[CONTENT]
March 14  2015, Saturday
editorial
Hand, foot and mouth disease
Dr KK AggarwalWe have been seeing a rise in the number of cases of hand, foot and mouth disease in Delhi among school children. These may be mistaken for chicken pox.

Hand, foot and mouth disease: Salient facts
  • Hand, foot and mouth disease is a viral illness most commonly caused by the Coxsackie virus A6.
  • Enteroviruses 71 (EV71) can also cause hand, foot and mouth disease.
  • Both adults and children can develop this infection. But young children below 5 years old are more susceptible.
  • It is a moderately contagious illness.
  • The incubation period is 5 days.
  • The illness begins with fever, which lasts for 24–48 hours.
  • Fever is followed by appearance of painful sores in mouth. They begin as small red spots that blister and then often become ulcers. Tongue is involved.
  • There are peripherally distributed small tender non itchy rash with blisters on palms of the hands, and soles of feet and buttocks.
  • The sores hurt on touch and swallowing is difficult.
  • There is proximal separation of nail from the nail bed.
  • The virus is present in mucus from nose, saliva, fluid from sores and traces of bowel movements.
  • The virus spreads in the first week of infection.
  • The infection spreads from person to person by direct contact with nasal discharge, saliva or blister fluid or from stool of infected persons.
  • The virus can persist in the stool for weeks.
  • The illness is not transmitted to or from pets or other animals
  • The illness stays for 2–3 days. It is usually mild and self limited.
  • Entero 71 virus is associated with brain involvement (meningitis and encephalitis), lungs and the heart.
  • The patient remains infectious after the symptoms have gone.
  • Test is not necessary.
  • There is no specific treatment.
  • Paracetamol tablet can be taken to relieve pain and fever.
  • Aspirin is to be avoided in children.
  • Dehydration should be avoided.
  • Eat ice cream to numb the pain.
  • Using mouthwashes or sprays that numb mouth
  • Regularly wash your hands with soap and water.
  • Avoid exposure to infected person.
  • Maintain touch hygiene to reduce your risk of acquiring the infection.
  • During first week of illness, the child should be kept in isolation.
  • Schools should be closed.
  • There is no vaccine currently available
eMedipics IMA,IJCP,HCFI
Press Conference on Not notifying TB unethical under MCI Ethics Regulations
News
  • Eating a plant-based diet rich in fruits, vegetables, and nuts and low in animal fats, dairy, and sweets tends to reduce the risk for stroke by up to 18% compared with a less healthy dietary pattern, reports a new study presented at the recent International Stroke Conference (ISC) 2015.
  • New research suggests that the top five causes of maternal mortality - cardiovascular disease, preeclampsia or eclampsia, hemorrhage, venous thromboembolism, and amniotic fluid embolism - might be preventable. The findings published in the April issue of Obstetrics & Gynecology revealed that 41% to 70% of these cases are preventable.
  • High-dose corticosteroids increase the risk of organ damage in patients with systemic lupus erythematosus (SLE), suggests a large cohort study published online in Lupus Science and Medicine.
  • Keep moving when knee or hip pain strikes: Mobility relies on the body's two largest joints, the hips and knees. We ask a lot of both these joints: they must bear our full weight and coordinate movement over a lifetime of standing, walking, running, dancing, and sports. Not surprisingly, hip and knee pain are common complaints, and nearly everyone who lives into old age can expect some trouble with these joints. But taking care of your hips and knees and managing any pain that arises will help you avoid losing mobility as you age. (Harvard)
  • WHO issues its first hepatitis B treatment guidelines: WHO today issued its first-ever guidance for the treatment of chronic hepatitis B, a viral infection which is spread through blood and body fluids, attacking the liver and resulting in an estimated 650 000 deaths each year – most of them in low- and middle-income countries. The "WHO guidelines for the prevention, care and treatment of persons living with chronic hepatitis B infection" lay out a simplified approach to the care of people living with chronic hepatitis B, particularly in settings with limited resources. The guidance covers the full spectrum of care from determining who needs treatment, to what medicines to use, and how to monitor people long-term.
Key recommendations include:

the use of a few simple non-invasive tests to assess the stage of liver disease to help identify who needs treatment; prioritizing treatment for those with cirrhosis - the most advanced stage of liver disease; the use of two safe and highly effective medicines, tenofovir or entecavir, for the treatment of chronic hepatitis B; and regular monitoring using simple tests for early detection of liver cancer, to assess whether treatment is working, and if treatment can be stopped.

The special needs of specific populations, such as people co-infected with HIV, as well as children and adolescents, and pregnant women are also considered.

Treatment can prolong life for people already infected with hepatitis B, but it is also important to focus on preventing new infections. WHO recommends that all children are vaccinated against hepatitis B, with a first dose given at birth. Some countries, particularly in Asia, have reduced the rates of childhood hepatitis B infection through universal childhood vaccination. The challenge now is to scale up efforts to ensure that all children worldwide are protected from the virus.

Another route of infection is through the reuse of medical equipment, in particular of syringes. WHO has recently launched a new policy on injection safety that will also help prevent new hepatitis B infections. The policy calls for the worldwide use of “smart” syringes to prevent the re-use of syringes or needles.

The new guidelines on treating hepatitis B follow on from the publication last year by WHO of its first ever guidelines on treating hepatitis C.
After polio, Amitabh Bachchan to lead India’s fight against hepatitis B
Sushmi Dey, TNN | Mar 13, 2015, 05.58 AM IST

Taking a cue from the success of pulse polio campaign, the government has again roped in Amitabh Bachchan as brand ambassador for its campaign against hepatitis B, a critical public health problem facing India.
Dr KK Spiritual Blog
Debts in Mythology

It is said that there are three debts which everybody has to pay in his or her lifetime. In Vedic language, they are called Dev Rin, Pitra Rin and Rishi Rin.

In medical language, the body consists of soul, physical body, mind, intellect and ego. The soul is given to us by God or Devtas (Dev Rin), the physical body by our parents (Pitra Rin) and the mind, intellect and ego by our Gurus (Rishi Rin).

In terms of computer language, if I see my body as a computer, then my body as a computer is made by my parents; operating software and my inner internet represent the soul or consciousness given by the Devtas and the application softwares i.e. Word, Excel and Power point, which we learn over a period of time are given to us by our Gurus. Therefore, we have to pay all these three debts while we are still alive.
IMA,IJCP,HCFI
Cardiology eMedinewS
  • A study published in JAMA revealed that among patients subjected to transcatheter aortic valve replacement, death rate after one year was nearly one in four; of those alive at 12 months, almost half had not been rehospitalized and approximately 25% had only one hospitalization.
  • Women who experience hot flashes early in the course of menopause are more likely to have markers of blood vessel dysfunction that could indicate a higher risk for the development of heart disease, suggests new research scheduled to be presented at the American College of Cardiology's 64th Annual Scientific Sessions.
Pediatrics eMedinewS
  • A quick simple vision test can be administered by parents and others on the sidelines of sports fields and arenas to help detect concussion in athletes as young as 5 years of age, suggests a new study. The study is published online in the Journal of Neuro-Ophthalmology.
  • Excessive pregnancy weight gain is associated with greater overall and abdominal body fat in children and obesity at age seven suggests a new study published online in the journal Maternal & Child Nutrition.
    Excessive pre-pregnancy weight gain was associated with an increased risk of childhood obesity of approximately 300 percent.
Events
IMA,IJCP,HCFI
Make Sure
Situation: A foreigner with a single loose stool developed sepsis.
Reaction: Oh my God! Why were antibiotics not started in time?
Lesson: Make sure that all foreigners are diagnosed to be suffering from Traveler’s diarrhea even if there is one single loose stool.
Medicolegal
(Contributed by Dr Sudhir Gupta, Prof & Head, Forensic Medicine & Toxicology, AIIMS)

Q. I outsource samples to larger laboratories and give the test reports to the patients on my own letterhead. Sometimes the patients want me to provide the original report from the laboratories concerned but the latter do not want me to do so. Please let me know the legal implications.

A.
  • If you are a doctor and collect samples and give reports on your own letterhead without clearly stating that you are merely a collecting agent for the specified laboratory, giving out openly its name and contact details etc., you are apparently holding out that the test has been carried out directly or indirectly by you and, thereby, you assume the role of service provider to a consumer of services. The patient will be legally entitled to sue you for any perceived deficiency in service. He will also be entitled to sue the laboratory concerned.
  • If the laboratories concerned do not want you to give their details to the patients/consumers, it amounts to lack of transparency and deficiency in service. The patient has full right to know who carried out the tests and in what manner.
  • If you do not have a qualification in Pathology, you would be further compounding your fault.
In my opinion, your actions are likely to be held violative of the Consumer Protection Act, 1986, and the Code of Medical Ethics Regulations, 2002.
Dr Good Dr Bad
Situation: A patient developed acute appendicitis within 7 days of taking Mediclaim policy.
Dr. Bad: Mediclaim will cover.
Dr. Good: May not cover.
Lesson: Any diseases other than specified in clause 4.3 contracted by the insured person during the first 30 days from the commencement date of policy are not covered under Mediclaim.

(Copyright IJCP)
IJCP Book of Medical Records
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IMA,IJCP,HCFI
eMedi Quiz
Ofleck's phenomenon is seen due to which component

a. Joint psoriasis
b. Mucosal psoriasis
c. Nail psoriasis
d. Pustular psoriasis

Yesterday’s Mind Teaser: Isotopic response is seen in scars of which condition

a. Orolabial herpes
b. Herpes genitalis
c. Pyoderma gangrenosum
d. Eosinophilic pustular folliculitis

Answer for yesterday’s Mind Teaser: c. Pyoderma gangrenosum
Correct Answers received from: Daivadheenam Jella, Dr Poonam Chablani, Dr Avtar Krishan.
Answer for 12th March Mind Teaser: d. Epitope spreading phenomenon
Correct Answers receives: Dr Poonam Chablani, Dr Avtar Krishan.
CPR 10
Total CPR since 1st November 2012 – 101090 trained
Video of the Day
Sameer Malik Heart Care Foundation Fund
The Sameer Malik Heart Care Foundation Fund is a one of its kind initiative by the Heart Care Foundation of India instituted in memory of Sameer Malik to ensure that no person dies of a heart disease because they cannot afford treatment. Any person can apply for the financial and technical assistance provided by the fund by calling on its helpline number or by filling the online form.
Madan Singh,
SM Heart Care Foundation Fund, Post CAG
Kishan, SM Heart Care Foundation Fund, Post CHD Repair
Deepak, SM Heart Care Foundation Fund, CHD TOF
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IMA NEWS
Facts about Tuberculosis (TB)
How does TB spread?
  • Although TB is an infectious disease, all forms of TB are not infectious.
  • Only those patients suffering from sputum-positive pulmonary TB are source of infection. When such a patient coughs or sneezes, TB bacteria spread into the air as droplets. People nearby may breathe in these bacteria and become infected.
  • An infectious case of TB, if untreated, can infect 10-15 people in one year
  • Extra-pulmonary TB is not infectious.
  • TB does not spread through handshakes, using public toilets, sharing food and utensils, blood transfusion and casual contact.

WMA News

Swine flu virus in India turns even more dangerous, MIT study warns

PTI | Mar 12, 2015, 01.11 PM IST

WASHINGTON: The swine flu virus in India which has already killed more than 1,500 people since December may have acquired mutations that make it more severe and infectious than previously circulating H1N1 strains, a new MIT study has warned.

The study by Massachusetts Institute of Technology (MIT) contradicts previous reports from Indian health officials that the strain has not changed from the version of H1N1 that emerged in 2009.

MIT researchers found that the recent Indian strains carry new mutations in the hemagglutinin protein that are known to make the virus more virulent. Hemagglutinin binds to glycan receptors found on the surface of respiratory cells and the strength of that binding determines how effectively the virus can infect those cells.

In the past two years, genetic sequence information of the flu-virus protein hemagglutinin from only two influenza strains from India has been deposited into publicly available influenza databases which makes it difficult to determine exactly which strain is causing the new outbreak and how it differs from previous strains.

"However, those two strains yielded enough information to warrant concern," said Ram Sasisekharan, the Alfred H Caspary, professor of Biological Engineering at MIT and the paper's senior author.

Sasisekharan and Kannan Tharakaraman, a research scientist in MIT's Department of Biological Engineering, compared the genetic sequences of those two strains (of 2014) to the strain of H1N1 that emerged in 2009 and killed more than 18,000 people worldwide between 2009 and 2012.

One of the new mutations is in an amino acid position called D225, which has been linked with increased disease severity, researchers said.

Another mutation, in the T200A position allows hemagglutinin to bind more strongly to glycan receptors, making the virus more infectious, the study found.

Sasisekharan said that more surveillance is needed to determine whether these mutations are present in the strain that is causing the current outbreak, which is most prevalent in Gujarat and Rajasthan and has infected more than 20,000 people so far.

Meanwhile, in New Delhi health ministry officials said they will take up the issue with the Indian Council of Medical Research (ICMR) since the latter has been saying till now that there have not been any mutations.

"So far the ICMR has been saying that there is no mutation. But since the study has come up, we will take it up with ICMR for a final view," additional secretary, health, Arun Panda said.

According to the latest figures from the Union health ministry data, as of March 10, as many as 1,537 people have perished due to swine flu while the number of infected people in the country is 27,234.
Media
IMA,IJCP,HCFI

Inspirational Story

The Burnt Biscuits


When I was a kid…my mom liked to make food for breakfast and for dinner every now and then. And I remember one night in particular when she had made dinner after a long, hard day at work. On that evening so long ago, my mom placed a plate of eggs, sausage and extremely burned biscuits in front of my dad. I remember waiting to see if anyone noticed! Yet all my dad did was reach for his biscuit, smile at my mom and ask me how my day was at school. I don’t remember what I told him that night, but I do remember watching him smear butter and jelly on that biscuit and eat every bite! When I got up from the table that evening, I remember hearing my mom apologize to my dad for burning the biscuits. And I’ll never forget what he said: "Honey, I love burned biscuits."

Later that night...I went to kiss Daddy good night and I asked him if he really liked his biscuits burned. He wrapped me in his arms and said, “Your Mom put in a hard day at work today and she’s real tired...And besides - a little burnt biscuit never hurt anyone!”

You know…life is full of imperfect things……and imperfect people. I’m not the best at hardly anything and I forget birthdays and anniversaries just like everyone else. What I’ve learned over the years is that learning to accept each other’s faults – and choosing to celebrate each other’s differences – is one of the most important keys to creating a healthy, growing and lasting relationship. Learn to take the good, the bad and the difficult parts of your life and take them for what they are worth. Because in the end, a burnt biscuit isn’t a deal–breaker! We could extend this to any relationship. In fact, understanding is the base of any relationship, be it a husband–wife or parent–child or friendship!

"Don’t put the key to your happiness in someone else’s pocket…keep it in your own." So please pass me a biscuit and yes…the burnt one will do just fine. Life is too short to wake up with regrets.
Wellness Blog
Artificial sweeteners

Artificial sweeteners like acesulfame, aspartame, saccharin, sucralose give the sweetness of sugar with virtually none of the calories. Most people who use artificial sweeteners or choose foods or beverages made with them do so because they want to lose weight. And for a lot of people, they do help. But some research suggests that the use of artificial sweeteners may actually promote weight gain.

Artificial sweeteners are hundreds to thousands of times sweeter than table sugar. People who use these sweeteners often may desensitize themselves to sweetness. If that happens, they may find healthy but not–so–sweet foods such as fruits and vegetables unappetizing by comparison.

Calories removed from the diet by swapping sugar for sweeteners may re–enter in the form of refined carbohydrates (like those found in crackers, chips, pastries, and the like) and unhealthy saturated and trans fats.
IMA in Social Media
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IMA Videos
Quote of the Day
Happy is the man who can do only one thing; in doing it, he fulfills his destiny. Joseph Joubert
Reader Response
Sir all BAMS and BHMS doctors all over India prescribe allopathy medicine without any fear. We cannot do anything, because we do not have unity as our allopath said. You should see their prescription; from top to bottom they (BAMS, BHMS) only prescribe allopathic medicines: Dr Ashok Gaikwad (Surgeon)
News on Maps
IMA Humor
Good Treatment

Bob went over to his friend Joe’s house and was amazed at how well Joe treated his wife. He often told her how attractive she was, complimented her on her cooking and showered her with hugs and kisses. "Gee," Bob remarked later, "you really make a big fuss over your wife". "I started to appreciate her more about six months ago," Joe said. "It has revived our marriage and we couldn’t be happier."

Inspired, Bob hurried home, hugged his wife and told her how much he loved her and said he wanted to hear all about her day. But she burst into tears. "Honey," Bob said, "what’s the matter?" "This has been the worst day," she replied. "This morning Billy fell off his bike and broke his ankle, then the washing machine broke. Now to top it off, you come home drunk!"
Not notifying TB unethical under MCI Ethics Regulations
As per Municipal Laws and Govt. of India’s Order – “TB is a Notifiable Disease” but over 10 lakh TB patients treated in India every year are not reported to the appropriate authorities.

Indian Medical Association in association with Central TB Division, DGHS, Govt of India has been able to notify 1,04,670 TB patients in the last one year, said Padma Shri Awardee, Dr A Marthanda Pillai, National President IMA, Dr N Appa Rao, National leader and Padma Shri Awardee, Dr K K Aggarwal, Hony. Secretary General, IMA.

Addressing a Press Conference, the IMA experts said that "Not notifying TB is a violation of MCI Code of Medical Ethics Regulations under Sections 5.2 & 7.14 and can lead to suspension of the license of the doctor."

TB and Swine flu spread differently. Swine flu is a droplet infection, while TB is droplet nuclei infection. Infected particles of size more than 5 microns are called droplet infection and of less than 5 microns are called droplet nuclei.

In contrast to larger droplets, airborne droplet nuclei can remain suspended in the air for extended periods, and thus they can be a source of human inhalational exposure to susceptible individuals.

The 3 feet distance rule of swine flu will not prevent TB. The TB bacilli remain in the atmosphere for a longer period and do not settle down on the earth. They may keep on circulating in the room, especially if a split AC is used. Similarly in the car, bus, trains or flights, an open TB patient may keep on infecting others.

Airborne precautions should be used in the care of patients with suspected or confirmed TB.

TB is principally transmitted in hospitals by droplet nuclei; hence, hospital can be a place where TB is transmitted to other patients and healthcare staff.

While prevention of flu requires simple three layered mask, the one for TB prevention requires N95 mask. Individuals entering the room of a patient with known or suspected TB must wear appropriate respiratory protection, an N95 mask. N95 masks filter particles =1 micron in diameter with at least 95 percent efficiency given flow rates up to 50 liters per minute. Patients with known or suspected TB should not wear N95 masks, since they are designed to filter air before it is inhaled. Instead, patients with known or suspected TB who require procedures outside an isolation room should wear a surgical mask; these are designed to prevent the respiratory secretions of the person wearing the mask from entering the environment.

All open TB patients needs to be immediately identified, treated till they become sputum negative and non-infective.

Most TB-positive patients do not disclose their TB status as they fear the associated social stigma and so keep spreading the disease to others. The public needs to be informed that every open sputum case of TB will infect and be responsible for 15 new more cases of TB if not taken care of with early treatment.

IMA has asked the government to come out with a policy, in which sputum-positive TB cases are given paid leave, so that such patients do not hide their illness.

In India 2.1 million new TB cases occur annually and 2,40,000 deaths occur every year due to TB.

All TB patients are not contagious, but those who are, need to be taken care of.

IMA’s fight in TB is not limited to notification of TB cases. IMA has sensitized more than 1 lakh doctors in providing a Standard TB Regimen in accordance with the standard guidelines.

IMA has also initiated 1771 PHIs (Peripheral Health Institutes) where private doctors are linked with the Govt. RNTCP Project through IMA branches.

IMA has appealed to 2.5 lakh doctors of IMA to notify each and every TB patient, the same can be done through IMA Website or through local Municipal Corporation/Appropriate Authority. IMA has also communicated to its members that TB patients should not default during their full course of treatment.

As a part of TB awareness, IMA will be organizing a series of programs for nurses, school/college Principals, TB Rally, medical education programs for doctors and nursing home owners, all-India Medical College TB Slogan contest and release of messages of Padma Awardees etc.

The Campaign will culminate on 7th April with a tableaux, which will roam around in Delhi & NCR to create awareness on TB.

Dr Suresh Gutta, National Coordinator & Dr R V Asokan Chairman Hospital Board of India also addressed the press Conference.
Rabies News (Dr A K Gupta)
What are the signs of rabies in dogs/cats?
  • Any change in normal behavior suggesting either undue aggression or depression.
  • Running aimlessly and attacking others without provocation.
  • Becomes too drowsy and withdraws to a corner.
  • Change in voice/bark.
  • Excessive salivation.
  • Refusal to feed or eating objects like stone, paper, wood, metal pieces etc.