November 14   2015, Saturday

Dr KK AggarwalDr KK Aggarwal Updates in Diabetes

• ARTS-DN: Among patients with diabetic nephropathy, most receiving an angiotensin-converting enzyme inhibitor or an angiotensin receptor blocker, the addition of finerenone, a nonsteroidal mineralocorticoid receptor antagonist, compared with placebo resulted in improvement in the urinary albumin-creatinine ratio. Further trials are needed to compare finerenone with other active medications.(1)

• EMPA-REG OUTCOME: Patients with type 2 diabetes at high risk for cardiovascular events who received empagliflozin, as compared with placebo, had a lower rate of the primary composite cardiovascular outcome and of death from any cause when the study drug was added to standard care. (2)

• Surgery is more effective than medical treatment for the long-term control of obese patients with type 2 diabetes and should be considered in the treatment algorithm of this disease. However, continued monitoring of glycaemic control is warranted because of potential relapse of hyperglycemia. (3)

• TECOS: Among patients with type 2 diabetes and established cardiovascular disease, adding sitagliptin to usual care did not appear to increase the risk of major adverse cardiovascular events, hospitalization for heart failure, or other adverse events. (4)

• In a network meta-analysis in patients with diabetes and hypertension, no BP-lowering strategy prolonged survival in adults with diabetes and kidney disease. ACE inhibitors and ARBs, alone or in combination, were the most effective strategies against end-stage kidney disease. Any benefits of combined ACE inhibitor and ARB treatment need to be balanced against potential harms of hyperkalaemia and acute kidney injury. (5)


1. Bakris GL, et al; Mineralocorticoid Receptor Antagonist Tolerability Study–Diabetic Nephropathy (ARTS-DN) Study Group. Effect of finerenone on albuminuria in patients with diabetic nephropathy: a randomized clinical trial. JAMA. 2015 Sep 1;314(9):884-94.

2. Zinman B, et al; EMPA-REG OUTCOME Investigators. Empagliflozin, Cardiovascular Outcomes, and Mortality in Type 2 Diabetes. N Engl J Med. 2015 Sep 17. (Epub ahead of print)

3. Mingrone G, et al. Bariatric-metabolic surgery versus conventional medical treatment in obese patients with type 2 diabetes: 5 yearfollow-up of an open-label, single-centre, randomised controlled trial. Lancet. 2015 Sep 5;386(9997):964-73.

4. Green JB, et al; TECOS Study Group. Effect of sitagliptin on cardiovascular outcomes in type 2 diabetes. N Engl J Med. 2015 Jul 16;373(3):232-42.

5. Palmer SC, et al. Comparative efficacy and safety of blood pressure-lowering agents in adults with diabetes and kidney disease: anetwork meta-analysis. Lancet. 2015 May 23;385(9982):2047-56.
Mr. Nilesh Aggarwal

We are extremely happy to have been part of IMA Satyagraha campaign and would like to congratulate the Indian doctor community as a whole. We are aiming to be a digital voice of all Indian doctors and will continue to work towards raising such important issues. Currently, we are in our Beta phase and we will soon be introducing features such as interesting cases, online CME's, conference updates etc. Please do register and read eMediNews, eIMANews as well as other engaging content on the website/app. You can also add other doctors to your network, find long lost alumni, chat and discuss cases, post questions for the medical fraternity, create your detailed medical resume and lots more.
Breaking News
New blood cancer drug clears first clinical trial
In the first-in-human trial, researchers from UK examined the efficacy of a new inhibitor, ONO/GS-4059, in the treatment of chronic lymphocytic leukemia and non-Hodgkin lymphoma patients resistant to current chemotherapies. ONO/GS-4059 targets BTK, a protein essential for the survival and proliferation of tumor cells. Ninety patients were enrolled for the study. Patients with chronic lymphocytic leukemia showed the best response and most of them are still on the study after 3 years, and remarkably without notable toxicities… (ET Healthworld – PTI)

New RA guidelines recommend Treat-to-Target strategy

The American College of Rheumatology (ACR) has released an updated set of recommendations for the treatment of rheumatoid arthritis (RA) which have been published in Arthritis & Rheumatology and Arthritis Care & Research. In patients with early disease, the guideline recommends starting treatment with a DMARD (disease-modifying anti-rheumatic drug) monotherapy, preferably with methotrexate, in those who have not previously received a DMARD. But if disease activity remains at a moderate or high level on DMARD monotherapy, either with or without additional steroids, a combination of DMARDs may be given, or a tumor necrosis factor (TNF) inhibitor may be started or a non-TNF biologic may be considered, with or without methotrexate, and “in no particular order of preference”… (Medpage Today)
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Dr Good Dr Bad
Indian Medical Association National Satyagraha for a Healthy India
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Specialty Updates
• Considering the alarming rise in the rates of diabetes worldwide, the International Diabetes Federation has released new data in support of its campaign to convince governments to impose taxes on unhealthy foods — especially sugar-sweetened beverages — and to use the revenues for diabetes-prevention efforts. The full IDF Diabetes Atlas, 7th edition, 2015 will be released December 1 at the IDF's World Diabetes Congress.

• The US Food and Drug Administration (FDA) have approved the addition of cobimetinib to vemurafenib to treat metastatic melanoma that has spread to other parts of the body or cannot be removed surgically and has a mutated BRAF gene.

• People whose parents die when they themselves are less than 18 years of age have a higher lifelong risk of suicide, suggested new research published in JAMA Psychology.

• Researchers at the Washington State University (WSU) in Pullman have developed a way of using electrical stimulation in wound dressing that may serve as an effective alternative to antibiotics. It was noted that when the electrochemical scaffold or e-scaffold was used on a biofilm of the highly multi-drug-resistant Acinetobacter baumannii, it killed nearly all of the microbes within 24 hours. The findings were published in the journal Scientific Reports.

• Intake of gluten up until two years of age increases the risk of celiac disease at least two-fold in children with genetic risk factors for the disease, suggested a study published in Clinical Gastroenterology and Hepatology.

• Elective induction of labor in first-time mothers with an unfavorable cervix increased the rate of cesarean deliveries compared with women who received expectant management; however, the differences were not statistically significant, reported a randomized clinical trial published in the December issue of Obstetrics & Gynecology.

• Six months of aerobic exercise led to increased blood flow in the brain and reduced levels of phosphorylated tau protein levels in cerebrospinal fluid (CSF) in adults with mild cognitive impairment (MCI) and prediabetes, according to findings presented at the 8th Clinical Trials Conference on Alzheimer's Disease.

• A study of American veterans presented at Kidney Week 2015 has shown that in patients with diabetes, there is an association between depression and the risk for cardiovascular disease, kidney disease, and all-cause mortality.
The 3 C’s: Don’t Criticize, Condemn, or Complain!

• Don’t Criticize, always look for positive in a person or a situation. There is always something positive in every situation.

• Don’t Condemn a situation (and a person) howsoever small it may be.

• Don’t Complain, unless it is a must.

You will not do any of the 3 Cs, if you are laughing. By avoiding the 3Cs, we avoid a lot of arguments that would usually naturally occur when you criticize, condemn or complain. If we criticize, condemn, complain, show resentment, or gossip about others, it comes back to "us." If we praise, support, encourage and forgive others, this too comes back to us.
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Legal Quote
State Consumer Disputes Redressal Commission, Kodali Venkateswara Rao vs Saumya Medicare International ... on 19 January, 2010: AP state

“Based on the principles laid down earlier in medical negligence cases the Honble Supreme Court in its recent decision in Martin F.D. Souza Vs. Mohd. Ishfak reported in 2009 Indian Law SC 174 once again made clear that in proof of the allegation of medical negligence it has to be supported by expert evidence, else, the complaint is liable to be dismissed.”
Developing an Investment Portfolio: Coordination with Retirement Plans

Many doctors have over time developed substantial amounts of retirement assets. In developing an investment portfolio, these assets must be an integral part of the overall design. Current assets and retirement assets need to be considered together.

(Source: IJCP)

22nd MTNL Perfect Health Mela, the annual flagship event of the Heart Care Foundation of India
Controlling diabetes: Tax sugar to fight obesity, say experts

Diabetes experts called on world leaders on Thursday to use sugar taxes to fight obesity, arguing such a move would save lives and slash healthcare budgets. Ahead of a meeting of G20 leaders, the International Diabetes Federation (IDF) wants the dual epidemics of obesity and diabetes to be placed on the global agenda alongside major geopolitical and financial issues. With one death every six seconds, diabetes is now a bigger killer than HIV , tuberculosis and malaria combined. The IDF estimates that most countries spend between five and 20% of their healthcare budget on the disease. Type-II diabetes, which is closely linked to obesity and sedentary lifestyles, accounts for approximately 90% of cases and is rising fast, particularly in developing economies where people are shifting to Western diets. The largest number of diabetics in the world now live in China… (ET Healthworld - Reuters)
Obese kids as young as 8 show signs of heart disease

Miami: Some obese children as young as eight show significant signs of heart disease, according to research presented at the recently concluded American Heart Association's Scientific Sessions in Orlando, Florida. Researchers compared 20 obese children and teenagers to 20 normal weight peers, and found that 40% of the obese children were considered at high-risk for heart disease because of thickened heart muscle which can interfere with the muscle's pumping ability. Overall, obesity was linked to 27% more muscle mass in the left ventricle of their hearts and 12% thicker heart muscles -- both signs of heart disease. Researchers warn that heart problems in youth may lead to even more severe disease in adulthood, and a higher likelihood of dying prematurely… (ET Healthworld – AFP)
Hypertension, respiratory issues among major health problems in India
One of the largest and first-of-its kind studies to assess ‘What Ails India’ has found that fever is the most common reason that leads patients to visit doctors. The study, based on analyses of 5,54,146 ailments reported in 2,04,912 patients’ visits has also revealed that hypertension is the most common diagnosis reported by physicians in India. This apart, respiratory problems are another major reason for visits to doctors. Other findings were that not all the sick visit a doctor, which means the burden of sick people in India is much higher. More males visited a doctor than females and this difference was greater in the pediatric age group, suggesting gender bias. Only 8% of the patients who visited a doctor were aged over 65, suggesting that old people do not visit a doctor as much as they should.… (The Indian Express)
Measles vaccination has saved an estimated 17.1 million lives since 2000
The number of measles-related deaths has decreased 79% from 546 800 at the beginning of the century to 114 900 in 2014. New data released by WHO for the Measles & Rubella Initiative, estimates that 17.1 million lives have been saved since 2000, largely due to increased vaccination coverage against this highly contagious viral disease. Measles vaccination has played a key role in reducing child mortality and in progress towards Millennium Development Goal 4. However, the new data published in this week’s edition of the Centers for Disease Control and Prevention's (CDC), "Morbidity and Mortality Weekly Report" and WHO’s "Weekly Epidemiological Record", shows that overall progress towards increasing global immunization coverage has recently stagnated. While coverage with the first dose of the measles vaccine increased globally from 72% to 85% between 2000 and 2010, it has remained unchanged the past 4 years... (WHO)
Gaining weight losing strength versus losing weight gaining strength

When we gain weight, we must acquire more strength and when we lose weight, we must lose the strength. This is a fundamental principle. If we gain weight and feel weak, it is a disease and when we lose weight and gain strength, we are recovering from the disease. One should not gain more than 5kg of weight after the age of 20 years. Any weight gain after that will only be due to accumulation of fat, which leads to insulin resistance. Insulin resistance does not allow food to convert into energy. In the state of insulin resistance, whatever you eat is converted into fat. As it is not converted into energy, you feel weak. When you reduce insulin resistance by drugs or walking, the metabolism becomes normal and whatever you eat gets converted into energy and you start gaining strength.
Bioethical issues in medical practice
Rights and duties of a parent

Smita N Deshpande

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

A girl suffering from intellectual disability, serious enough so that she could not take care of herself became pregnant at the care home. By the time the pregnancy was discovered she was pregnant for over four months. The girl was admitted to a government hospital and assessed for MTP. The girl insisted- from the point of view of her limited understanding of the matter- that she wanted to keep the child and bring it up herself. Doctors at the hospital where she was admitted after the pregnancy was discovered were of the opinion that she was intellectually unfit to look after herself, what to say of a child. What should the doctors do?

a) Carry out MTP regardless of the girl’s wishes

b) Allow the pregnancy to continue possibly to the future detriment of the unborn baby.

c) Any other recourse such as going to court – but what if the court orders continuance of the pregnancy? Who will look after the baby?

Do write in with views and your solutions!

Responses received

• The pregnancy should be allowed to be continued. Efforts should be made to find out the father. He should be compelled to take care of the child and in case he is unable to take care of, he should be prosecuted for rape and child be sent to some social organisation along with the mother. Dr BR Bhatnagar
Inspirational Story
Trust Your Relationship

When you've seen a couple fight or having a pity argument, what is the first thing that comes in your mind?

Probably you think that you will never allow arguments to set in your relationship (especially when you get married), or will never think to start one, but arguments seem to come naturally. You argue about the brand of coffee, or what to eat at lunch, who will do the dishes, etc. Sometimes, more than that, but regardless of your reasons for the argument (or fight), patching up a troubled relationship and having a solution is very important.

Second to God, our partners are a believer's most valuable asset. Companions provide a listening ear for our troubles, support for our dreams, and a safety net when we fall. They give us love, even when we are unlovable. They are and must be our friends. Inevitably, though, sometimes we go through troubled periods and a solution should be sought through the following steps:

1. Address the situation. Acknowledge to your partner that something is amiss and needs to be fixed.

2. Determine the problem. Together, discuss where the relationship veered off course and what wrongs may have been spoken or committed. Be honest and let your honesty be in its proper place. Remember, you are talking to your partner, another half of yourself.

3. Apologize. As believers we accept responsibility for our actions and seek forgiveness.

4. Refuse to blame. In addition, we must avoid defending ourselves. There could be a temptation to argue over who did what; however, the goal is not proving who is right but saving the relationship.

5. Begin repairs. Ask, "What can I do to rebuild our closeness?" The key here is to do willingly whatever is requested.

6. Commit to rebuilding. Immediately start investing your time, energy, and love in restoring the relationship.

In order to have the blessing of a good relationship, with a partner who accepts and loves us, we must be willing to pay the high price of patching things up. Walking away might seem easier, but in the long run, we would lose a valuable treasure.
eMedi Quiz
High resolution computed tomography of the chest is the ideal modality for evaluating:

1. Pleural effusion.
2. Interstitial lung disease.
3. Lung mass.
4. Mediastinal adenopathy.

Yesterday’s Mind Teaser:  All of the following conditions may predispose to pulmonary embolism except:

1. Protein S deficiency.
2. Malignancy.
3. Obesity.
4. Progesterone therapy.

Answer for Yesterday’s Mind Teaser: 4. Progesterone therapy.

Answers received from: B R Bhatnagar, Dr P K Sasidharan, Dr Bitaan Sen & Dr Jayashree Sen, Dr Avtar Krishan, Dr Poonam Chablani.

Answer for 12th November Mind Teaser: 2. Sympathetic ophthalmia.

Answers received from: Dr K Raju, Dr J Daivadheenam, Dr B R Bhatnagar, Dr Avtar Krishan.
A doctor of psychology was doing his normal morning rounds, and he entered a patient’s room to find his patient sitting on the floor, sawing at a piece of wood with the side of his hand. Meanwhile, another patient was in the room, hanging from the ceiling by his feet. The doctor asked his patient what he was doing, sitting on the floor.

The patient replied in an irritated fashion, "Can’t you see I’m sawing this piece of wood in half?" The doctor inquired, "And what is the fellow hanging from the ceiling doing?" "Oh. He’s my friend, but he’s a little crazy. He thinks he’s a light bulb."

The doctor asks, "If he’s your friend, don’t you think you should get him down from there before he hurts himself?" "What? And I work in the dark!?!"
Readers column
Dear Sir, Very informative newspaper. Regards: Dr Kartik
Press Release
Ministry of Health orders a special working committee to evaluate the five demands put forward by IMA towards the increasing violence against doctors

Committee to submit its report and recommendations within six weeks

This marks a historical day for team IMA which has over the past one-month managed to get over 50,000 signatures in support of its Satyagraha

National IMA has been perusing five community oriented demands including reducing violence against the medical fraternity for over a year now. In this direction, they delivered a notice to the Prime Minister, Union Health Minister, Minister of Consumer Affairs, Home Minister and Union Law Minister disclosing their plan to observe a Satyagraha on November 16th. They also partnered with eMediNexus, a social networking platform for doctors, to initiate a petition in support of their demands. The petition garnered signatures of over 50,000 doctors in its support.

A live webcast was also organized by IMA hosted on eMediNexus with the Attorney General of India – Mr. Mukul Rohatgi to discuss the ideal approach to the situation in hand. He recommended that a comprehensive plea be made to all ministries including health, home, consumer, and law.

In a historic move, the Ministry of health represented by Shri Jagat Prakash Nadda, met with the IMA leaders earlier this week and ordered the formation of a special time-bound working committee to evaluate the five-point demands put forth by the Indian Medical Association. He in his letter stated that the committee would study all the suggestions and amendments given by Indian Medical Association on all five issues and submit a report within six weeks. The ministry will then expeditiously act on the suggestions and amendments.

The committee formed will consist of the Additional Secretary Health, Joint Secretary Law, Joint Secretary Home, Joint Secretary Home, and Joint Secretary Consumer Affairs. In addition to this, the committee will have three representatives of IMA and one from MCI.

Speaking on the achievement, 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, “This is a victory for Team IMA for this is the first time in the history of the association’s functioning that an inter-ministerial committee has been formed to look into its demands. Taking into consideration of the above facts and sequences Team IMA is postponing the Satyagraha from November 16th. We thank all those who signed our petition in support of the cause and hope that together we can bring about the necessary amendments needed to safeguard the nobility of the medical profession in India.”

Supporting the initiative, founders of eMediNexus, Mr. Nilesh Aggarwal and Mr. Amit Sharma in a joint statement said, "We are extremely happy to have been part of this campaign and would like to congratulate the Indian doctor community as a whole on this achievement. We hope that we can help be the consolidated voice of the medical fraternity in the future as well”.

The five issues put forward by the Indian Medical Association on grounds that they are causing disaffection amongst the fraternity of doctors include:

1) Frequent instances of assault on doctors and clinical establishments across the country and the need for a Central Hospital and Medical Doctors’ Protection Act

2) Urgent amendments in the PCPNDT Act to ensure that strict penalties are imposed only on the actual act of sex determination and female foeticide and not for clinical errors in the maintenance of registers etc. The IMA is also of the view that registration should be of ultrasound machines and not of doctors not providing pelvic ultrasound.

3) Single doctors establishments should be exempted from the purview of the Clinical Establishments Act and the need for pre-registration inspection may not be there for those clinical establishments, which already have entry level NABH accreditation, and above

4) Suitable amendments must be made in the Consumer Protection Act for capping the compensation amount as the current compensation practice, apart from being very high at times, is also tilted in favor of those with higher incomes

5) The non- MBBS and non-BDS doctors should not be allowed to prescribe medicines under the modern system of medicine (scheduled H, H1, X) and the other stream practitioners like AYUSH doctors, etc. should not be allowed to practice through bridge courses and through government orders

The IMA also suggested that the budgetary allocation for health should be increased to 5% of GDP