt (dahi) as anything fermented aggravates Pitta. Though Ayurveda says that curd should not be eaten in the month of Bhadon season, from allopathic point of view, it should be true for all fermented foods including alcohol, dosa, idli or dhokla etc.
Kapha producing substances like milk and butter milk are avoided in Sharad Ritu as at that time Kapha is accumulating and Pitta is aggravated.

As per the Ayurveda in the month of Shravan and Bhadon, the digestive fire is weak and, therefore, any substance which can obstruct the digestive channels should be avoided and curd is one of them.

Ayurveda also prohibits eating curd in the night throughout the year as after 6 pm the digestive fire in the body is weak, Kapha is predominant and any curd food taken at that time will block the digestive channels.

Naturopathy is in agreement with Ayurveda but Allopathy is silent on this issue. Without going into the details of the subject the conclusion is to avoid eating curd in the month of bhadon.


Emedinews:Insights on Medicolegal issues:Doctor is neither a detective nor a curtain between patient and police

• Presumption, assumption hypothesis, and mere conclusion on self-defined interpretation is not a proof, and conjecture is not medical evidence which may be used by a doctor for his/her patient
• The primary and absolutely transparent duty of a doctor/ hospital is to provide medical services to sick and injured patient may be an alleged criminal to save his health/limb and life without any discrimination.
• when the medical care records is required for judicial/police investigation the records becomes medico-legal in nature and the same may be required to testify under oath in the court of law by treating doctor.
• The doctor should acquire the habit of making a careful note of all the facts observed by him with exact time and date.
• doctor should examine the facts which come to his knowledge in his special medical man capacity, draw his conclusions logically and correctly after a detailed consideration of the pros and cons of the case, and elaborate in the Court that interpretation, along with the medical grounds on which it is based.
• Presumption is not proof, and conjecture is not evidence. The Court has no special medical knowledge. It relies on medical witness for an opinion and expects him to assist it with his special knowledge and experience in perusal of truth.

(Contributed by Dr Sudhir Gupta)

Emedinews:Makesure: A 28–year–old male presents with increased frequency and occasional blood in urine.

Situation: A 28–year–old male presents with increased frequency and occasional blood in urine. Urine examination shows sterile pyuria.
Reaction: Oh my God! Why didn’t you check for TB?
Lesson: Make Sure to rule out TB in patients with frequency, dysuria, hematuria. A sterile pyuria is the first clue to diagnosis.

Emedinews: Dr Good Dr Bad: A patient in insulin pump was taking a flight.

Situation: A patient in insulin pump was taking a flight.
Dr Bad: Its ok to use the pump.
Dr Good: Disconnect the pump at landing and taking off.
Lesson: According to a study published online Aug. 4 in the journal Diabetes Care, changes in airliner cabin pressurization during take-off and landing may affect how much insulin is delivered by an insulin pump. Pumps should be disconnected during take-off and landing and during any flight situations in which a loss of cabin pressure results.

Emedinews : Inspiration: Be Positive

Father: "I want you to marry a girl of my choice."
Son: "I will choose my own bride!"
Father: "But the girl is Bill Gate's daughter."
Son: "Well, in that case... ok"
Next Father approaches Bill Gates.
Father: "I have a husband for your daughter."
Bill Gates: "But my daughter is too young to marry!"
Father: "But this young man is vice-president of the World Bank."
Bill Gates: "Ah, in that case... ok"
Finally Father goes to see the president of the World Bank.
Father: "I have a young man to be recommended as your vice-president."
President: "But I already have more vice-presidents than I need!"
Father: "But this young man is Bill Gate's son-in-law."
President: "Ah, in that case... ok"
This is how business is done!!
Moral: Even if you have nothing, you can get anything. But your attitude should be positive.
(Contributed by Ms Ritu Sinha)


Tuesday, August 23, 2011

Emedinews: Dr Good Dr Bad: A woman between the ages of 30 and 60 years of age with a current normal Pap test


Situation: A woman between the ages of 30 and 60 years of age with a current normal Pap test came with no current human papillomavirus (HPV) test results and history of 2 consecutive normal Pap test results.
Dr Bad: Go for annual pap smear test
Dr Good: get the pap smear every three years
Lesson: Low-risk women be tested every three years as per a report in American Journal of Obstetrics and Gynecology on Aug. 18.

Emedinews: Dr Good Dr Bad: A patient in insulin pump was taking a flight


Situation: A patient in insulin pump was taking a flight
Dr Bad: Its ok to sue the pump
Dr Good: Off the pump at landing an taking off.
 Lesson: According to a study published online Aug. 4 in the journal Diabetes Care, changes in airliner cabin pressurization during take-off and landing may affect how much insulin is delivered by an insulin pump.  Pumps should be disconnected during take-off and landing and during any flight situations in which a loss of cabin pressure results.

Emedinews: Inspiration: Always remember those who serve

In the days when an ice cream sundae cost much less, a 10-year-old boy entered a hotel coffee shop and sat at a table. A waitress put a glass of water in front of him."How much is an ice cream sundae?""Fifty cents," replied the waitress. The little boy pulled his hand out of his pocket and studied a number of coins in it."How much is a dish of plain ice cream?" he inquired. Some people were now waiting for a table and the waitress was a bit impatient. "Thirty-five cents," she said brusquely.The little boy again counted the coins. "I'll have the plain ice cream," he said. The waitress brought the ice cream, put the bill on the table and walked away. The boy finished the ice cream, paid the cashier and departed.

When the waitress came back, she began wiping down the table and then swallowed hard at what she saw. There, placed neatly beside the empty dish, were two nickels and five pennies - Her Tip

(Contributed by Ms Ritu Sinha)

Emedinews: Dr Good Dr Bad: A patient with visceral obesity had episodes of night chest burning.

Situation: A patient with visceral obesity had episodes of night chest burning.
Dr Bad: its acidity
Dr Good: Rule out CAD.
Lesson: Nighttime acute coronary syndrome occurs more often in patients with visceral fat accumulation and sleep-disordered breathing
(Nakagawa Y, Kishida K, Mazaki T, et al. Impact of sleep-disordered breathing, visceral fat accumulation and adiponectin levels in patients with night-time onset of acute coronary syndrome. Am J Cardiol 2011; Aug 12. [Epub ahead of print)

Emedinews: A patient with prosthetic heart valves (bioprosthetic) developed infective endocarditis.

Situation: A patient with prosthetic heart valves (bioprosthetic) developed infective endocarditis.
Reaction: Oh my God! Why was he not given infective endocarditis prophylaxis?
Lasson: Make sure that all patients with prosthetic heart valves (bioprosthetic or homograft) are given infective endocarditis prophylaxis.

Emedinews:Insights on Medicolegal issues:Doctor is a professional of Medical science with neutrality, and impartiality

• When a doctor appears as medical witnesses in the court of law must strive to achieve respect, good medical understanding and biggest thing is credibility before the honorable judge as well legal counsel of both sides.
• Doctor must give the appearance of being independent medical witnesses of truth based on medical science with neutrality, impartiality and authentic characteristics. Vagueness and theory has no place in legal medicine
• Vagueness and theory have no place in legal medicine hence a Medical witness, should remain a man of science; you have no victim to avenge, no guilty person to convict, and no innocent person to save.
• Doctor must bear testimony within the limits of medical/allied science”. The attitude of a medical/clinician/scientific witness should be the same whether he is called by the defense or prosecution. The doctor really testifies neither for nor against the prosecution or the defense. The doctor’s expertise is in the application of science to a legal controversy and the proper interpretation of scientific findings.
• Doctor sole obligation is to present the truth as he sees it, adding nothing, withholding nothing and distorting nothing mean revealing whole truth.
• Doctor should not concern himself with the previous character of the accused or with other evidence in the case.
• Doctor should not be influenced in any way by emotional consideration, such as sympathy or antipathy. The doctor must be honest, the honesty gives the confidence with enlightened conscience and the success in the court of law depends upon your confidence.
• Honest perusal of medical science, confidence and medical ethics are tripods of this noble medical professional
(Contributed by Dr Sudhir Gupta)

HCFI Update: Opt for medical treatment for heart blockages with low left heart functions

For most patients with systolic left heart pumping function (LVEF) of 35 percent or less and coronary heart blockages amenable to bypass surgery one should first initiate optimal medical therapy alone rather than medical therapy plus bypass surgery, said Padmashri and Dr B C Roy National Awardee Dr K K Aggarwal President Heart Care Foundation of India and MTNL Perfect Health Mela.

Earlier view had been that compared with medical therapy, surgical bypass of viable heart muscle improves both survival and left heart function. This view was based on the fact that up to 50 percent of patients with left heart pumping dysfunction due to coronary heart blockages have a significant amount of viable heart muscles.

The results of Surgical Treatment for Ischemic Heart Failure (STICH), a randomized trial have shown that compared with optimal medical therapy alone, optimal medical therapy plus bypass surgery resulted in no significant improvement in the primary outcome of all-cause mortality at a median follow-up of 56.

The current recommendation that one should initiate optimal medical therapy alone rather than optimal medical therapy plus bypass surgery is based upon the significant morbidity associated with bypass surgery. Bypass surgery, however, is preferred by patients with ongoing anginal symptoms despite optimal medical therapy.

Monday, August 22, 2011

Emedinews: Dr Good Dr Bad: A dialysis patient was getting recurrent catheter related infections


Situation: A dialysis patient was getting recurrent catheter related infections
Dr Bad: Try heparin lock
Dr Good: Try minocycline-
EDTA lock 
Lesson:  Dialysis patients had significantly fewer catheter-related infections when minocycline - EDTA was used as a catheter-lock solution instead of heparin," according to a study  in the Journal of the American Society of Nephrology. The catheter-related bacteremia rate was one per 1,000 catheter days, a three-fold decrease compared with use of a heparin lock.

Emedinews: Dr Good Dr Bad: A patient with metabolic syndrome was found to have low kidney functions


Situation: A patient with metabolic syndrome was found to have low kidney functions
Dr Bad: They are not related
Dr Good: They are related
 Lesson: People with metabolic syndrome are at 55% increased risk for kidney disease (reduced kidney functions), according to a study to appear in the Clinical Journal of the American Society of Nephrology.

Why no leafy vegetables in Shravan and curd is taken in Bhadon month


              "Savan me saag nahi, bhado me dahi nahi, ashwin me doodh nahi, kartik me tel nahi"

It is a traditional Ayurveda saying that one should not take green leafy vegetables in the month of Shravan, curd (yogurt, dahi) in the month of Bhadon, milk in the month of Ashwin and butter milk (mahi, matha), pulses and oil in the month of Kartik.

To answer these questions, we need to understand the concept of Vata, Pitta and Kapha from Ayurveda. In terms of modern medicine, Vata represents movement; Pitta metabolism and Kapha structure and water.

 As per Ritucharya (seasonal routine), Vata or movement functions in the body are aggravated in Varsha Ritu (rainy season) which coincides with Shravan and Bhado months. In this month Pitta functions starts accumulating.

 Pitta or metabolism is aggravated in Sharad Ritu (Ashwin and Kartik months) and Kapha in the Vasant Ritu (Chaitra and Vaisakha).  In Sharad Ritu when Pitta gets aggravated the Kapha is accumulating.
In the month of Shravan, as Vata or movement function is aggravated, any food item which aggravates Vata or movement will cause harm to the body. Ground leafy vegetables increase Vata, therefore, are prohibited in the month of Shravan. As per the modern medicine, being a rainy season, most of the ground worms will also come to the surface and infect the leafy vegetables. This is another reason why leafy vegetables are harmful to the body in the month of Shravan.

In Varsha Ritu (Rainy season), Vata is aggravated but Pita has stated accumulating which gets aggravated in Sharad Ritu. Therefore in the month of Bhadon, it is advised to eat fewer yogurts (dahi) as anything fermented aggravates Pitta. Though Ayurveda talks that curd should not be eaten in the month of Bhadon season, from allopathic point of view, it should be true for all fermented foods including alcohol, dosa, idli or dhokla etc.
Kapha producing substances like milk and butter milk are avoided in Sharad Ritu as at that time Kapha is accumulating and Pitta is aggravated.

As per the Ayurveda in the month of Shravan and Bhadon, the digestive fire is weak and, therefore, any substance which can obstruct the digestive channels should be avoided and curd is one of them.

Ayurveda also prohibits eating curd in the night throughout the year as after 6 pm the digestive fire in the body is weak, Kapha is predominant and any curd food taken at that time will block the digestive channels.
Naturopathy is in agreement with Ayurveda but Allopathy is silent on this issue.  Without going into the details of the subject the conclusion is to avoid eating curd in the month of bhadon. 

Emedinews:Barrett's esophagus and high-grade dysplasia management

For most patients with Barrett’s esophagus and high-grade dysplasia who are fit to undergo endoscopy one should opt for endoscopic eradication therapy rather than esophagectomy or intensive endoscopic surveillance. Guidelines issued by the American Gastroenterological Association in 2011 now suggest endoscopic eradication therapy as the preferred approach for patients with Barrett’s esophagus and high-grade dysplasia.

To tackle increased risk for esophageal adenocarcinoma, uptill now neoplastic epithelium was removed by esophagectomy but the procedure carried significant procedure-related mortality and long-term morbidity.

The current recommendation is endoscopic eradication therapy, which includes endoscopic mucosal resection followed by radiofrequency ablation.

American Gastroenterological Association. American Gastroenterological Association Medical Position Statement on the Management of Barrett's Esophagus. Gastroenterology 2011; 140:1084.

Emedinews: WMA Declaration of Malta on Hunger Strikers

1. Physicians must assess individuals' mental capacity. This involves verifying that an individual intending to fast does not have a mental impairment that would seriously undermine the person's ability to make health care decisions. Individuals with seriously impaired mental capacity cannot be considered to be hunger strikers. They need to be given treatment for their mental health problems rather than allowed to fast in a manner that risks their health.

2. As early as possible, physicians should acquire a detailed and accurate medical history of the person who is intending to fast. The medical implications of any existing conditions should be explained to the individual. Physicians should verify that hunger strikers understand the potential health consequences of fasting and forewarn them in plain language of the disadvantages. Physicians should also explain how damage to health can be minimised or delayed by, for example, increasing fluid intake. Since the person's decisions regarding a hunger strike can be momentous, ensuring full patient understanding of the medical consequences of fasting is critical. Consistent with best practices for informed consent in health care, the physician should ensure that the patient understands the information conveyed by asking the patient to repeat back what they understand.

3. A thorough examination of the hunger striker should be made at the start of the fast. Management of future symptoms, including those unconnected to the fast, should be discussed with hunger strikers. Also, the person's values and wishes regarding medical treatment in the event of a prolonged fast should be noted.

4. Sometimes hunger strikers accept an intravenous saline solution transfusion or other forms of medical treatment. A refusal to accept certain interventions must not prejudice any other aspect of the medical care, such as treatment of infections or of pain.

5. Physicians should talk to hunger strikers in privacy and out of earshot of all other people, including other detainees. Clear communication is essential and, where necessary, interpreters unconnected to the detaining authorities should be available and they too must respect confidentiality.

6. Physicians need to satisfy themselves that food or treatment refusal is the individual's voluntary choice. Hunger strikers should be protected from coercion. Physicians can often help to achieve this and should be aware that coercion may come from the peer group, the authorities or others, such as family members. Physicians or other health care personnel may not apply undue pressure of any sort on the hunger striker to suspend the strike. Treatment or care of the hunger striker must not be conditional upon suspension of the hunger strike.

7. If a physician is unable for reasons of conscience to abide by a hunger striker's refusal of treatment or artificial feeding, the physician should make this clear at the outset and refer the hunger striker to another physician who is willing to abide by the hunger striker's refusal.

8. Continuing communication between physician and hunger strikers is critical. Physicians should ascertain on a daily basis whether individuals wish to continue a hunger strike and what they want to be done when they are no longer able to communicate meaningfully. These findings must be appropriately recorded.

9. When a physician takes over the case, the hunger striker may have already lost mental capacity so that there is no opportunity to discuss the individual's wishes regarding medical intervention to preserve life. Consideration needs to be given to any advance instructions made by the hunger striker. Advance refusals of treatment demand respect if they reflect the voluntary wish of the individual when competent. In custodial settings, the possibility of advance instructions having been made under pressure needs to be considered. Where physicians have serious doubts about the individual's intention, any instructions must be treated with great caution. If well informed and voluntarily made, however, advance instructions can only generally be overridden if they become invalid because the situation in which the decision was made has changed radically since the individual lost competence.

10. If no discussion with the individual is possible and no advance instructions exist, physicians have to act in what they judge to be the person's best interests. This means considering the hunger strikers' previously expressed wishes, their personal and cultural values as well as their physical health. In the absence of any evidence of hunger strikers' former wishes, physicians should decide whether or not to provide feeding, without interference from third parties.

11. Physicians may consider it justifiable to go against advance instructions refusing treatment because, for example, the refusal is thought to have been made under duress. If, after resuscitation and having regained their mental faculties, hunger strikers continue to reiterate their intention to fast, that decision should be respected. It is ethical to allow a determined hunger striker to die in dignity rather than submit that person to repeated interventions against his or her will.

12. Artificial feeding can be ethically appropriate if competent hunger strikers agree to it. It can also be acceptable if incompetent individuals have left no unpressured advance instructions refusing it.

13. Forcible feeding is never ethically acceptable. Even if intended to benefit, feeding accompanied by threats, coercion, force or use of physical restraints is a form of inhuman and degrading treatment. Equally unacceptable is the forced feeding of some detainees in order to intimidate or coerce other hunger strikers to stop fasting.
(Adopted by the 43rd World Medical Assembly, St Julians, Malta, November 1991 and revised at the 44th WMA Marbella, Spain, September 1992and revised by the 57th WMA General Assembly, Pilanesberg, South Africa, October 2006)

Preamble
1. Hunger strikes occur in various contexts but they mainly give rise to dilemmas in settings where people are detained (prisons, jails and immigration detention centres). They are often a form of protest by people who lack other ways of making their demands known. In refusing nutrition for a significant period, they usually hope to obtain certain goals by inflicting negative publicity on the authorities. Short-term or feigned food refusals rarely raise ethical problems. Genuine and prolonged fasting risks death or permanent damage for hunger strikers and can create a conflict of values for physicians. Hunger strikers usually do not wish to die but some may be prepared to do so to achieve their aims. Physicians need to ascertain the individual's true intention, especially in collective strikes or situations where peer pressure may be a factor. An ethical dilemma arises when hunger strikers who have apparently issued clear instructions not to be resuscitated reach a stage of cognitive impairment. The principle of beneficence urges physicians to resuscitate them but respect for individual autonomy restrains physicians from intervening when a valid and informed refusal has been made. An added difficulty arises in custodial settings because it is not always clear whether the hunger striker's advance instructions were made voluntarily and with appropriate information about the consequences. These guidelines and the background paper address such difficult situations.

Principles
1. Duty to act ethically. All physicians are bound by medical ethics in their professional contact with vulnerable people, even when not providing therapy. Whatever their role, physicians must try to prevent coercion or maltreatment of detainees and must protest if it occurs.
2. Respect for autonomy. Physicians should respect individuals' autonomy. This can involve difficult assessments as hunger strikers' true wishes may not be as clear as they appear. Any decisions lack moral force if made involuntarily by use of threats, peer pressure or coercion. Hunger strikers should not be forcibly given treatment they refuse. Forced feeding contrary to an informed and voluntary refusal is unjustifiable. Artificial feeding with the hunger striker's explicit or implied consent is ethically acceptable.
3. 'Benefit' and 'harm'. Physicians must exercise their skills and knowledge to benefit those they treat. This is the concept of 'beneficence', which is complemented by that of 'non-maleficence' or primum non nocere. These two concepts need to be in balance. 'Benefit' includes respecting individuals' wishes as well as promoting their welfare. Avoiding 'harm' means not only minimising damage to health but also not forcing treatment upon competent people nor coercing them to stop fasting. Beneficence does not necessarily involve prolonging life at all costs, irrespective of other values.
4. Balancing dual loyalties. Physicians attending hunger strikers can experience a conflict between their loyalty to the employing authority (such as prison management) and their loyalty to patients. Physicians with dual loyalties are bound by the same ethical principles as other physicians, that is to say that their primary obligation is to the individual patient.
5. Clinical independence. Physicians must remain objective in their assessments and not allow third parties to influence their medical judgement. They must not allow themselves to be pressured to breach ethical principles, such as intervening medically for non-clinical reasons.
6. Confidentiality. The duty of confidentiality is important in building trust but it is not absolute. It can be overridden if non-disclosure seriously harms others. As with other patients, hunger strikers' confidentiality should be respected unless they agree to disclosure or unless information sharing is necessary to prevent serious harm. If individuals agree, their relatives and legal advisers should be kept informed of the situation.
7. Gaining trust. Fostering trust between physicians and hunger strikers is often the key to achieving a resolution that both respects the rights of the hunger strikers and minimises harm to them. Gaining trust can create opportunities to resolve difficult situations. Trust is dependent upon physicians providing accurate advice and being frank with hunger strikers about the limitations of what they can and cannot do, including where they cannot guarantee confidentiality.


Emedinews : Inspiration: A real story ...A chat between a Solider and Software Engineer in Shatabdi Train

An interesting and a must read!

Vivek Pradhan was not a happy man. Even the plush comfort of the air-conditioned compartment of the Shatabdi express could not cool his frayed nerves. He was the Project Manager and still not entitled to air travel. It was not the prestige he sought, he had tried to reason with the admin person, it was the savings in time. As PM, he had so many things to do!! He opened his case and took out the laptop, determined to put the time to some good use. "Are you from the software industry sir," the man beside him was staring appreciatively at the laptop. Vivek glanced briefly and mumbled in affirmation, handling the laptop now with exaggerated care and importance as if it were an expensive car. "You people have brought so much advancement to the country, Sir. Today everything is getting computerized."

"Thanks," smiled Vivek, turning around to give the man a look. He always found it difficult to resist appreciation. The man was young and stockily built like a sportsman. He looked simple and strangely out of place in that little lap of luxury like a small town boy in a prep school. He probably was a railway sportsman making the most of his free traveling pass.

"You people always amaze me," the man continued, "You sit in an office and write something on a computer and it does so many big things outside."

Vivek smiled deprecatingly. Naiveness demanded reasoning not anger. "It is not as simple as that my friend. It is not just a question of writing a few lines. There is a lot of process that goes behind it." For a moment, he was tempted to explain the entire Software Development Lifecycle but restrained himself to a single statement. "It is complex, very complex."

"It has to be. No wonder you people are so highly paid!," came the reply.

This was not turning out as Vivek had thought. A hint of belligerence crept into his so far affable, persuasive tone. "Everyone just sees the money. No one sees the amount of hard work we have to put in. Indians have such a narrow concept of hardwork. Just because we sit in an air-conditioned office, does not mean our brows do not sweat. You exercise the muscle; we exercise the mind and believe me that is no less taxing."

He could see, he had the man where he wanted, and it was time to drive home the point. "Let me give you an example. Take this train. The entire railway reservation system is computerized. You can book a train ticket between any two stations from any of the hundreds of computerized booking centres across the country. Thousands of transactions accessing a single database, at a time concurrently; data integrity, locking, data security. Do you understand the complexity in designing and coding such a system?"

The man was awestuck; quite like a child at a planetarium. This was something big and beyond his imagination. "You design and code such things."

"I used to," Vivek paused for effect, "but now I am the Project Manager." "Oh!" sighed the man, as if the storm had passed over, "so your life is easy now."

This was like the last straw for Vivek. He retorted, "Oh come on, does life ever get easy as you go up the ladder. Responsibility only brings more work. Design and coding. That is the easier part. Now I do not do it, but I am responsible for it and believe me, that is far more stressful! My job is to get the work done in time and with the highest quality. To tell you about the pressures, there is the customer at one end, always changing his requirements, the user at the other, wanting something else, and your boss, always expecting you to have finished it yesterday."

Vivek paused in his diatribe, his belligerence fading with self-realisation. What he had said, was not merely the outburst of a wronged man, it was the truth. And one need not get angry while defending the truth. "My friend," he concluded triumphantly, "you don't know what it is to be in the Line of Fire".

The man sat back in his chair, his eyes closed as if in realization. When he spoke after sometime, it was with a calm certainty that surprised Vivek. "I know sir,..... I know what it is to be in the Line of Fire......." He was staring blankly, as if no passenger, no train existed, just a vast expanse of time. "There were 30 of us when we were ordered to capture Point 4875 in the cover of the night. The enemy was firing from the top. There was no knowing where the next bullet was going to come from and for whom. In the morning when we finally hoisted the tricolour at the top only 4 of us were alive."

"You are a...?"

"I am Subedar Sushant from the 13 J&K Rifles on duty at Peak 4875 in Kargil. They tell me I have completed my term and can opt for a soft assignment. But, tell me sir, can one give up duty just because it makes life easier. On the dawn of that capture, one of my colleagues lay injured in the snow, open to enemy fire while we were hiding behind a bunker. It was my job to go and fetch that soldier to safety. But my Captain Batra Sahib refused me permission and went ahead himself. He said that the first pledge he had taken as a Gentleman Cadet was to put the safety and welfare of the nation foremost followed by the safety and welfare of the men he commanded... ....his own personal safety came last, always and every time. He was killed as he shielded and brought that injured soldier into the bunker. Every morning thereafter, as we stood guard, I could see him taking all those bullets, which were actually meant for me . I know sir....I know, what it is to be in the Line of Fire."

Vivek looked at him in disbelief not sure of how to respond. Abruptly, he switched off the laptop. It seemed trivial, even insulting to edit a Word document in the presence of a man for whom valour and duty was a daily part of life; valour and sense of duty which he had so far attributed only to epical heroes.

The train slowed down as it pulled into the station, and Subedar Sushant picked up his bags to alight. "It was nice meeting you sir." Vivek fumbled with the handshake.

This hand... had climbed mountains, pressed the trigger, and hoisted the tricolour.

Suddenly, as if by impulse, he stood up at attention and his right hand went up in an impromptu salute. it was the least he felt he could do for the country.

PS: The incident he narrated during the capture of Peak 4875 is a true-life incident during the Kargil war. Capt. Batra sacrificed his life while trying to save one of the men he commanded, as victory was within sight. For this and various other acts of bravery, he was awarded the Param Vir Chakra, the nation's highest military award.

Live humbly, there are great people around us, let us learn! Life isn't about how to survive the storm, but how to dance in the rain!!!

(Contributed by Dr Anupam Sethi Malhotra)

Emedinews: Dr Good Dr Bad: A patient with normal LDL and high CRP wanted to know his risk of CAD.

Situation: A patient with normal LDL and high CRP wanted to know his risk of CAD.
Dr Bad: You are not at risk.
Dr Good: Get cardiac 64 CT test done
Lesson: Among asymptomatic individuals with normal LDL cholesterol levels and elevated high-sensitivity C-reactive protein measuring the burden of calcium in the coronary arteries with cardiac CT appears to stratify the risk of cardiovascular disease

 (Ref: Blaha M, et al. Associations between C-reactive protein, coronary artery calcium, and cardiovascular events: implications for the JUPITER population from MESA, a population-based cohort study. Lancet 2011;378:684-92).

Emedinews:Makesure: A 62–year–old–diabetic with coronary artery disease, on treatment for the same, comes for follow up.

Situation: A 62–year–old–diabetic with coronary artery disease, on treatment for the same, comes for follow up.
Reaction: Oh my God! Why did not you put him on antioxidants?
Lesson: Make Sure to add antioxidants to the prescription because of their free radical scavenging and other beneficial effects.

Emedinews: Insights on Medicolegal issues - Reconstitution of the body following an autopsy

An important component of the autopsy is the reconstitution of the body such that it can be viewed as normal following the autopsy procedure.

• After the conduction of postmortem examination, the body has an open and empty chest cavity with chest flaps open on both sides, the top of the skull is missing, and the skull flaps are pulled over the face and neck. All organs and tissue must be returned to the body unless permission is given by the family to retain any tissue for further investigation.
• Normally the internal body cavity is lined with cotton wool or an appropriate material; the organs are then placed into a plastic bag to prevent leakage and returned to the body cavity. The chest flaps are then closed and sewn back together and the skull cap is sewed back in place.
• The cases of mutilation/dismembered corpse must be surgically repaired into a normal anatomical position.
• Then the body must be properly sutured and reconstructed by the doctor conducting the autopsy with a cosmetic and parlor touch and then only it should be handed over to the relative of deceased as a regard of human corpse for ritual cremation.

(Contributed by Dr Sudhir Gupta)

HCFI Update: Acetone in the urine means fat is used as a source of energy

Anna Hazare’s urine shown presence of acetone which means that his fat is now becoming the source of energy, said Padmashri and Dr B C Roy National Awardee Dr K K Aggarwal President Heart Care Foundation of India and MTNL Perfect Health mela. As long as fat content in the body remains more than 10% the body can tolerate fasting. Anna being 70 kg can afford to lose 10 kg weight.

The fall of upper BP by 30 and rise of pulse by 10 means dehydration and need for more fluids.
1. Ketonuria is a medical condition in which ketone bodies are present in the urine. Medically it is presence of acetone in the urine.
2. It is seen in conditions in which the body produces excess ketones as an alternative source of energy. It is seen during starvation or in diabetes. Higher levels of ketones in the urine indicate that the body is using fat as the major source of energy.
3. Production of ketone bodies is a normal response to a shortage of glucose, meant to provide an alternate source of fuel from fatty acids.
4. In prolonged fasting insulin deficiency increases fat lysis and increased free fatty acid delivery to the liver. Glucagon excess promotes conversion of free fatty acids into ketoacids in the liver.
5. Ketone bodies that appear in the urine when fats are burned for energy are acetoacetate and beta-hydroxybutyric acid. Acetone is also produced. Normally, the urine should not contain a noticeable concentration of ketones to give a positive reading.
6. The body continues to use fat for as long as there is fat to consume. The body will generally indicate to the faster when fat levels are running extremely low (less than 7% and 10% of body weight for males and females, respectively) with an increased urge for food. Fasts are usually broken long before this point. If the fast is not broken, starvation begins to occur, as the body begins to use protein for fuel. Health complications associated with fast-induced starvation include electrolyte imbalances, thinning hair, lanugo, cardiac arrhythmia and renal failure. Death can occur if fasting is pursued to the point of complete starvation.
7. While fasting one should not take paracetamol as it can case fatal liver damage.
8. Acetone can be tested by a dipstick or by a lab. The results are reported as small, moderate, or large amounts of acetone. A small amount of acetone is a value under 20 mg/dl; a moderate amount is a value of 30–40 mg/dl, and a finding of 80 mg/dl or greater is reported as a large amount. In prolonged fasting the Ketoacid levels do not exceed 10meq/L and plasma bicarbonate concentration is typically above 14meq/L. The limitation in the degree of ketone formation with fasting in part reflects the ability of ketonemia to promote insulin secretion, thereby limiting the availability of free fatty acids. There is also increased ketoacid uptake by the brain as it switches from glucose to ketones as a source of fuel.
9. Fasting ketoacidosis is treated by administration of dextrose and saline solutions. The dextrose will increase insulin and reduce glucagon secretion, while the saline will repair any fluid deficit.
10. The plasma phosphate concentration may fall to low levels with therapy as insulin drives phosphate into the cells. When present, severe hypophosphatemia may be associated with marked and possibly life-threatening complications in these patients, including heart attack.

Emedinews : In what direction would Anna’s fast end?

Most Satyagraha should end up in a win-win situation. No party should seem to look that they have won. What can happen during a Satyagraha?

1. The fast is broken after demands are met.
2. The demands are not met but the fast is broken on the promises made.
3. The demands are not met but the fast is broken after a committee is constituted to look into the demands.
4. The fast is broken on the mediation by a religious or an important person in the society.
5. The fast is broken after the President of the country intervenes.
6. The fast is broken on medical grounds.
7. The fast is broken by the order of a court.
8. The fast is broken on the intervention of local administration or the local police.
9. The fast is broken on the request of the followers.
10. Some shift from complete fast to a relay fast.



Sunday, August 21, 2011

#AskDrKK: What does the new technology (drug eluting balloon) say and its benefits over the old one?

#DrKKAnswers: Recent advances in the field of intravascular medicine have seen the emergence of drug eluting balloon (DEB) technologies as a viable alternative for treating blocked arterial vessels. Balloon catheter delivers an anti-reblockage drug, such as paclitaxel, at the site of arterial blockage. Within coronary applications, stents are still the ‘gold standard’ but DEBs will have great impact in coronary applications e.g. for the treatment of in-stent restenosis and bifurcation lesions. Furthermore, in combination with bare metal stents they may overcome some of the limitations of DES”.


#AskDrKK: What are the methods of treating heart blockages?

#DrKKAnswers:
The methods of treatment can be understood by “Dr KK’s formula of easing out traffic congestion”. In any traffic one uses green and red lights to discipline the traffic; post a traffic inspector to divert the traffic; hire an architect to see the status of the roads; o widening of the arteries and build fly over or underpasses with or without stopping the traffic.

In terms of heart blockages green and red light indicates correcting and to discipline the life style. Red light indicate don’ts in life and green light indicates do’s in life.
Hiring of a traffic inspector indicates hiring a cardiologist to prescribe drugs to reduce the demand and increase the blood supply and divert the flow to smaller channels through drugs.

Hiring the architect means hiring an interventional cardiologist to do angiography to know the extent of blockages and the alternative repair procedures available.

Widening of the roads means opening the blocked arteries with balloon angioplasty. To prevent re encroachment of the roads railings are put on the roads. In terms of heart blockades it is equivalent to open the artery with balloon and put a metallic stent.

When a stent is put it can be bare metal stent or a drug eluting stent. Drugs are eluted on a metallic stent to prevent formation of a clot over them. Now a days instead of using drug eluting stents some cardiologists are eluting the baloons with the drugs so that either they can avoid a stent altogether or put a bare metal stent after that to reduce the cost.

Finally if stent cannot be put building fly over is equated to doing a bypass surgery.

#AskDrKK: What are the causes of the heart blockages?

#DrKKAnswers: Heart blockages are caused by faulty life style. Wild animals do not get heart blockages as they live in accordance with the laws of nature. To develop heart blockages one need to work against the laws of nature for over a decade.

The chances of heart attack can be detected by knowing Dr KK’s formula of eighty. Anybody with fasting sugar, lower blood pressure, bad cholesterol levels, abdominal circumference and resting heart rate of more than 80 have more chances of getting a heart attack. To reduce the chances one should walk 80 minutes a day, with the sped of 80 steps per minute; eat less than 80 mg or ml of caloric food each meal, drink less than 80 ml alcohol if cannot stop, do 8-0 cycles of pranayama a day and take 80 mg aspirin if prescribed.

Another formula is “Dr KK’s formula of 2” and that is a person who can climb 2 flights of stairs’ walk 2 kilometers or has performed sex with his partners on last two occasions without getting any symptoms is not at risk.