Saturday, December 14, 2019

Who is at risk of suicide

Who is at risk of suicide

Dr KK Aggarwal
President CMAAO and HCFI

A new California NIH funded study has shown that people who presented to  emergency departments with deliberate self-harm had a suicide rate in the year after their visit 56.8 times higher than those of demographically similar people.  People who presented with suicidal ideation had suicide rates 31.4 times higher than those of demographically similar people in the year after discharge. 

The findings, published in JAMA Network Open, reinforce the importance of universal screening for suicide risk in emergency departments and the need for follow-up care. 

Question: Like suicide ideation do we also have criminal ideation. Can we prevent crime and rapes?

Friday, December 13, 2019

Potassium good for hypertension provided you are not on ACE Inhibitors or AR blockers

Potassium good for hypertension provided you are not on ACE Inhibitors or AR blockers

Dr KK Aggarwal
President CMAAO and HCFI

Potassium regulates the heartbeat, ensures proper function of the muscles and nerves, and is vital for synthesizing protein and metabolizing carbohydrates.

Earlier the so-called Paleolithic diet delivered about 16 times more potassium than sodium. Today, most people get barely half of the recommended amount of potassium in their diets.

The average diet contains about twice as much sodium as potassium, because of the preponderance of salt hidden in processed or prepared foods.

This imbalance, is  a major contributor to high blood pressure.

The adequate intake recommendation for potassium is 4,700 mg. Bananas are often touted as a good source of potassium, but other fruits (such as apricots, prunes, and orange juice) and vegetables (such as squash and potatoes) also are a good source.

Diets ( DASH) that emphasize greater potassium intake can help keep blood pressure in a healthy range, compared with potassium-poor diets.

Higher potassium in diet is also associated with a lower stroke incidence.

Take home message: All should take high potassium in diet. But if you are hypertensive check before you take K if you are on ACE inhibitors or AR blockers, both can raise potassium.

Thursday, December 12, 2019

Why retire at any age?

Why retire at any age?

Dr KK Aggarwal
President CMAAO and HCFI

It has been a practice in India to retire people after the age of 58. In some cases, the age has been 60, 62, 65 or 70. Let us understand the science behind this retirement.

Retirement is based on the fact that after the age of 50 one starts developing age related minimal cognitive impairment. One start losing memory for immediate recall, recent memory, starts losing the names of common people and common places.

 Quite often when one is speaking on a phone and his attention is diverted by someone, the person forgets what he was speaking.

In this age most people start entering the name of a person in the phone book by linking it to his profession, relation, JOB ETC.

Most politicians will start relying on the PPT presentations or start reading their speech.

Very few will continue oral extempore presentations. The situation is worse with vegetarians due to Vitamin B 1w2 deficiency which further impairs memory.

Premature atherosclerosis, diabetes, hypertension, recurrent mini strokes also add to this insult.

Therefore, the age of retirement should not be decided by chronological age but by the degree of age related cognitive impairment present.

All patients with age related cognitive dysfunction should be evaluated and treated for reversible causes of cognitive impairment, including medication side effects, sleep disturbances, depression, vitamin B12 deficiency, and hypothyroidism.

Doctors and toll tax and red-light exemptions

Doctors and toll tax and red-light exemptions

Dr KK Aggarwal
President CMAAO and HCFI

The lawyers and doctors, including IMA have asked the government to provide toll  tax exemption on National Highways. Currently the ambulances are exempted.

As per the definition an ambulance is a vehicle equipped to provide emergency care to sick or injured people and to get them to hospital. Ambulances can also be used to transport patients between hospitals. There are several types of ambulance, all specially equipped and including: vans (the most common type of ambulance) four-wheel drives.

I personally feel that doctor are different than the community,  they are allowed to prefix Dr in front of their name and are supposed to say no tro any emergency.

They must be allowed this privilege not only for toll tax but also to cross the roads in preference as given to any ambulance. Also during odd even restrictions doctors vehicles should be exempted.

Simultaneously it is also the duty of every doctor to equip their vehicle in question with all basic emergency facilities to handle any emergency. The government may certify these vehicles separately.

Would like to know from other NMAs if such privileges are given in any country.

Toll Tax

While this tax is mandatory and is charged in toll plazas along the highways across India, the rates vary because each toll plaza is accountable for a certain distance of the road. This taxation does is exempted for certain people including VIPs in the country of certain officials who have been listed in the last section.

Toll Tax Policy

Policy for collecting toll tax is based on the National Highways Act, 1956 (48 of 1956) provisions as well as the National Highways Fee (Determination of Rates and Collection) Rules, 2008, when this amendment was made. As of 2016 there are 390 toll tax collection fee plazas across the national highways in India. Based on the current policy literature any road with 6 lanes with 4 lanes already running is tolled even if the highway is not fully completed. As of 2016, there is no separate regulatory authority running independently for this taxation.

Toll Tax Exemption List

Any vehicle which has the following people will be exempted toll tax across India:

1.            President of India;
2.            Prime-Minister of India;
3.            Vice-President of India;
4.            Chief Justice of India;
5.            Governor of any State in India;
6.            Speaker of the House of People;
7.            Cabinet Minister of the Union
8.            Judge of the Supreme Court;
9.            Governor of any State in India;
10.         Minister of State of the Union;
11.         Member of Parliament;
12.         Lieutenant Governor of any Union Territory in India;
13.         Chief of Staff holding a full General or equivalent rank;
14.         Chairman of the Legislative Council of a State;
15.         Speaker of the Legislative Assembly of any State in India;
16.         Chief Justice of a High Court;
17.         Judge of a High Court;
18.         Army Commander or Vice-Chief of Army Staff and equivalent in other services;
19.         Foreign dignitary on State visit;
20.         Chief Secretary to a State Government within concerned State;
21.         Secretary to the Government of India;
22.         Secretary, Council of States;
23.         Secretary, House of People;
24.         A Member of Legislative Assembly of a State in the state premises, with identity proof.
25.         A Member of Legislative Council in the borders of their respective State, with identity proof.
26.         Awardees of the following recognition, with adequate identity proof:
             Param Vir Chakra, Ashok Chakra,
             Maha Vir Chakra, Kirti Chakra,
             Vir Chakra,
             Shaurya Chakra.

The other vehicles which are exempted from the toll tax include:

1.            Vehicle under or with a passenger who is from the Ministry of Defence including people eligible for toll exemption based on the provisions of the Indian Toll (Army and Air Force) Act, 1901 and laws including the Navy;

2.            Central and State armed forces in uniform including para military forces and police;

3.            An executive Magistrate;

4.            Vehicle belonging to the fire-fighting Department or organisation;

5.            Vehicle belonging to the National Highways Authority of India;

6.            Vehicle belonging to any other Government agency or organisation for purposes of survey, inspection, operation or construction and maintenance of national highways;

7.            Vehicle used as ambulance;

8.            Vehicle used as funeral van

Simple Aspirin as Good as Newer drugs for aborting or preventing acute migraine attack

Simple Aspirin as Good as Newer drugs for aborting or preventing acute migraine attack
Dr KK Aggarwal
President CMAAO and HCFI

Old aged aspirin is as effective for acute treatment and prevention of recurrent migraine attacks as more expensive medications.

A review of randomized trials suggests that high-dose aspirin is effective and safe for acute migraine and that low-dose aspirin may help prevent migraine attacks. The study was published online October 12 in the American Journal of Medicine.

Migraine affects an estimated 14% of the general population and is more prevalent in women (18%) than men (9%). About 90% of migraine patients report moderate to severe pain associated with their attacks. More than 50% report severe impairment, which often results in reduced work and school productivity.

The study assessed randomized trials and meta-analyses in which participants received 900 mg to 1200 mg of aspirin for acute migraine or 81 mg to 325 mg daily for prevention of recurrence.

High-dose aspirin was more effective than placebo in multiple trials that examined relief of acute migraine attacks. Efficacy was comparable to other medications, including 400-mg ibuprofen or 50-mg sumatriptan.

However,   100-mg sumatriptan, the researchers note that sumatriptan provides faster relief.

Overall, 81 mg to 325 milligrams aspirin daily "may be an effective and safe treatment option for the prevention of recurrent migraine headaches. 

Wednesday, December 11, 2019

Medications as effective as stents or bypass for stable heart blockages: A must for Asian countries

Breaking Trial
Medications as effective as stents or bypass for stable heart blockages
Dr KK Aggarwal
President CMAAO and HCFI

The ISCHEMIA trial, a new study reported at November’s American Heart Association meeting, suggests that for most, managing heart blockages with optimal drugs alone is as safe and effective as putting a stne tor doing a bypass surgery.

The trial followed over 5,000 patients with significant narrowing in one or more heart arteries. Half of the patients were randomly selected to receive optimal medical therapy (OMT) and lifestyle changes. The other half were given OMT and also sent for cardiac catheterization or a bypass surgery.

The group that received stents did report greater relief of angina, or chest pain but, there was no significant difference between the two groups in terms of rates of heart attack, death, or hospitalization for worsening heart pain.

OMT makes more sense because it addresses all the arteries in the heart, not just the small section of narrowing addressed by a stent that may be causing angina.

However, stents remain an effective at relieving angina in patients who continue to experience symptoms despite being on appropriate medicines.

Unlike unstable angina, patients with stable angina have more predictable, chronic symptoms that can be managed with medications. Stable angina worsens with exertion or sometimes with emotional stress, and improves with rest. Reduction of stable angina involves improving the mismatch between oxygen supply and demand. This can be accomplished either by lowering demand or improving supply.

Demand can be reduced with optimal drug therapy, which may include beta blockers, which slow down the heart rate, or nitroglycerin, which decreases the work of the heart by relaxing blood vessels. Statins and aspirin are another important components as they help to stabilise the blockage.

Tuesday, December 10, 2019

Dengue Vaccine : The Asian Concerns

Dengue Vaccine : The Asian Concerns

Dr KK Aggarwal
President CMAAO and HCFI

The Health Minister Dr Harsh Wardhan told the parliament that India is near ready for the dengue vaccine. Let us know the facts

Indian Scenario

1.      A live attenuated vaccine known as Dengvaxia, developed by Sanofi, was licensed in 2015. Following this, long-term follow-up of the Sanofi phase III efficacy trial participants has revealed potential safety concerns.

2.    This vaccine, which appears to predispose dengue-na├»ve recipients to an increased risk of hospitalization in the future, is recommended by the WHO only for adults with a history of prior dengue virus infection.

3.    India is poised now to test out two different dengue vaccine candidates in clinical trials in the near future, an LAV, TetraVax-DV, and a recombinant protein-based vaccine, DSV4.

4.    All current tetravalent LAV approaches are based on physical mixtures of empirically determined amounts of four monovalent vaccine viruses. Such mixtures manifest a tendency of viral interference and could simulate a monotypic infection. In such a situation, seronegative recipients may be potentially sensitized to antibody-dependent enhancement (ADE) later in life, upon natural DENV infection.

Scientific facts

1.     Infection with one DENV type provides long-term protection against reinfection with that same type, supporting the feasibility of an effective dengue vaccine.

2.      Also following infection with one type, there is short-lived immunity and cross-protection against disease caused by the other three DENV types.

3.     But in view of the association between previous exposure to DENV types and severe disease, and the recognition that all four DENV types are capable of causing severe disease, ideally any candidate vaccine should produce protective immunity against all four DENV types (tetravalent immunity).

1.     Can India afford ruling out prior infection in every case before giving the vaccine?

2.     Will the tetravalent vaccine not produce ADE?

3.     Will the vaccine be cost effective?

4.     Given that the rate of clinically relevant third or fourth DENV infection is low, do we require tetravalent immunity?

5.     Since waning immunity might also increase the risk for severe disease in vaccine recipients the aim should be only to have long lived vaccine-induced protective immunity.