December 19   2015, Saturday

Dr KK AggarwalDr KK Aggarwal Choosing Wisely Recommendations for Hematologists

1. Don’t image for suspected pulmonary embolism (PE) without moderate or high pretest probability of PE (from the American College of Radiology)

2. Don’t routinely order thrombophilia testing on patients undergoing a routine infertility evaluation (from the American Society for Reproductive Medicine)

3. Don’t perform repetitive complete blood count and chemistry testing in the face of clinical and lab stability (from the Society for Hospital Medicine – Adult Hospital Medicine)

4. Don’t transfuse red blood cells for iron deficiency without hemodynamic instability (from the American Association of Blood Banks)

5. Avoid using PET or PET–CT scanning as part of routine follow–up care to monitor for a cancer recurrence in asymptomatic patients who have finished initial treatment to eliminate the cancer unless there is high–level evidence that such imaging will change the outcome (from the American Society of Clinical Oncology)

American Society of Hematology (ASH) 57th Annual Meeting. Presented December 7, 2015.

Breaking News

Ovarian cancer screening can reduce mortality rate

Ovarian cancer tends to be diagnosed at an advanced stage, with 60% of patients dying within 5 years. The United Kingdom Collaborative Trial of Ovarian Cancer Screening (UKCTOCS), one of the largest ever randomized trials hypothesized that ovarian cancer screening in the general population can reduce disease mortality without significant harm. According to the results of the trial published in The Lancet, ovarian cancer screening may reduce the number of deaths from the disease by 20% after follow–up of up to 14 years. Further follow–up in UKCTOCS will provide greater confidence about the precise reduction in mortality which is achievable. It is possible that the mortality reduction after follow–up for an additional 2–3 years will be greater or less than these initial estimates.”

Most cancer cases ‘caused by lifestyle, environment – not bad luck’
A study published in the journal Science in January, had suggested that the majority of cancer cases are down to "bad luck." In that study, Johns Hopkins researchers claimed 65% of cancer cases are a result of random DNA mutations, while the remaining 35% of cancer cases are explained by a combination of these mutations and environmental and hereditary factors. According to new research published in the journal Nature overall findings indicate that lifestyle and environmental factors account for around 70–90% of cancer cases, while intrinsic factors account for around 10–30% – findings that highly contradict those of the Science study.
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Specialty Updates
• Patients with chronic heart failure (CHF) are likely to have intestinal overgrowth of pathogenic gut flora and permeability that is associated with disease severity, suggests new research published online in JACC: Heart Failure.

• Updated guidelines by the Infectious Diseases Society of America (IDSA), published in the journal Clinical Infectious Diseases, recommend that candidiasis - a serious, life-threatening fungal infection - needs to be treated early, aggressively and appropriately. The guidelines recommend a shift from fluconazole to echinocandins for the initial treatment of invasive infections.

• Women with type 2 diabetes have a higher risk for vascular dementia than men with diabetes, reported a new meta-analysis published in Diabetes Care.

• The brains of children who suffer clinical depression as preschoolers develop abnormally, compared with the brains of preschoolers unaffected by the disorder, suggested new research published December 16 in JAMA Psychiatry.

• Laparoscopic liver resection (LLR) is associated with fewer complications and shorter hospital stay, with no increase in mortality, compared with open liver resection (OLR), reported a systematic review of more than 9,000 LLR cases and 2,900 OLR cases worldwide. The findings are published online in Annals of Surgery.

• Previous studies have linked obesity with persistent sleepiness, lack of energy during the day, and poor sleep quality. Now, a new study, published in the journal Sleep, has suggested that weight loss due to dietary changes can improve sleepiness at any weight.

• A uniquely acting antiplatelet agent, PZ-128, appears to be safe and fast for preventing blood clots and its effects are reversible, reducing the risk for excessive bleeding, suggested new research published in Arteriosclerosis, Thrombosis and Vascular Biology. The drug helps prevent dangerous clotting in patients undergoing angioplasty and other such cardiac procedures.

• To prevent preeclampsia, new research suggests that low-dose aspirin should be given prophylactically to all women at high risk - those with diabetes or chronic hypertension - and any woman with two or more moderate risk factors - including obesity, multiple gestation and advanced maternal age. The report is published in the December 2015 edition of Obstetrics & Gynecology.
Is time and place of death pre–defined?

Some gurus teach us that the time and place of death is predefined and some do not. I personally feel that it is life and respiration that are predefined and not the day and time of death.

The following example can help understand this. Water in a sponge will become empty when every drop of water comes out but it does not matter how much time it takes to come out. It is therefore possible to postpone or prolong the fulfillment of Prarabhdha Karma and postpone death.

As per the Karma theory, unless our Prarabdha Karmas (decided at the time of death and birth) are enjoyed and fulfilled, one cannot die. But once the Prarabhdha Karmas are fulfilled, death is inevitable.

Another unanswered question is ‘can Prarabdha karma be modified’? Fate or destiny may not change, which means one may not be able to prolong the quantity of life but can definitely change the quality of life. The quality of life can be changed by modifying Agami karmas (present Karmas).

Sanchit Karmas can be burnt with the file of knowledge about self. Prarabdha Karmas have to be experienced and Agami Karma can be neutralized by positive and negative Karmas to Zero in the present life.

The last few Prarabdha Karma experienced can thus be slowed down by the net positive result of their Agami karmas.
Legal Quote
Samira Kohli vs. Prabha Manchanda Dr. & ANR. 1(2008)CPJ 56 (SC

"The ’adequate information’ to be furnished by the doctor (or a member of his team) who treats the patient, should enable the patient to make a balanced judgment as to whether he should submit himself to the particular treatment as to whether he should submit himself to the particular treatment or not . "
Use of social media in nephrology education and research

Dr Om Kumar, Patna

• SONNET (Social media in nephrology education and training): Randomized study to see if bringing social media into a nephrology fellowship improves educational outcomes. The trial includes all nephrology fellows joining in the first year of their nephrology training in North America.

• Critical message: Rules of offline behavior apply to online behavior where there is much wider audience.

• Errors will occur: Develop a social media policy -provide orientation and training. View mistakes as learning opportunities.

• There is great power in the conversation. Know the risks and behave accordingly. Do not be so risk averse that you do not participate

• Social media has potential to promote individual and public health

• Will facilitate professional development and advancement.

• Various platforms of Social media have facilitated patient care in many ways and has potential to transform the delivery of newer age medicine with greater efficiency.

• We need to abide by the ethical and professional commitments for the best use of social media.

A case of systemic sclerosis with severe HT

Dr K Praveen Kumar

• Scleroderma renal crisis (SRC), interstitial fibrosis and glomerulonephritis all occur in scleroderma.

• SRC requires prompt diagnosis and treatment with ACEIss.

• Renal biopsy confirms diagnosis and provides critical insight into pathogenesis.

• Endothelin is a logical potential target for therapy in renal scleroderma.

Dr Soumita Bagchi
New Delhi

Management of antibody mediated rejection

• AMR can develop any time after transplant.

• Management of AMR begins before transplant by screening.

• Types of AMR: Hyperacute rejection ? Acute/active AMR ? Chronic AMR ? Accommodation

• What you do may not always be ideal; it depends on lab, immunologist, if available.

• Diagnosis and screening strategies are still evolving: According to the risk profile, ?Non HLA antibodies/?Complement fixing antibodies, ?Frequency of monitoring, ?Protocol biopsy

• Treatment of AMR has evolved in a targeted fashion base on pathogenesis.

• No consensus on optimum treatment protocol.

• Sensitization is not always a contraindication for transplantation.

• Late and chronic AMR have poor outcome; no consensus on how aggressively it should be treated.

• Evidence for all therapies is low to very low; all are off label use; none are FDA approved.

• No reported studies till date directly comparing plasma exchange with IADS in terms of efficacy and safety for treatment of AMR

• Rituximab: Attractive proposition, may be too slow to act in a serious setting, high risk of serious infections; RITUX ERAH – game changing trial for rituximab, no additional benefit of adding rituximab to a regime of steroids, plasmapheresis, IVIg

• Bortezomib: More effective before the onset of significant renal dysfunction (serum creatinine >3 mg/dL) or proteinuria (>1 g/day) (Transplantation 2010;90:1486)

• Rescue therapy: Splenectomy for resistant cases; complement inhibition (flavor of the season)

• Barriers to treatment: Cost of therapy and risk of infection.
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22nd MTNL Perfect Health Mela, the annual flagship event of the Heart Care Foundation of India
Bioethical issues in medical practice
Protecting the privacy and confidentiality of patients

Smita N Deshpande
Head, Dept. of Psychiatry, De–addiction Services
PGIMER-Dr. Ram Manohar Lohia Hospital
Park Street, New Delhi

You are a member of an informal discussion group of doctors who meet regularly to discuss difficult cases. At all these discussions, the conversation is frank and detailed, with all details of the patients, social situation, family issues etc. are discussed threadbare. Sometimes this discussion spills over into the hospital lifts, corridors and canteens. When these issues are really interesting, you discuss them at home with your spouse– a doctor– as well. Many times the name, address, and other details of patients are discussed as well.

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

Any suggestions? Do write in!

Adapted from: Bioethics Case Studies (AUSN and EEI, November 2013):

Responses received

Medical discussions of difficult cases are very important from the doctor’s point of view and also from the patient’s point of view. They should definitely be discussed at home, in medical get-togethers, but not in lifts, hotels and public places. Medical science is based on discussions and exploration of the knowledge what one has. Dr BR Bhatnagar
Is Caffeine Good For The Health?

• Caffeine is the most consumed stimulant in the world,
• It is consumed in the form of coffee and tea.
• At present there is no scientific data for promoting or discouraging coffee and/or tea consumption in the daily diet.
• Short term benefits include mental alertness and improved athletic performance.
• Short term adverse effects including headache, anxiety, tremors, and insomnia.
• Long term adverse affects include generalized anxiety disorder and substance abuse disorders.
• Long–term benefits are dose–dependent. Caffeine is associated with a reduced risk of Parkinson disease, Alzheimer disease, alcoholic cirrhosis, and gout. Both caffeinated and decaffeinated coffee are also associated with a lower risk of type 2 diabetes.
• Heavy coffee intake may trigger coronary and arrhythmic events in susceptible individuals, although coffee intake is not considered a long–term risk factor for myocardial disease.
• Most studies show a modest inverse relationship between coffee consumption and all–cause mortality. Caffeine withdrawal is a well–documented clinical syndrome with headache being the most common symptom. (Source: Uptodate)
WP(C) No.8706/2015 titled “Indian Medical Association Vs. Union of India & Anr (NCERT)” Delhi High Court, New Delhi

Click here to read the proposed changes
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Inspirational Story
The Rebellion against the Stomach

Once a man had a dream in which his hands and feet and mouth and brain all began to rebel against his stomach.

"You good–for–nothing sluggard!" the hands said. "We work all day long, sawing and hammering and lifting and carrying. By evening we’re covered with blisters and scratches, and our joints ache, and we’re covered with dirt. And meanwhile you just sit there, hogging all the food."

"We agree!" cried the feet. "Think how sore we get, walking back and forth all day long. And you just stuff yourself full, you greedy pig, so that you’re that much heavier to carry about."

"That’s right!" whined the mouth. "Where do you think all that food you love comes from? I’m the one who has to chew it all up, and as soon as I’m finished you suck it all down for yourself. Do you call that fair?"

"And what about me?" called the brain. "Do you think its easy being up here, having to think about where your next meal is going to come from? And yet I get nothing at all for my pains." And one by one the parts of the body joined the complaint against the stomach, which didn’t say anything at all.

"I have an idea," the brain finally announced. "Let’s all rebel against the lazy belly, and stop working for it." "Superb idea!" all the other members and organs agreed. "We’ll teach you how important we are, you pig. Then maybe you'll do a little work of your own."

So they all stopped working. The hands refused to do lifting and carrying. The feet refused to walk. The mouth promised not to chew or swallow a single bite. And the brain swore it wouldn’t come up with any more bright ideas. At first the stomach growled a bit, as it always did when it was hungry. But after a while it was quiet.

Then, to the dreaming man’s surprise, he found he could not walk. He could not grasp anything in his hand. He could not even open his mouth. And he suddenly began to feel rather ill. The dream seemed to go on for several days. As each day passed, the man felt worse and worse. "This rebellion had better not last much longer," he thought to himself, "or I’ll starve."

Meanwhile, the hands and feet and mouth and brain just lay there, getting weaker and weaker. At first they roused themselves just enough to taunt the stomach every once in a while, but before long they didn't even have the energy for that.

Finally the man heard a faint voice coming from the direction of his feet. "It could be that we were wrong," they were saying. "We suppose the stomach might have been working in own way all along." "I was just thinking the same thing," murmured the brain. "It’s true that he's been getting all the food. But it seems he's been sending most of it right back to us."

"We might as well admit our error," the mouth said. "The stomach has just as much work to do as the hands and feet and brain and teeth." "Then let’s get back to work," they cried together. And at that the man woke up.

To his relief, he discovered his feet could walk again. His hands could grasp, his mouth could chew, and his brain could now think clearly. He began to feel much better.

"Well, there’s a lesson for me," he thought as he filled his stomach at breakfast. "Either we all work together, or nothing works at all."
Formation of antibody against acetyl choline receptor in pemphigus can be explained by

a. desmoglein compensation theory
b. antibody excess prozone phenomenon
c. anti idiptypic
d. epitope spreading phenomenon

Yesterday’s Mind Teaser: The exaggerated lepromin test seen in cases of lucin phenomenon is known as

a. mitsuda’s reactionion
b. medina ramirez reaction
c. fischer’s test
d. fernandez reacto

Answer for Yesterday’s Mind Teaser: b. medina ramirez reaction

Answers received from: Dr Poonam Chablani, Dr.Bitaan Sen & Dr.Jayashree Sen, Dr Jainendra Upadhyay, Dr.K.Raju, Daivadheenam Jella, Dr.K.V.Sarma

Answer for 15th December Mind Teaser: c. Nail psoriasis

Answers received from: Dr Jainendra Upadhyay, Daivadheenam Jella, VISWANATHA SARMA, Dr.K.Raju, Dr Avtar Krishan
Readers column
Dear Sir, Very informative news. Regards: Dr Karan
Getting rid of the problem

A farmhand is driving around the farm, checking the fences. After a few minutes he radios his boss and says, "Boss, I’ve got a problem. I hit a pig on the road and he’s stuck in the bull–bars of my truck. He’s still wriggling. What should I do?"

"In the back of your truck there’s a shotgun. Shoot the pig in the head and when it stops wriggling you can pull it out and throw it in a bush." The farm worker says okay and signs off. About 10 minutes later he radios back. "Boss I did what you said, I shot the pig and dragged it out and threw it in a bush.”

”So what’s the problem now?” his Boss snapped.

”The blue light on his motorcycle is still flashing!”
Press Release
Winters may be the cause of your raised cholesterol levels

Blood lipid levels may exhibit mild seasonal variation with a peak in total cholesterol level in the winter and a drop in the summer. The variation can be up to 5 mg/dL.

Speaking about the importance of keeping cholesterol levels under control, Padma Shri Awardee Dr. A Marthanda Pillai – National President and Padma Shri Awardee Dr. KK Aggarwal – Honorary Secretary General IMA in a joint statement said, "Blood cholesterol levels are closely related to increased risks of getting heart disease. The higher your blood cholesterol level, the greater your risk for developing heart disease or having a heart attack. Heart disease is one of the leading killers of women and men in the India. For every 10% drop in your cholesterol level, your heart attack risk falls by 20% to 30%. It is thus important to raise awareness about detection of high cholesterol, management and prevention."

Serum total and HDL–cholesterol can be measured in fasting or non–fasting individuals. There are only small clinically insignificant differences in these values when measured in the fasting or non–fasting state.

The total cholesterol can vary by 4 to 11 percent within an individual due to multiple factors including stress, minor illness and posture. Values may also vary between different laboratories, with data suggesting that a single measurement of serum cholesterol can vary as much as 14 percent. Therefore in an individual with "true" serum cholesterol concentration of 200 mg/dL the range of expected values is 172 to 228 mg/dL. More than one measurement of total cholesterol should therefore be obtained when treatment considerations demand a precise determination. Measurement of serum HDL–C and triglycerides may demonstrate even greater variability.

A standard serum lipid profile consists of total cholesterol, triglycerides, and HDL–cholesterol. Lipid profile should be performed after 12 to 14 hours of fasting to minimize the influence of postprandial hyperlipidemia. One can use either a plasma or serum specimen can be used. The serum cholesterol is approximately 3 percent lower than the plasma value.

A few ways in which people can keep their cholesterol levels in control this winter include:

Choose healthy fats. Avoid saturated fats, which increase unhealthy LDL levels, and steer clear of trans fats, which both raise LDL and lower protective HDL. Instead, substitute healthier unsaturated fats found in fish, nuts, and vegetable oils.

Go with whole grains. Whole–grain breads, pastas, and cereals help prevent a blood sugar roller coaster and make you feel full longer. Many of these foods contain fiber, which can help lower LDL levels.

Make other healthy choices. Eat more fruits and vegetables. Ideally, substitute these for processed foods and sweets. Choose fat–free milk instead of whole milk. Opt for low–fat yogurt and pick brands that are not loaded with sugar.