December 27   2015, Sunday
Dr KK AggarwalDr KK Aggarwal Revisiting Cardiology 2015 (Contd.)

• The EMPA-REG Outcome trial has been hailed as a landmark trial because it's the first time a drug for diabetes, empagliflozin (a sodium glucose cotransporter-2 (SGLT-2) inhibitor), has lowered death rates in patients with type 2 diabetes. However, the FDA has issued a warning about ketoacidosis and bone fractures with these drugs and the mechanism as to how this drug lowers mortality is not known.

• Idarucizumab (Praxbind, Boehringer Ingelheim), the dabigatran reversal agent received FDA approval in October.

• Andexanet alfa, the factor Xa reversal agent safely reversed the anticoagulant effect of apixaban and rivaroxaban in older volunteers (November issue of New England Journal of Medicine).

• A wireless revolution in cardiac pacing began this year with both the NanoStim LP leadless pacemaker (St Jude Medical) and the Micra TPS (Medtronic) performed well. Both devices have earned CE Mark in Europe, and FDA approval is likely.

• Five clinical trials demonstrated clear benefit for the use of endovascular treatments alone or as an add-on to tPA in patients who present with acute stroke.

• Periprocedural bridging in patients taking anticoagulants resulted in higher bleeding rates and no lowering in thrombotic events. But, the BRIDGE trial researchers excluded high-risk patients with mechanical valves and previous stroke. So we don't know the answer for these patients. For most, though, less is clearly more. (Medscape)
Breaking News

Study links tooth loss to stroke and cardiac death

Findings from the Stabilization of Atherosclerotic Plaque by Initiation of Darapladib Therapy (STABILITY), a 4-year international observational study, suggest that increasing degrees of self-reported tooth loss—a surrogate for periodontal disease—was linked with a higher likelihood of adverse cardiac outcomes. Every increase in five levels of greater tooth loss predicted a 6% increased risk of the primary outcome—a major adverse cardiovascular event (MACE), a composite of cardiovascular death, nonfatal MI, and nonfatal stroke. However, when researchers looked deeper, every worse level of tooth loss was associated with a 17% increase in risk of cardiovascular death and a 14% increase in stroke, but there was no increased risk of MI. The study published December 17, 2015 in the European Journal of Preventive Cardiology by Dr Ola Vedin (Uppsala University, Sweden) and colleagues, included more than 15,000 patients with prior MI, prior revascularization, or multivessel coronary heart disease… (Medscape)

The national essential drugs list revised

India has revised its list of essential medicines to add drugs for diseases ranging from cancer and HIV/AIDS to hepatitis C, in a move aimed at making them more affordable. The update to the National List of Essential Medicines (NLEM) is just the third since it was compiled in 1996. It increased the list to 376 medicines from 348 and includes drugs ranging from analgesics and antivirals to contraceptives, cardiovascular and anti-tuberculosis drugs… (ET Healthworld)
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Specialty Updates
• Fibroblast growth factor 21 (FGF21), a hormone derived from the liver, can prevent overconsumption of sugar, suggest two new studies published in Cell Metabolism.

• An article, published recently in the SIAM Journal on Applied Mathematics, introduces a new mathematical model which offers a simplified approach to studying the spread of the infectious virus, Dengue fever, in urban areas, specifically breaking down the epidemic dynamics across a city and its varying neighborhoods and populations. The model is important for studying how varying neighborhood conditions affect the spread of Dengue fever and how to contain it.

• Patients with stable angina taking the heart-rate reducing drug ivabradine had similar self-reported physical limitation scores as patients taking placebo, but better quality of life on other measures, suggested a substudy of the SIGNIFY trial published online in the journal Circulation: Cardiovascular Quality and Outcomes.

• Low aerobic fitness during late adolescence increases the risk for early death, reported a study published online in the International Journal of Epidemiology.

• Immune cells - resident memory T cells - known to fight the flu in mice may also help fight RSV, a virus that is one of the main causes of the common cold in humans, suggested a new study published in the journal Nature Communications. Researchers noted that people with high levels of these cells appear less likely to show symptoms of RSV infection.

• Non-steroidal anti-inflammatory drugs (NSAIDs) were safe and worked as well as opiates for managing pain from chest tube insertion and pleurodesis due to malignant pleural effusion, suggests new research published in the Journal of the American Medical Association.

• Active and passive exposure to tobacco may increase the risk for infertility and lower the age of natural menopause, reported a study published online in Tobacco Control.

• A recent study of elderly men, published in the Annals of the American Thoracic Society, found no evidence that obstructive sleep apnea (OSA) increased in severity (or prevalence) as a result of vitamin D deficiency.

• On a population level, universal new born hearing screening (UNHS) has led to improved language outcomes at school age, reported an Australian study scheduled for online publication in Pediatrics.

• Two studies and an editorial, published online in JAMA Dermatology, identified the relationship between skin disorders and endocrine diseases. While the first study revealed that the prevalence of insulin resistance was higher among the men with acne compared with the healthy control patients, the second study found that 91.7% women who met the criteria for PCOS had at least one skin finding.
The spiritual meaning of the word ‘Artha’

Dharma, Artha, Kama and Moksha are the four fundamental principles of our very existence which means earning righteously with a desire to fulfill the inner happiness. Righteous earning is called ‘Artha’ and mistakenly it has been linked to materialistic money. In mythology, Artha is synonymous with Lakshmi, Saraswati and Kali where Lakshmi represents righteously earned materialistic wealth, Saraswati represents wealth of knowledge and Kali represents wealth of wisdom to fight the bad in you and in the society. In any country, it is the wealth of knowledge, which is more important. India was ruled initially by warriors (Kali), later by money (Lakshmi) and in future will be ruled by knowledge (Saraswati). It is the human resources, which today decide the growth of a company and the amount of money invested. If you have good human resources, your company is going to succeed.
Legal Quote
V. N. Shrikhande vs Anita Sena Fernandes on 20 October, 2010 Civil Appeal No.8983 of 2010

“… the District Forum, the State Commission and the National Commission are not bound to admit each and every complaint.”
The switch from trivalent to bivalent oral polio vaccine

18th December, 2015

Role of DCG(I)/CDSCO /State Drug Controller

• Ensure bOPV supplies in open market 2 weeks prior to switch date and withdrawal of tPOV from open market after switch.
• Share list of suppliers of tOPV and bOPV in private market.
• Sensitize the manufacturers on switch including timelines, overlap period of tOPV and bOPV, etc.
• All existing license for tOPV to be modified/cancelled to ensure that tOPV should not be supplied for use post switch except in exigency condition as and directed by the MoHFW.
• Initiate communications with State and District drug controllers to
o Ensure availability of bOPV 2 weeks prior to switch and secondary packaging of bOPV not to be opened before switch date.
o Recall of tOPV immediate after switch from open market and destroy.
o Monitor switch in private OPV supply chain
• Role of Clearing & Forwarding agents (CFA) critical in private setup
IMA Digital TV
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The Year in Medicine 2015: News That Made a Difference
The first direct-to-consumer genetic test gets FDA go-ahead

The FDA agreed to let 23andMe sell directly to consumers a test designed to identify healthy people who carry a gene that could cause Bloom syndrome. People can order the test, which they can use at home. The approval is a significant shift for the agency. In 2013, the FDA sent 23andMe a warning letter directing the company to stop selling a personal genome service. The letter said the company had not obtained proper approval or demonstrated that their tests were accurate and clinically meaningful… (Medscape)
Mandrola's Top 10 Cardiology Stories 2015
Interventional breakthrough not in the heart but in the brain

Five clinical trials have demonstrated clear benefit for the use of endovascular treatments alone or as an add-on to tPA in patients who present with acute stroke. The numbers needed to prevent major long-term disability were consistently less than 10. Previous studies of endovascular therapy in patients with acute stroke had not shown benefit. The difference in the newer studies: faster interventions, newer-generation retrievable stents, and inclusion of patients with documented occlusion of a major vessel… (Medscape)
Indian Heart Journal: The Year in Review 2015

Prof Sundeep Mishra
Hony Editor
Indian Heart Journal

Controversy No 10: Can we depend on Western CVS Risk Calculator for Indian patients?

Controversy No 9: Is Bivalirudin still useful in patients undergoing PCI? and

Controversy No 8: Is Wilkins Score to predict outcome of BMV still relevant? and

Controversy No 7: Do we need to change our Medical Curriculum?

Controversy No 6: Can BVS be implanted in left main bifurcation lesion?

Controversy No 5: Should we look beyond LDL-c in Indians and develop drugs for non-LDL-c lipid parameters? and

Controversy No 4: Can we accept the Western Guidelines like gospel truth or do we need to develop our own guidelines?

Controversy No 3: Can we do PCI as a day-care procedure?

Controversy Number 2: Should we choose cutting edge techniques in bypass surgery or should we stick to a more practical approach in CABG? and

Controversy Number 1: Should we continue using Warfarin in the current era? and

We do hope you will like our pro-active approach to identify, discuss all the polemics prevailing in cardiology workplace, attempt to develop consensus and even provide some solution to it. Find discussion of these controversies on Social Media & take active part in the polls; Facebook and Twitter
The Hony Secretary General,
New Delhi

Sub: Email with the subject Doctran di mili bhagat nal scan centre te laboratorian di lutt bare

Dear Sir

In context of the subject cited above, a meeting was held with Dr S K Babuta, the Civil Surgeon, Hoshiarpur on 22nd December, 2015 in the office of Civil Surgeon, Hoshiarpur. IMA Hoshiarpur was represented by Dr Ashok Kumar Gupta, Dr Pawan K Kalia President & Hony Secretary, IMA Hoshiarpur respectively, Dr Rajender K Sharma President-Elect 2017, IMA Punjab & Dr Kuldip Singh Past President IMA Punjab.

The meeting was held in a cordial atmosphere and the above said issue was discussed in detail. The Civil Surgeon told that a complaint was made to the Deputy Commissioner, Hoshiarpur. The Deputy commissioner forwarded the letter to the Civil Surgeon for necessary action. The Civil Surgeon, in turn forwarded the letter to President IMA, Hoshiarpur without any change in subject or subject matter for compliance. The civil surgeon told that there was no intention to hurt anybody in any manner and as patron of IMA Hoshiarpur, he has got regards for the medical fraternity. He assured that in future care will be taken that such thing does not happen again. The matter has been solved amicably and may not be pursued further.


Dr Ashok Kumar Gupta,
President IMA Hoshiarpur Branch
Hoshiarpur, Punjab
Exemption of doctors from odd even rule

Dear All

I request our National President and Secretary General along with all office-bearers of IMA to take up the matter of exemption of doctors from the odd even rule from 1st Jan. I request all of you again to ask these politicians to let us know if Doctors are exempt from the rule of odd even from Jan 1st.

Many doctors visit multiple hospitals/clinics and may need to carry their equipment. It is impossible to go on autos and taxis on alternate days. What is going to happen is that finally the fee will get raised to bear the expenses and the patients will suffer. In case we are not exempt then this should be clearly mentioned so that we are not liable to medicolegal action by the patients in case of reaching late/not being able to attend the patient in case of no availability of public transport This is a practical issue and lots of patients will complain if we are not on time.

So in the interest of the very aam aadmi who voted for them they should kindly let us know the verdict urgently so that it can be communicated to the hospitals we visit and also to the patients.


Dr Neeraj Gupta
National convener- IMA HQ (E-Connect)
Consultant IMA Clinic (IMAHQ, ITO)
Member Working committee, Haryana State (2015-16)
Health Ministry launches program to reduce anemia among adolescents

On Wednesday, the Health Ministry officially launched a program ‘Weekly Iron and Folic Acid Supplementation’ (WIFS) to cut down on anemia levels among the large adolescent population in the country. Government data show that at least 56% of girls and 30% of boys in the age group of 15-19 years in India are anemic, with a large percentage suffering from moderate to severe anemia. Under this program, adolescent children, who go to government or aided school as well as those who have dropped out, will be administered a tablet once a week for 13 months. Counselling and a proper information campaign will also be conducted to ensure timely implementation of the program… (Indian Express)
NPPA once again extends date to register under IPDMS

The National Pharmaceutical Pricing Authority (NPPA) has once again extended the last date till January 15, 2016 for registration of manufacturers under the Ingredient Pharmaceutical Database Management System (IPDMS), which was aimed at facilitating on-line submission of mandatory returns/reports under the Drugs Price Control Order (DPCO), 2013 by manufacturers as defined under 2(1) (n) of the DPCO, 2013. The NPPA had issued a notice dated 16.11.2015 to all manufacturing and marketing companies to register themselves in IPDMS and file all the forms as required under DPCO, 2013 on or before December 15, 2015.… (Pharmabiz - Ramesh Shankar)
IPC Code to know

IPC 304-A

Causing death by negligence: Whoever causes the death of any person by doing any rash or negligent act not amounting to culpable homicide shall be punished with imprisonment of either description for a term which may extend to two years, or with fine, or with both.
World Medical Association Secretariat at IMA HQs., IMA Guest House and Team IMA complex inaugurated by Dr. Ketan Desai, President Elect, WMA
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

• As regards Bioethical issues as deliberated above, may I suggest to keep discussion anonymous, important material for discussion are clinical facts and not the identification of the patient. This way perhaps we may not breach the confidentiality issues. Dr VJ Mahhadik

• The right skin cream can keep your skin looking young: For reducing wrinkles, the topical treatment with the best evidence behind it is retinoic acid (as in Retin-A). The best ways to keep wrinkles at bay are using sunscreen and not smoking.

• Antibacterial soap is best for keeping your skin clean: Many experts are concerned that the use of antibacterial soap could lead to more antibiotic-resistant bacteria. Antibacterial soap is not necessary for everyday use. Regular soap is fine. Thorough and consistent hand-washing, not antibacterial soap, is what helps prevent the spread of infection.
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
IMA Live Webcast

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Inspirational Story
Determination and Persistence

This is a real life story of engineer John Roebling building the Brooklyn Bridge in New York, USA back in 1870…

The bridge was completed in 1883, after 13 years. In 1883, a creative engineer named John Roebling was inspired by an idea to build a spectacular bridge connecting New York with the Long Island. However, bridge building experts throughout the world thought that this was an impossible feat and told Roebling to forget the idea. It just could not be done. It was not practical. It had never been done before. Roebling could not ignore the vision he had in his mind of this bridge. He thought about it all the time and he knew deep in his heart that it could be done. He just had to share the dream with someone else. After much discussion and persuasion he managed to convince his son Washington, an up and coming engineer, that the bridge in fact could be built. Working together for the first time, the father and son developed concepts of how it could be accomplished and how the obstacles could be overcome. With great excitement and inspiration, and the headiness of a wild challenge before them, they hired their crew and began to build their dream bridge.

The project started well, but when it was only a few months underway a tragic accident on the site took the life of John Roebling. Washington was also injured and left with a certain amount of brain damage, which resulted in him not being able to talk or walk. “We told them so.” “Crazy men and their crazy dreams.” “It’s foolish to chase wild visions.” Everyone had a negative comment to make and felt that the project should be scrapped since the Roebling’s were the only ones who knew how the bridge could be built.

In spite of his handicap Washington was never discouraged and still had a burning desire to complete the bridge and his mind was still as sharp as ever. He tried to inspire and pass on his enthusiasm to some of his friends, but they were too daunted by the task. As he lay on his bed in his hospital room, with the sunlight streaming through the windows, a gentle breeze blew the flimsy white curtains apart and he was able to see the sky and the tops of the trees outside for just a moment. It seemed that there was a message for him not to give up. Suddenly an idea hit him. All he could do was move one finger and he decided to make the best use of it. By moving this, he slowly developed a code of communication with his wife. He touched his wife’s arm with that finger, indicating to her that he wanted her to call the engineers again. Then he used the same method of tapping her arm to tell the engineers what to do. It seemed foolish but the project was under way again.

For 13 years Washington tapped out his instructions with his finger on his wife’s arm, until the bridge was finally completed. Today the spectacular Brooklyn Bridge stands in all its glory as a tribute to the triumph of one man’s indomitable spirit and his determination not to be defeated by circumstances. It is also a tribute to the engineers and their team work, and to their faith in a man who was considered mad by half the world. It stands too as a tangible monument to the love and devotion of his wife who for 13 long years patiently decoded the messages of her husband and told the engineers what to do.

Perhaps this is one of the best examples of a never-say-die attitude that overcomes a terrible physical handicap and achieves an impossible goal.

Often when we face obstacles in our day-to-day life, our hurdles seem very small in comparison to what many others have to face. The Brooklyn Bridge shows us that dreams that seem impossible can be realized with determination and persistence, no matter what the odds are.
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: The extent to which ionisation of a drug takes place is dependent upon pKa of the drug and the pH of the solution in which the drug is dissolved. Which of the following statements is not correct?

1. pKa of a drug is the pH at which the drug is 50% ionized.
2. Small changes of pH near the pKa of a weak acidic drug will not affect its degree of ionisation.
3. Knowledge of pKa of a drug is useful in predicting its behaviour in various body fluids.
4. Phenobarbitone with a pKa of 7.2 is largely ionized at acid pH and will be about 40% non-ionized in plasma.

Answer for Yesterday’s Mind Teaser: 4.Phenobarbitone with a pKa of 7.2 is largely ionized at acid pH and will be about 40% non-ionised in plasma.

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

Answer for 25th December Mind Teaser: b. Medina-Ramirez reaction

Answers received from: Dr Jainendra Upadhyay, Dr Avtar Krishan
Readers column
Dear Sir, our team is trying hard for fruitful negotiations. A matter of concern is the definition of 'Single Doctor Establishment'. It should be cleared at this juncture only. The definition shall be: “Single Doctor Establishment means

i. Any clinical establishment which is registered in the name of a single doctor or husband & wife or parent & child under that particular State's Nursing Home Act as having up to 50 bed occupancy,

ii. OPD Clinics without indoor facilities, Pathology Labs, Radiology Centers, Day Care Centers and such

iii. Any other clinical establishment declared by the State Government as 'single doctor establishment'.”

Please note that inclusion of this definition is mandatory otherwise CEA will eradicate small nursing home and life of doctors will equivalent to that of laborers. Thanks. Jai IMA: Dr Dinesh B Thakare
Trouble on the Roof

Mike and Rob were laying tile on a roof when a sudden gust of wind came and knocked down their ladder. "I have an idea," said Mike. "We'll throw you down, and then you can pick up the ladder." "What, do you think I'm stupid?" Rob replied." I have an idea. I'll shine my flashlight, and you can climb down on the beam of light." "What, do you think I'm stupid?" Mike answers. "You'll just turn off the flashlight when I'm halfway there."
Press Release
Indian Medical Association has requested Government of Delhi to consider exempting doctors from the alternate even-odd number of vehicle

While addressing the conference today Padma Shri Awardee, Dr. A Marthanda Pillai, National President, IMA and Padma Shri Awardee, Dr K K Aggarwal, Hony. Secretary General, IMA, in a joint statement said- that special status should be given to all above the age of 65 driving alone & also to doctors who are going for work.

In the present system only women have been exempted from driving alone and elderly people are not included.

IMA also suggested the Government for different Office timing i.e from 8:00 am to 4:00 pm and from 10:00 am to 6:00 p.m. This can be for odd-even building.

Doctors who wear aprons and are traveling for work should be exempted.

IMA is also having its two day Central Council Meeting to be held at Hotel le Meriden, new Delhion Sunday and Monday, December 27-28, 2015 where large number of resolution are likely to be passed.