January 31 2015, Saturday
editorial
Walking 2000 steps extra lower cardiovascular risk
Dr KK Aggarwal Walking 20 minutes at a moderate pace each day is associated with improved cardiovascular outcomes in patients with impaired glucose tolerance, according to a study in The Lancet.

People who walked 2,000 steps more per day at baseline had a 10% lower risk of cardiovascular death, paralysis or heart attack during an average follow–up of 6 years according to Thomas Yates, PhD, of the University of Leicester in England, and colleagues.

And those who increased the amount they walked by 2,000 steps per day from baseline to 1 year had a similar reduction in risk of cardiovascular events.

The findings from NAVIGATOR trial support both the promotion of increased ambulatory activity, and the avoidance of decreased ambulatory activity irrespective of the starting level, as important targets in the prevention of chronic disease.
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Health Check Up and CPR 10 Camp at G B S.S. School, Varun Marg, Defence Colony, New Delhi on 22nd December 2014
News Around the Globe
  • Tight control of prenatal hypertension did not improve mortality rates or risk of serious complications vs less-tight control: Among 987 pregnant women, most of whom had pre-existing hypertension, 30.7% of those in the tight control group experienced a loss of pregnancy or gave birth to a child in need of high-level neonatal care for more than 48 hours versus 31.4% of women assigned to looser blood pressure targets, according to Laura A. Magee, MD, of the University of British Columbia, and colleagues. But severe hypertension rates were higher among the less-tight control arm at 40.6% compared with the tight control arm at 27.5%, the researchers reported in The New England Journal of Medicine. (MedPage Today)
  • Use of common anticholinergic drugs linked to increased dementia risk: A new report in JAMA Internal Medicine links long-term use of anticholinergic medications to an increased risk of dementia. Anticholinergic drugs include some antihistamines (like Benadryl), and some tricyclic antidepressants, medications to control overactive bladder, and drugs to relieve the symptoms of Parkinson's disease. (Health Beat)
  • Antimicrobial use for travelers' diarrhea increased risk for colonization by extended-spectrum drug-resistant beta-lactamase-producing Enterobacteriaceae, according to the findings of a study published online January 21 in Clinical Infectious Diseases. The researchers therefore suggest that travelers be advised not to use antibiotics for mild to moderate TD. (Medscape)
  • The current US physical activity guidelines emphasize all three aspects of fitness. Here are the recommendations:
    • All adults — including people with various disabilities — should aim for a total of 150 min of moderate aerobic activity, or 75 min of vigorous activity, or an equivalent mix of the two throughout the week.

      20 min of moderate activity is roughly equal to 10 min of vigorous activity. During moderate activities, you can talk, but not sing; during vigorous activities, you can manage only a few words aloud without pausing to breathe. Adding time — up to 300 min of moderate activity, or 150 min of vigorous activity, or a mix — increases the health benefits gained.
    • Twice-weekly strengthening activities for all major muscle groups (legs, hips, back, abdomen, chest, shoulders, and arms) are recommended, too.
    • Balance exercises are particularly important for older adults at risk of falling.
    • Flexibility exercises may be helpful, too. (Source Health Beat)
Dr KK Spiritual Blog
Why are most temples located in faraway places?

Most temples represent God or the spirit or the deity located in the temple or mandir situated in an area at the outskirts of the city. A spiritual atmosphere is one that is devoid of pollution and which promotes rajasik or tamasik behavior. The silence of the spiritual atmosphere reduces the internal noise and helps us onward in our inner journey. The inner journey of being in touch with one’s consciousness requires detachment from worldly pleasures and the withdrawal of the five senses of the body

To be in touch with one’s consciousness one needs to bypass the disturbed state of consciousness controlled by emotion, memories and desires, through mind, intellect and ego. This usually requires a prolonged period of persistence and undertaking the inward journey devoid of external stimuli. The parikrama, which means “the path surrounding something”, incorporating many long walks helps to detoxify the mind and thus shifts the consciousness from a disturbed state to an undisturbed, calm state.

A long walk not only offers physical benefits but one also gets the benefits of nature as one’s inner stimuli are exposed to the outer stimuli during the parikrama. The person is often required to walk bare foot on natural ground, inhale pure air and concentrate and listen to the sounds of the nature, birds and trees. This proximity to nature helps in the inward spiritual journey and shifts one from the sympathetic to parasympathetic mode described by lowering of blood pressure and pulse rate. The final happiness invariably comes from within us at the time of final darshan when a person invariably closes his eyes and experiences God within his heart.

Most temples today are being constructed in residential colonies and provide a holy atmosphere to people right at their doorstep. However, they do not have the same spiritual significance and benefits as a temple located at the outskirts of a city.

There is no way a person can go to a temple in the vicinity of his house and detoxify his mind as this can hardly be achieved in minutes unless you are a siddha yogi, and if you are one, you need not go to a temple as the temple is within you.

In Vedic texts, it has been clearly mentioned that to acquire powers and inner happiness, rishi, munis had to do tapasya for months and years together. This tells us that spiritual well-being is acquired over an extended period of time as the process of detoxification is a long drawn process. Cars and other vehicles should not be allowed near temples as the basic motive is to have a pollution-free atmosphere and to give time and space for the mind to detoxify.
Cardiology eMedinewS
  • The full implementation of the Eighth Joint National Committee (JNC 8) guidelines for the management of adult hypertension could prevent approximately 56 000 cardiovascular events and 13 000 deaths each year in the US, without increasing costs to the healthcare system, points a new analysis published January 28 in the New England Journal of Medicine.
  • A paper-clip-sized implant inserted between the artery and vein in the central arterial tree, designed to shunt blood out of the artery and into the vein, has shown positive results in early testing, suggests a new study published in the Lancet.
Pediatrics eMedinewS
  • Sustained lung inflation (SLI) at birth for preterm infants reduces their need for mechanical ventilation, reveals new research published online in Pediatrics.
  • A diet- and lifestyle-counseling program aimed at kids, started while they were infants and provided through parents and school, appeared to drop the rate of metabolic syndrome (MetS) by about 40% by the time they had reached age 15 to 20, suggested a randomized trial published online in Circulation.
Make Sure
Situation: A patient died after receiving penicillin injection.
Reaction: Oh my God! Why was anaphylaxis not suspected?
Lesson: Make Sure that each time a patient is given penicillin injection, anti anaphylaxis measures are available.
Medicolegal
If the defendant does not appear before the Council, can the Council take action against him?

If the complainant or the defendant does not appear before the Council in spite of repeated notices or does not file written statements, the Council is free either to discharge the case if the complainant does not appear or to go ahead and listen to the complainant and take the case on merit depending upon the available medical records.

In an order DMC/DC/F-14/609/2010 dated 18 August 2010, the Council heard the case on merit as the operating surgeon neither filed his written statement nor participated in the proceedings. No action was taken against the operating surgeon for not appearing.
Dr Good Dr Bad
Situation: An elderly patient after IV ondansetron 16 mg dose developed irregular heart rhythm
Dr Bad: It cannot be due to the drug
Dr Good: It is due to the drug
Lesson: ECG interval changes, including prolongation of the QTc interval, are a class effect of the first-generation serotonin antagonists, including ondansetron; potentially fatal cardiac arrhythmias may result. QTc prolongation occurs in a dose-dependent manner, and is expected to be greater with faster rate of infusion and larger doses for IV administration. The current recommendation is to limit single IV doses to no more than 16 mg. Canadian guidelines place additional dosing restrictions on IV ondansetron to mitigate the risk of QT prolongation, particularly in older adults, in whom the initial dose should not exceed 8 mg (Source: healthycanadians.gc.ca/recall-alert-rappel-avis/hc-sc/2014/39943a-eng.php (Accessed on June 16, 2014).

(Copyright IJCP)
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eMedinewS Humor
On Trial

After a trial had been going on for three days, Finley, the man accused of committing the crimes, stood up and approached the judge’s bench. "Your Honor, I would like to change my plea from ‘innocent’ to ‘guilty’ of the charges."

The judge angrily banged his fist on the desk. "If you’re guilty, why didn’t you say so in the first place and save this court a lot of time and inconvenience?" he demanded.

Finley looked up wide–eyed and stated, "Well, when the trial started I thought I was innocent, but that was before I heard all the evidence against me."
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Twitter of the Day
Dr KK Aggarwal: Soul is the biggest pharmacy in the world – Dr KK Aggarwal http://bit.ly/15QdVeB #Health

Dr Deepak Chopra: Your true self is the ground state of the universe http://bit.ly/15QdVeB #Health
CPR 10
Total CPR since 1st November 2012 – 101090 trained
Rabies News (Dr A K Gupta)
What are the common side effects of intra-dermal rabies vaccination?

Cell culture vaccines have proved to be remarkably safe and free of significant adverse events. However, mild symptoms of pain, erythema, irritation or swelling at the intradermal injection sites occur in 3–92% of patients. The most frequent symptom is local irritation in 7–64% of vaccines. Generalized symptoms reported by 3–14% of recipients include headache, fever and influenza–like illness. Transient macular, papular and urticarial rashes are occasionally seen. All these adverse effects are mild, transient and self limiting and rarely call for the use of antihistamines and analgesics.
Video of the Day
Press Release of the Day
Should a diabetic with tight sugar control drive?

Worldwide, diabetics are required to produce proof of good blood sugar control to keep their driving license. A study by Dr. Donald A. Redelmeier, professor of medicine at the University of Toronto has shown that diabetics, who keep their blood sugar tightly controlled run the risk of having traffic accidents due to low blood sugar, said Padma Shri, Dr. B C Roy National Awardee & DST National Science Communication Awardee, Dr. K K Aggarwal, President Heart Care Foundation of India and Honorary Secretary General Indian Medical Association.

The risk was substantial, accounting for almost 50 percent of the accidents. The accidents were mostly related to severe hypoglycemia in association with strict blood sugar control. The findings were published online in PLoS Medicine. For the study, Redelmeier's team collected data on 795 diabetic drivers. They found that one in 14 of the drivers had been involved in car accidents. Those with low blood sugar were more likely to have had an accident than were diabetics whose blood sugar was not as well controlled. Moreover, the risk for having a car accident increased fourfold if the person had a history of hypoglycemia.

Diabetics should not to drive if they feel dizzy or have other symptoms of hypoglycemia. If some one has had a hypoglycemic episode the previous day, he or she should not drive the car next day.

Patients with diabetes should drive only if diabetes is under control and there is no evidence of end organ disqualifying disease. Definitive criteria are not available but an American Diabetes Association table indicates upper limits for acceptable control as follows:
  1. Fasting sugar: Normal 115 mg/dL (acceptable 140 mg/dL)
  2. 2 hour postprandial plasma glucose: Normal 140 mg/dL (acceptable 200 mg/dL)
  3. Glycosylated hemoglobin A1C: Normal 6 percent (Acceptable 8 percent)
Sameer Malik Heart Care Foundation Fund
The Sameer Malik Heart Care Foundation Fund is a one of its kind initiative by the Heart Care Foundation of India instituted in memory of Sameer Malik to ensure that no person dies of a heart disease because they cannot afford treatment. Any person can apply for the financial and technical assistance provided by the fund by calling on its helpline number or by filling the online form.
Madan Singh,
SM Heart Care Foundation Fund, Post CAG
Kishan, SM Heart Care Foundation Fund,
Post CHD Repair

Deepak, SM Heart Care Foundation Fund,
CHD TOF
About the Editor

Padma Shri, National Science Communication and Dr B C Roy National Awardee, Honorary Secretary General IMA, Immediate Past Senior National Vice President IMA, Professor of Bioethics SRM University, Sr. Consultant Medicine & Cardiology, Dean Board of Medical Education, Moolchand, President Heart Care Foundation of India, Chairman Legal Cell Indian Academy of Echocardiography, Editor in Chief IJCP Group of Publications & eMedinewS, Member Ethics Committee Medical Council of India (2013-14), Chairman Ethical Committee Delhi Medical Council (2009-14), Elected Member Delhi Medical Council (2004-2009), Chairman IMSA Delhi Chapter (March 10- March13), Director IMA AKN Sinha Institute (08-09), Finance Secretary IMA (07-08), Chairman IMAAMS (06-07), President Delhi Medical Association (05-06)
The Year in Medicine 2014: News That Made a Difference
FDA Drug Warnings, Recalls

Several drug alerts made the news this year: The FDA said clinicians should stop prescribing combination prescription pain relievers that contain more than 325 mg of acetaminophen, citing the risk for liver damage. The agency also lowered the recommended starting dose of the sleep aid eszopiclone (Lunesta, Sunovion Pharmaceuticals). "Data show that eszopiclone levels in some patients may be high enough the morning after use to impair activities that require alertness, including driving, even if they feel fully awake," the FDA said in a statement. Finally, certain over-the-counter topical acne products can cause "rare but serious and potentially life-threatening" allergic reactions or severe irritation, the FDA warned. (Source: Medscape)
News on Maps
IMA NEWS
30-63% of Rs 10,000 crore medical devices faulty

Rema Nagarajan, TNN | Jan 28, 2015, 06.31AM IST: NEW DELHI: Anywhere between 30% and 63% of roughly Rs 10,000 crore worth of existing medical equipment in public health facilities across all states is dysfunctional.

The Centre is now proposing to allocate special funds to the states to engage medical equipment maintenance agencies to tackle this problem as part of the effort to improve the public healthcare infrastructure. The agency engaged will be expected to maintain everything from a weighing machine or ECG machine to a dialysis machine or X-ray in public facilities.

While the government says this will be a public private partnership, it stresses that it is different from privatization since property rights and ownership rights are not transferred to the private agency. With more than half the machines lying in a non-functional state in many cases, the government expects that an investment of about 3% of inventory value will bring medical equipment worth thousands of crores to life.

The centre has asked all states to identify the entire medical inventory in their facilities and budget the maintenance cost under the National Health Mission (NHM).

The Centre is said to have estimated that approximately Rs 400 crore will have to be disbursed to states for this maintenance programme. States have been asked to initiate a comprehensive maintenance program for all medical equipment from rural primary care centres to district-based large hospitals, starting April 1, 2015.

While small states will be expected to engage a single agency to do the maintenance, bigger states like Uttar Pradesh could engage three or four agencies among whom the districts can be divided.

In the new program of comprehensive equipment maintenance under the NHM, some states have already got the money for the scheme while others have been asked to put it into their annual requirement. Without functional diagnostic equipment, none of the forthcoming schemes of the government such as providing free diagnostics in public health facilities, can be a success and hence the push to adopt this innovative maintenance program.

In the new system, anyone from a nurse to the radiologist can register a complaint regarding any machine at one toll free number in each state. The complaint will be electronically tracked to see how soon it is addressed. The contract with the maintenance agency would include penalties for any machine having a down time of more than a week or ten days.

While welcoming the idea, administrators of government hospitals TOI spoke to wondered if there were agencies in India big enough to handle the huge task of maintaining machines of all government facilities from primary level up to the tertiary level in an entire state and who could stock parts of machines of all companies.

They also raised questions about what would happen to existing annual maintenance contracts or warranty on machines already purchased, which would become useless if the machines are opened or repaired by anyone not from the company.

"In the current scenario, where any government hospital has hundreds of machines bought from various companies, it is a headache for the hospital to track each company individually to fulfill its annual maintenance contracts (AMCs). It was found that only 2% of machines in government facilities are under any kind of maintenance contracts with the company from which it purchased the machine," explained a health ministry official. Moreover, having an agency would also mean that each state government will not have to engage a large number of biomedical engineers for maintaining its inventory of machines as that would be the task of the agency hired.

The entire Narayana Health (formerly known as Narayana Hrudyalaya) chain of hospitals uses a similar method of engaging a single agency to maintain all its machines across all its hospitals. "It is an excellent way to ensure that all machines work, provided the contracts are drawn up properly, performance is tracked and penalties are imposed for excessive downtime of any machine," said Dr Devi Shetty of Narayana Health.

He added that AMCs or comprehensive maintenance contracts (CMCs) could be as much as 10% of the price of a machine, which is a lot of money. "Moreover, companies are interested in making you buy newer machines and so after about five years they say the machines are beyond repair and push you to buy a new one. We have found that engaging a third party for maintenance, who is not the seller, helps extend the life of machines. Plus, we have one person in the hospital from the agency who is the face of the machines and who we can take to task if there is any problem," said Dr Shetty.

2. Dear Sir, now a days the registration fee of the various conferences are so high that many doctors , particularly retired , cannot afford the same. Can such conferences provide discount to retired doctors, who are not in service or practice? Dr AK Saxena, CMO& GM (Medical), JK White Cement Works Gotan-342902, Distt. Nagaur, Rajasthan.

10 Worst Medical Treatment Dangers 2015

Errors in Patient Data

When electronic health record systems malfunction, information that is incomplete, inaccurate, or out-of-date can end up in a patient's record, potentially leading to incorrect treatment decisions. Once errors are introduced, they can be difficult to identify and correct.

Some examples: One patient's data winds up in another patient's record; missing data or delayed data delivery; default values being used by mistake, or fields being filled with erroneous data; inconsistencies in patient information when both paper and electronic records are used; and outdated information being copied and pasted into a new report.

(Source: Medscape)

Medscape Family Physician Lifestyle Report 2015

How Severe is Physicians Burnout

Burnout has been shown to negatively affect patient care,(3) and many of the factors that lead to burnout are also associated with a higher likelihood of physicians leaving their practice.(2) Rates of suicide are higher in physicians than in the general population,(4) with studies indicating that job stress is a factor.(5) Medscape asked burned-out family physicians to rate the severity of their burnout from 1 ("does not interfere with my life") to 7 ("so severe that I'm thinking of leaving medicine"). Family physicians gave their burnout a score of 4.17, which was eighth highest in severity. Of interest, the three specialties reporting the highest severity ratings—nephrology (4.30), cardiology (4.29), and plastic surgery (4.28)—were not those with the largest percentage of burned-out physicians.

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Launch of IMA Rise and Shine Web Lecture Series
Date of webcast
8th February 2015
Time of webcast
11:00 AM - 11.30 AM
Mode
Live webcast http://www.ima-india.org/ima/
Opening remarks:
Dr K K Aggarwal, Honorary Secretary General, IMA - 2 minutes
Introduction of President IMA and Chairman Apollo Hospitals Group
Dr. Anupam Sibal, Group Medical Director, Apollo Hospitals - 3 minutes
Presidential Address
Dr. Marthanda Pillai, National President – IMA - 7 minutes
Leadership Qualities: My personal Journey and Healthcare challenges
Dr. Prathap C Reddy, Chairman Apollo Hospitals Group - 15 minutes
Concluding Remarks and Thanks
Dr. K K Aggarwal - 3 minutes
Inspirational Story
The Here and Now

The critical time for accomplishing anything is in the here and now. Every day is a day to dare to do my best. Each day provides opportunity for self-improvement/self-renewal. Today's accomplishments, not yesterday's or tomorrows, produce the most satisfaction as what I accomplish today can give me an immediate feeling of self confidence and direction.

The critical time for accomplishing anything is in the here and now, today. The most important ingredient in future performance is present performance. The most difficult tasks are consummated, not by a single explosive burst of energy or effort, but by consistent daily application of the best I have within me.

Practice is an opportunity to improve my skills. Approach each practice with enthusiasm, as nothing great has ever been accomplished without it. Challenge myself mentally as well as physically and I will start to enjoy the price of success rather than pay for it. Desire... the "want to" is the extra which enables an athlete to take whatever ability he/she has and utilize it to the maximum. Total effort gives an athlete a special kind of victory... victory over himself/herself. I will make this the best day and the best practice ever.
Quote of the Day
Heart tells the eyes "See less, because you see and I suffer lot". Eyes replied, "Feel less because you feel and I cry a lot".
IMA in the News
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Reader Response
  1. Dear sir, excellent job; requires lots of efforts to collect so much info-kudos to your team, warm regards: Dr Santanu Singha, DNB (SS) Pediatric Surgery.
  2. Respected Dr KK Aggarwal, Heartiest Congratulations Sir. I am greatly inspired by you since I watched your show on DD National. Your efforts to cure are really appreciable. Is there any facility for Genetic course by Government? Best Regards: Dr. Kusum R. Gandhi, Assistant Professor, Dept. of Anatomy, Rural Medical College, Pravara Institute of Medical Sciences, Loni, Maharashtra
Wellness Blog
The Science of Hygiene

All of us are taught about hygienic living and this subject should be included as a chapter in the curriculum of every school. There are many different kinds of hygiene.

Respiratory hygiene: This is important to prevent cross infection, specifically, from flu and related respiratory illness. One should keep a distance of minimum 3 ft, from a person who is coughing, sneezing or singing. Most respiratory particles are more than 5 microns in size and do not travel a distance of more than 3 ft. This respiratory hygiene, however, will not prevent transmission of the tuberculosis bacteria, which are less than 5 microns and keep circulating in the area.
Hand hygiene: This is the fundamental principle for any disease prevention and the catch phrase is “before and after”, i.e. one should wash hands before and after eating food, touching any infected material, seeing a patient or after normal evacuation of stool in the morning.
Food hygiene: This basically means maintaining hygiene at home while cutting, serving and eating food. While cutting a vegetable, it involves clean hygienic surface, knife, hands, water, utensils etc. If that hygiene is not possible, follow the formula of ‘boil it, heat it, peel it, cook it or forget it’. This means that any food which has been boiled, heated or peeled is safe for eating. Peeling means removing the skin of a fruit such as banana or oranges.
Water hygiene: This involves drinking safe water, safe drinking glass, proper washing of glass, not washing multiple glasses in the same utensil and picking up glasses properly. People often pick up four glasses of water at the same time with one finger in each glass.
Sexual hygiene: This involves washing local areas before and after sexual contact.
Body hygiene: This involves 16 upchars, as mentioned in mythology. Out of these 16 basic steps, some are related to body hygiene and they involve washing feet first and then hands followed by mouth and finally the body. Washing of the feet is the most important as they are the ones which carry infections into one’s house.

Cleaning of mouth is cleaning the teeth with one finger, gums with two fingers, tongue with three fingers and palate with thumb.

Abhishekam or the snana of the body involves multiple steps. Ancient steps have been washing the body with milk water (rose water etc.) followed by rubbing with curd (soap), honey (moisturizers), ghee
(oil), sugar (the drying agent) and finally with milk water again. This facilitates natural bathing and not dependent on soap.

Nail hygiene: This is also a very important hygiene, especially for food handlers, because they are responsible for causation of water and food disease. It is important that they be given typhoid vaccines and de-worming tablets every three months.

The most important hygiene to be observed at our homes is that of the servants or the help. They are often provided soap at the start of the month and they are supposed to continue using that soap for a month. If by any chance, they lose that soap in 2-3 weeks’ time, they are apprehensive in asking the owners for soap. As a result, they may wash their hands without soap for the next 2-3 weeks, which includes washing of hands in morning.
eMedi Quiz
All of the following are the electrocardiographic features of severe hyperkalemia except:

1. Peaked T waves.
2. Presence of U waves.
3. Sine wave pattern.
4. Loss of P waves.

Yesterday’s Mind Teaser: All of the following infections are often associated with acute intravascular hemolysis except:

1. Clostridium tetani.
2. Bartonella bacilliformis.
3. Plasmodium falciparum.
4. Babesia microti.

Answer for yesterday’s Mind Teaser: 1. Clostridium tetani.
Correct Answers received from: Dr.K.V.Sarma, Dr Avtar Krishan, Daivadheenam Jella.
Answer for 29th Jan Mind Teaser: 4. Neurotoxic.
Correct Answers receives: Daivadheenam Jella, Dr Avtar Krishan, Dr Poonam Chablani, Dr K V Sharma, Dr Saminathan, Chennai, Dr Prafull Naik, Raju Kuppusamy.
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