Sunday, June 23, 2019

HR/June 19/8: Increasing global recognition for tobacco harm reduction

Dr KK Aggarwal

The following quotes demonstrate an increasing global recognition for tobacco harm reduction.

“We (in 2007) suggested that making effective, affordable, socially acceptable, low-hazard nicotine products available to smokers as a market alternative to tobacco could generate significant health gains, by allowing smokers to stop smoking tobacco, without having to stop using the nicotine to which they are addicted. As most of the harm caused by smoking arises not from nicotine but from other components of tobacco smoke, the health and life expectancy of today’s smokers could be radically improved by encouraging as many as possible to switch to a smoke-free source of nicotine.” Royal College of Physicians, Nicotine without smoke, 2016.

“We will help people quit smoking by permitting innovative technologies that minimise the risk of harm. We will maximise the availability of safer alternatives to smoking.” UK Department of Health, Towards a smoke-free generation, 2017.

“The BMA’s ambition to achieve a tobacco-free society, leading to substantially reduced mortality from tobacco-related disease. Given that e-cigarettes are now the most popular device used in attempts to quit smoking, and that many people have used them to successfully quit tobacco use, they have significant potential to support this ambition, and help reduce tobacco-related harm.” British Medical Association, E-cigarettes: balancing risks and opportunities, 2017

“These individuals (who cannot quit smoking) should be encouraged to switch to the least harmful form of tobacco product possible; switching to the exclusive use of e-cigarettes is preferable to continuing to smoke combustible products.” American Cancer Institute, Position statement on e-cigarettes, 2018

“If long term smokers who have been unable to quit smoking tobacco cigarettes switch to e-cigarettes, thousands of lives could be saved.” Trent Zimmerman MP, Chair of the Australian parliamentary committee report into the use and marketing of electronic cigarettes and personal vaporisers in Australia, 2018.

“If the great majority of tobacco smokers who are unable or unwilling to quit would switch without delay to using an alternative source of nicotine with lower health risks, and eventually stop using it, this would represent a significant contemporary public health achievement.” WHO, Electronic nicotine delivery systems and electronic non-nicotine delivery systems, 2016.

“Tobacco control’ means a range of supply, demand and harm reduction strategies that aim to improve the health of a population by eliminating of reducing their consumption of tobacco products and exposures to tobacco smoke.” WHO, Framework Convention on Tobacco Control, 2003

(Source: No Fire, No Smoke Global State of Tobacco Harm Reduction, 2018 (2018). London: Knowledge-Action-Change)

Dr KK Aggarwal
Padma Shri Awardee
President Elect Confederation of Medical Associations in Asia and Oceania   (CMAAO)
Group Editor-in-Chief IJCP Publications
President Heart Care Foundation of India
Past National President IMA

Bihar children deaths: Could refeeding syndrome precipitated by litchis be the cause?

Dr KK Aggarwal

What do we know so far about these deaths: Mostly malnourished children < 10 years old, linked to lychee orchids, convulsions early in the morning, no fever, high mortality the same day, all had low sugar but mortality still high even after infusing sugar.

This only means that some other metabolic factor is also at play apart from the sugar.

What might be happening? If significantly malnourished children, who have not eaten food for more than 3 days eat oral carbohydrates (litchi in this case), it can cause electrolyte and fluid shifts that may precipitate disabling or fatal medical complications.

This is the so-called refeeding syndrome characterized by hypophosphatemia, hypokalemia, congestive heart failure, peripheral edema, rhabdomyolysis, seizures, fever and hemolysis.  The hallmark feature is hypophosphatemia.

Rapidly treating hypoglycemia with lychee will harm, if phosphate levels are not managed. The best food in such situations is sugarcane juice and not litchi. Remember, sugarcane is the juice used to break all starvation fasts.

The risk of hypophosphatemia during refeeding appears to be greater in patients who are more severely malnourished and at lower percent of ideal body weight. 

Stores of phosphate are depleted during episodes of starvation. When nutritional replenishment starts and patients are fed carbohydrates, glucose causes release of insulin, which triggers cellular uptake of phosphate (and potassium and magnesium) and a decrease in serum phosphorous levels. Insulin also causes cells to produce a variety of depleted molecules that require phosphate (adenosine triphosphate and 2,3-diphosphoglycer1ate), which further depletes the body’s stores of phosphate.

The subsequent lack of phosphorylated intermediates causes tissue hypoxia, myocardial dysfunction, respiratory failure due to an inability of the diaphragm to contract, hemolysis, rhabdomyolysis and seizures.

Risk factors for the re-feeding syndrome include low baseline levels of phosphate, potassium, or magnesium prior to re-feeding the patient; and little or no nutritional intake for the previous 5 to 10 days. Patients are at the highest risk for the re-feeding syndrome in the first 1 to 2 weeks of nutritional replenishment and weight gain.

Generally, the risk progressively dissipates over the next few weeks if there has been consistent forced intake and weight gain.

Excerpts from Dr T Jacob John, Retired Professor of Virology from CMC Vellore

·         All it would have taken was to ensure that the children had a meal the preceding night
·         The disease is not encephalitis but encephalopathy.
·         Encephalitis results from a viral infection, unless proved otherwise. The pathology is primarily in the brain. Encephalopathy is a biochemical disease, unless proved otherwise.
·         Encephalopathy is eminently treatable.
·         Hypoglycemia is usually due to an overdose of insulin in children with diabetes. It is easily corrected with oral sugar or intravenous glucose. The easily available 5% glucose solution suffices. Hypoglycaemic encephalopathy, however, is different from simple hypoglycemia.
·         The disease broke out during the months when litchi was harvested, i.e. April, May and June. The illness started suddenly; children were found vomiting, displayed abnormal movements, were semi-conscious, and were convulsing between 4 a.m. and 7 a.m. The disease progressed fast — children went into coma and died within a few days. When sick children were tested, the blood glucose level was always below normal.
·         This disease was reminiscent of the Jamaican Vomiting Disease, a form of hypoglycaemic encephalopathy. It is triggered when unripe cake fruits are eaten. These fruits contain a substance, ethylene cyclopropyl alanine, which blocks a biochemical process called fatty acid oxidation, or gluconeogenesis.
·         There are two essential steps: gluconeogenesis is turned on and is then blocked midway by methylene cyclopropyl alanine. The back-up molecules of the unfinished process are certain amino acids that are highly toxic to the brain cells. Ackee and litchi belong to one plant family. We found generous quantities of methylene cyclopropyl glycine in litchi fruit pulp.
·         The disease affected only malnourished children between the ages of two and 10.
·         A majority of them were from families camping in orchards for fruit harvesting. No child from the nearby towns fell ill. Children of well-to-do families never fell ill.
·         Litchi harvest usually begins by 4 a.m., which means that families are awake before that. They go to sleep early. If children go to sleep without dinner, parents usually do not wake them up and feed them. Litchis are collected in bunches and sent to the collection points, but single fruits fall to the ground. Children are free to collect and share the fruits with their friends.
·         After prolonged fasting, malnourished children slipped into hypoglycaemia in the morning. Since they had very little reserve glycogen in their livers, they were unable to mobilise glucose from liver glycogen, unlike well nourished children. The brain needs glucose as a source of energy. As a result of lack of liver glycogen, gluconeogenesis was turned on. Had there not been litchi methylene cyclopropyl glycine, the glucose levels would have been maintained, and the children would have come to no harm. As the children had consumed litchis the previous day, gluconeogenesis had been blocked, aminoacidemia had developed, and brain functions had been affected. Hypoglycaemic encephalopathy had set in.
·         We were unable to demonstrate aminoacidemia in children with hypoglycaemic encephalopathy, but that was done by investigators from the US Centers for Disease Control and Prevention (CDC). The only missing piece in our studies was filled in by CDC colleagues.
·         The disease can be prevented if children are well nourished, but that is not possible in the immediate term. It can also be prevented by ensuring that children eat a meal at night. All families were taught to provide a cooked meal to children before going to sleep at night. Preventing children from eating litchis is not easy, but the quantity of the fruit can be restricted with parental supervision. With all this health education, I was told that the disease number had come down drastically in 2016-18 compared to what it was in 2014-2015. I don’t know what went wrong this year.
·         In 2015, all primary health centres were supplied with glucometers to check the blood glucose levels of sick children. Doctors were instructed to take a blood sample for glucose estimation and, irrespective of the results, infuse 10% glucose intravenously. To correct mild hypoglycaemia, 5% glucose is enough, but here the problem is not hypoglycaemia alone, but aminoacidemia as a result of blocked gluconeogenesis. To prevent any further back-up amino acid from accumulating, the fatty acid oxidation process has to be turned off quickly. That requires raising blood glucose level to abnormally high levels so that insulin secretion is stimulated, and that in turn turns off the gluconeogenesis.
·         If ill children are infused with 10% glucose within four hours of onset of brain dysfunction, recovery is fast and complete. If only 5% glucose is given, or if 10% glucose is not administered within four hours, recovery is unlikely.
·         Glucometers have not been maintained well. Health education was not sustained. New doctors are not familiar with all the information. Instead of 10% glucose, 5% is given.
·         Ambulances take more than four hours to reach the city hospitals from many rural clinics.

The final answer

·         Refeeding syndrome
·         Shortened duration added with litchi toxins
·         Prevention: Evening mid-day meal
·         In hospital, treat low sugar, low phosphates, low magnesium, low potassium

Dr KK Aggarwal
Padma Shri Awardee
President Elect Confederation of Medical Associations in Asia and Oceania   (CMAAO)
Group Editor-in-Chief IJCP Publications
President Heart Care Foundation of India
Past National President IMA

Saturday, June 22, 2019

HR/June 19/7: Safer nicotine products

·           E-cigarettes are estimated to be 95% safer than smoking cigarettes
·           Snus is not inhaled, so there is no risk of respiratory disease which accounts for nearly half of all smoking-related deaths; and no risk to bystanders. There is no significant association with premature deaths, diabetes, pancreatic and oral cancers, heart disease or strokes
·           It is estimated that by 2021, over 55 million people will be using e-cigarettes or heat-not-burn tobacco products and that the global market will be worth USD $35 billion
·           Use of heat-not-burn products in Japan has seen cigarette sales fall by 27% in two years, an unprecedented national decrease in smoking
·           In Sweden snus has been instrumental in reducing smoking related mortality to the lowest in the EU
·           If the EU ban on snus is lifted, then around 320,000 premature deaths a year could be prevented in the EU
·           As Norwegian smokers switch to snus, the smoking rate among young Norwegian women has dropped to a world record of 1%
·           Over 50% of the UK’s 3 million e-cigarette users are ex-smokers
·           39 countries have inappropriately banned SNP including countries whose smoking prevalence is predicted to rise
·           62 countries regulate e-cigarettes under tobacco legislation.

(Source: No Fire, No Smoke Global State of Tobacco Harm Reduction, 2018 (2018). London: Knowledge-Action-Change)

Dr KK Aggarwal
Padma Shri Awardee
President Elect Confederation of Medical Associations in Asia and Oceania   (CMAAO)
Group Editor-in-Chief IJCP Publications
President Heart Care Foundation of India
Past National President IMA

4-day-old girl died at a government hospital in Bareilly after being shunted between different departments

 There is a need for a transparent policy on hospital admissions

Dr KK Aggarwal

A 4-day-old girl died at a government hospital in Bareilly after being shunted between different departments for 3 hours, reported India Today on Thursday.

The Chief Medical Superintendent (CMS) of the men's wing at the government hospital was suspended after the death of the four-day-old girl, an official release stated. Departmental proceedings have also been ordered against CMS, women's wing. "A critically ill child was brought to the men's wing of the hospital, where paediatricians were available. Instead of stablising the child, her family was sent to the women's wing, from where the child was sent back," officials said. According to reports, the four-day-old baby girl died after being shuttled from one wing of the hospital to another. The girl born at a private hospital on June 15 had difficulty in breathing after which her parents brought her to the government hospital in Bareilly. Her family alleged they were made to run from one wing of the hospital to another for over three hours due to which the infant died.

There is an unspoken rule that most hospitals will not admit outside serious patients, those who are not being treated in their hospitals. 

For instance AIIMS (and many government hospitals) across the country does not accept

·         Outside patients on ventilator or on CPAP/BiPAP 
·         Patients diagnosed and undergoing dialysis outside the hospital
·         Patients for blood tests done unless they are inpatients or are undergoing treatment at the hospital.
·         Neonates born outside
·         Non booked delivery emergency cases
·         Patients to provide terminal care
·         Patients to provide home care
·         Patients to provide long term care

A needy patient on ventilator in a private hospital is in a soup; he cannot be transferred to a government hospital and also cannot afford up to one lakhs day in the private sector. The end result is frustration, which may at times manifest as violence.

These unwritten norms also has been exploited by the commercial sector and made them the costliest segment of the hospital treatments. Emergency care, which needs to be the cheapest in any social sector, has become the costliest. 

The question arises under which law, have these norms been created.

The four guiding tenets of medical ethics are beneficence (do good) and nonmaleficence (to do no harm) along with patient autonomy and justice. As clinicians, we have been trained to use our skills and knowledge to diagnose illnesses that patients suffer from and treat them. It is important that equity, equality and justice should prevail in any health care decision. The basic concepts of dignity, equality, liberty and brotherhood, without discrimination of any kind, have been established in Articles 1 and 2 of the Universal Declaration of Human Rights.

Right to equality is a fundamental right guaranteed by the Constitution of India.

Article 14 guarantees the right to equality “Equality before law”, which means that every citizen is equal before the law and is equally protected by the laws of the country, which cannot be denied by the state: “The State shall not deny to any person equality before the law or the equal protection of the laws within the territory of India Prohibition of discrimination on grounds of religion, race, caste, sex or place of birth.”

Article 15 prohibits discrimination on grounds of religion, race, caste, sex or place of birth.

Article 21 protects life and personal liberty and states “No person shall be deprived of his life or personal liberty except according to procedure established by law.” The scope of Article 21 has been expanded considerably and now also includes right to health, right to clean environment, right to live with dignity, right to adequate nutrition, right to education. In 2017, the Supreme Court declared right to privacy as a fundamental right under Article 21.

The patient has the Right to non-discrimination as listed in the draft of Patient rights Charter prepared by National Human Rights Commission, which says, “Every patient has the right to receive treatment without any discrimination based on his or her illnesses or conditions, including HIV status or other health condition, religion, caste, ethnicity, gender, age, sexual orientation, linguistic or geographical/social origins. The hospital management has a duty to ensure that no form of discriminatory behaviour or treatment takes place with any person under the hospital’s care...”

The format for medical record as prescribed in Appendix 3 of the MCI Code of Ethics Regulations, 2002 does not include socioeconomic or financial status of the patient.


(see regulation 3.1)
Name of the patient :

Age :

Sex :

Address :

Occupation :

Date of 1st visit :

Clinical note (summary) of the case:

Prov. : Diagnosis :

Investigations advised with reports:

Diagnosis after investigation:

Advice :

Follow up 


Signature in full ………………………….

Name of Treating Physician  

ICMR and AIIMs have launched Mission DELHI (Delhi Emergency Life Heart-Attack Initiative) within a range of 3 km around AIIMS. It is an emergency medical service, where motorbike-borne medical assistance unit can be quickly summoned for a person suffering heart attack or chest pain as the “first responders”. The pilot project has been launched in a radius of 3 kms around All India Institute of Medical Sciences (AIIMS), New Delhi and would be linked with Centralized Ambulance Trauma Services (CATS). Recently one of the patients was refused admission because at 3.2 km, he was outside the radius of 3 km.

Clause 2.1.1 of the MCI Code of Ethics Regulations reminds us of our obligations to the sick. “Though a physician is not bound to treat each and every person asking his services, he should not only be ever ready to respond to the calls of the sick and the injured, but should be mindful of the high character of his mission and the responsibility he discharges in the course of his professional duties. In his treatment, he should never forget that the health and the lives of those entrusted to his care depend on his skill and attention... A physician advising a patient to seek service of another physician is acceptable, however, in case of emergency a physician must treat the patient. No physician shall arbitrarily refuse treatment to a patient. However for good reason, when a patient is suffering from an ailment which is not within the range of experience of the treating physician, the physician may refuse treatment and refer the patient to another physician.”

Patients come to hospitals with great hope. 

Where will they go, if they run the risk of being denied care at a hospital and are asked to go to another hospital, which might again turn them away and this cycle may continue....precious time is lost.

Clearly, there is a need for a transparent policy on hospital admissions.

Dr KK Aggarwal
Padma Shri Awardee
President Elect Confederation of Medical Associations in Asia and Oceania   (CMAAO)
Group Editor-in-Chief IJCP Publications
President Heart Care Foundation of India
Past National President IMA