Sunday, November 23, 2014

The first Indian Ebola patient can be a potential cure for a future patient

New Delhi, November 22nd, 2014: The use of whole blood or serum from convalescent Ebola virus disease survivors is being used for the treatment of affected patients.

The World Health Organization has issued interim guidance for the collection and administration of convalescent whole blood or plasma for treatment of Ebola virus disease (EVD).

“The patient who is currently undergoing convalescence from Ebola should be persuaded to donate blood or plasma for a future patient”, said Padma Shri, National Science Communication and Dr. B C Roy National Awardee Dr. K K Aggarwal President Heart Care Foundation of India and Senior National Vice President Indian Medical Association.

Giving his valuable insights on the deadly virus Dr. Aggarwal said, "While there is no proven treatment available for Ebola virus disease, whole blood collected from patients in the convalescent phase of infection has been used as an empirical treatment with promising results in a small group of cases with Ebola virus disease and the concept that this treatment could be efficacious is biologically plausible, as convalescent plasma has been used successfully for the treatment of a variety of infectious agents".

 WHO guidelines cover all aspects of this procedure. Patients who have recovered from EVD and been discharged from Ebola treatment centers or units could be potential donors for convalescent whole blood or plasma from 28 days after their day of discharge.
Only those EVD patients who have been discharged according to the WHO criteria as clinically asymptomatic and have twice tested negative for EBOV RNA by molecular techniques, should be considered as potential donors.  The two samples for EBOV RNA testing should be taken at least 48 hours apart, and the test results should be negative on each sample.

Donated convalescent whole blood should be stored between +2 degree and +6 degree (never frozen) preferably in a separate blood bank refrigerator dedicated to convalescent whole blood or plasma units, fitted with a temperature monitoring system and alarm. Plasma separated from whole blood donations or collected by apheresis may be stored as ‘Liquid Plasma’ between +2 degree and six degree in blood bank refrigerators for up to 40 days. Alternatively, it may be frozen either within 8 hours of collection as ‘Fresh Frozen Plasma’ or within 18-24 hours of collection as ‘Plasma Frozen within 24 hours’ and stored for up to 12 months at or below -18 degree.

Only patients with confirmed EVD preferably in its early stages should be considered for transfusion, as an empirical treatment for EVD. ABO and RhD matched blood or plasma units that need to be selected for transfusion.

About HCFI

Initiated in 1986, the Heart Care Foundation of India is a leading National NGO working in the field of creating mass health awareness among people from all walks of life and providing solutions for India’s everyday healthcare needs. The NGO uses consumer based entertainment modules to impart health education and increase awareness amongst people. A leading example of this is the Perfect Health Mela, an annual event started in 1993 that is attended by over 2-3 lakh people each year. The Mela showcases activities across categories such as health education seminars and checkups, entertainment programs, lifestyle exhibitions, lectures, workshops and competitions. In addition to this, the NGO conducts programs and camps to train people on the technique of hands only CPR through its CPR 10 mantra for revival after a sudden cardiac arrest. They currently hold three Limca Book of World Records for the maximum number of people trained in hands only CPR in one go. Keeping article 21 of the Indian constitution in mind, which guarantees a person Right to Life, Heart Care Foundation of India has also recently initiated a project called the Sameer Malik Heart Care Foundation Fund to ensure that no one dies of a heart disease just because they cannot afford treatment.

Saturday, November 22, 2014

Heart Care Foundation of India and Indian Medical Association now part of NCD Alliance

Heart Care Foundation of India and Indian Medical Association now part of NCD Alliance

New Delhi India: Heart care Foundation of India and Indian Medical Association have joined the NCD Allincae, said Padma Shri Awardee Dr K K Aggarwal President Heart Care Foundation of India and incoming Honorary Secretary General IMA.

The NCD Alliance was founded by four international NGO federations representing the four main NCDs – cardiovascular disease, diabetes, cancer, and chronic respiratory disease.  

These involved International Diabetes Federation, World Heart Federation, and the Union for International Cancer Control.

Together with other major international NGO partners, the NCD Alliance unites a network of over 2,000 civil society organizations in more than 170 countries.  The mission of the NCD Alliance is to combat the NCD epidemic by putting health at the centre of all policies.

The NCD Alliance uses targeted advocacy and outreach to ensure that NCDs are recognized as a major cause of poverty, a barrier to economic development, and a global emergency. 

Other member associations from India are Disease Management Association of India; India800 Foundation, Breastfeeding Promotion Network of India, Indian Centre for Alcohol Studies, Indian Alcohol Policy Alliance and Indian Medical Association.

NCD Global Facts

Non-communicable diseases (NCDs) are the world’s number one killer, bringing hardship to rich and poor nations alike.

NCDs make the largest contribution to mortality both globally and in the majority of low- and middle- income countries (LMICs). 

Worldwide, NCDs account for 60% (35 million) of global deaths.

The largest burden - 80% (28 million) - occurs in LMICs, making NCDs a major cause of poverty and an urgent development issue. They will be the leading global cause of disability by 2030.

NCDs in LMICs also put G20 nations at risk since we all benefit from healthy individuals and stable populations around the globe. 8 million people below the age of 60 die each year in LMICs from preventable causes, which include tobacco use, unhealthy diets, alcohol consumption, and physical inactivity. Lack of access to affordable medicines and health care services are also major causes of these preventable deaths.

Globally, the NCD burden will increase by 17% in the next ten years, and in the African region by 27%. The highest absolute number of deaths will be in the Western Pacific and South-East Asia regions.

This rapidly changing health and disease profile has serious implications for poverty reduction and economic development. NCDs strangle macro-economic development and keep the bottom billion locked up in chronic poverty. NCDs have a severe impact on individuals, communities and countries. The magnitude and rapid spread of NCDs means we are all headed for a sick future unless we take action now. Low-income countries still grappling with heavy burdens of infectious disease risk being overwhelmed by this wave of largely preventable NCDs.

Friday, November 21, 2014

Honorary Professor in Bioethics Awarded to Dr K K Aggarwal

Honorary Professor in Bioethics Awarded to Dr K K Aggarwal

Retired Justice of Supreme Court of Indian and Former Chairman Law Commission of India A R Lakshmanan delivered key note address on Bioethics during a National Conclave on the subject organized by Asia Pacific Network of UNESCO Bioethics organised at SRM University Potheri, Chennai.

Vice Chancellor of SRM University Doctor Dr T P Ganesan, Awarded "Honorary Professor in Bioethics" to incoming Indian Medical Association National President Dr A Marthanda Pillai and its incoming Honorary Secretary General Dr K K Aggarwal. Both of them are Recipients of Padma Shiri Awards.  They said IMA will educate all hits 2,50,000 members on Bioethics though IMA e-Connect program.

Dr N Dinesh Professor Psychiatry Amrita Institute of Medical Sciences Cochin also received the Honorary Professorship.

Tamilnadu State President of IMA Dr M Balasubramainan said that it is a great Honor for IMA Top Office Bearers to receive honorary professorships.

Dr Ruseell F D’ Souza Chairman of Asia Pacific network of UNESCO Bioethics said that UNESCO will join hands with IMA in the coming year to propagate the message of bioethics amongst the medical professionals with a standard curriculum.

Dr P Thangaraju SRM Pro Vice Chancellor, Dr Balakrishnan, Dean Medical Research, SRM University and Prof. Dr James Pandian, SRM Dean were present on the occasion and also deliberated on the subject.

Delegates from Tamilnadu, Kerala, Karnataka, Maharashtra, Delhi, Manipur & Nepal participated in the conclave.

Wednesday, November 19, 2014

Ebola can persist in the semen

Ebola in the semen

1. Ebola can be present in saliva, stool, semen, breast milk, tears, nasal blood, and a skin swab.

2. A study published in the Journal of Infectious Diseases (J Infect Dis. 1999 Feb;179 Suppl 1:S28-35) evaluated if convalescent body fluids contain Ebola virus and if secondary transmission occurs during convalescence. Twenty-nine Ebola hemorrhagic fever  convalescents and  their 152 house hold contacts were monitored for up to 21 months. Blood specimens were obtained and symptom information was collected from convalescents and their house hold contacts.  other body fluid specimens were also obtained from convalescents.  Joint and muscle pains were reported significantly more often by convalescents than house hold contacts. Evidence of Ebola virus was detected by reverse transcription-polymerase chain reaction in semen specimens up to 91 days after disease onset; however, these and all other non-blood body fluids tested negative by virus isolation.
 Among 81 initially antibody negative house hold contacts none became antibody positive.
Blood specimens of 5 house hold contacts not identified as Ebola hemorrhagic fever  patients were initially antibody positive. No direct evidence of convalescent-to- house hold contract transmission of Ebola fever was found, although the semen of convalescents may be infectious.
The existence of initially antibody-positive house hold contacts suggests that mild cases of Ebola virus infection occurred.

3. Who is a high risk Ebola Patient: Percutaneous (needle stick) or mucous membrane exposure to blood or body fluids (feces, saliva, sweat, urine, vomit, and semen) of a person with symptomatic Ebola virus disease and Exposure to the blood or body fluids (feces, saliva, sweat, urine, vomit, and semen) of a person with symptomatic Ebola virus disease without appropriate personal protective equipment (PPE). In both situations a person has to be symptomatic.

4. There is no identifiable risk when the contact is with an asymptomatic person who had contact with a person with Ebola and also contact with a person who is later diagnosed with Ebola virus disease, before the person developed symptoms.

5. Viral persistence — Virus can persist for some time in certain bodily fluids, such as semen and breast milk.

a     Follow-up studies of 40 survivors in the 1995 Kikwit, Democratic Republic of Congo outbreak showed that viral RNA sequences could be detected by RT-PCR in the semen of male patients for up to three months, and infectious virus was recovered from one individual 82 days after disease onset. [J Infect Dis. 1999;179 Suppl 1:S28.]
         In only one known instance, during the 1967 Marburg outbreak, has viral persistence in semen led to virus transmission through sexual contact. [Curr Top Microbiol Immunol. 1999;235:49, Trans R Soc Trop Med Hyg. 1969;63(3):295.]
      A study of patient samples collected during the outbreak of Ebola Sudan virus disease in Gulu, Uganda in 2000 detected virus in the breast milk of a patient, even after virus was no longer detectable in the bloodstream. Two children who were breast-fed by Ebola-infected mothers died of the disease. [J Infect Dis. 2007 Nov;196 Suppl 2:S142-7.]
         During the 2014 outbreak in West Africa, virus was cultured from a patient’s urine 12 days after the last positive culture was identified in plasma. [N Engl J Med. 2014 Oct]

6. Convalescent period of Ebola and Marburg virus disease is prolonged, and marked by weakness, fatigue, and failure to regain weight that was lost during illness. Extensive sloughing of skin and hair loss are commonly observed, possibly as a result of virus-induced necrosis of infected sweat glands and other dermal structures

7. There is no evidence that asymptomatic persons still in the incubation period are infectious to others.  But all symptomatic individuals should be assumed to have virus in the blood, and other body fluids, and appropriate safety precautions should be taken. [Arch Virol Suppl. 1996;11:141.]

8. Convalescence from Ebola Virus Disease is long and often associated with sequelae such as myelitis, recurrent hepatitis,  psychosis, or uveitis. Data on the post-recovery viraemic period are limited. As said above shedding of Ebola virus has been  reported in breast milk and semen after the virus has been cleared from blood. Viable virus has been isolated  from semen up to many weeks or months after recovery, and spermatogenic transmission of Marburg virus has been  documented. There is a paucity of data on Ebola virus in human egg cells. The risk of Ebola transmission should be considered in connection with reproductive cell donations, both for ‘partner’ and ‘other than partner’ donations.

However, the evidence that Ebola virus may persist for some time in the human body after recovery from Ebola Fever is  insufficient to define a specific deferral period for donors who have recovered from Ebola Fever. The current guidance  stipulates deferral for 12 months following recovery from a viral hemorrhagic fever and this recommendation  also applies to donors who have recovered from Ebola Fever. In addition, living or deceased donors of substances of human origin should be negative for Ebola virus by NAT testing

9. A deferral of donation for two incubation periods will provide a reasonable margin of safety for asymptomatic donors returning from Ebola affected areas. The longest incubation period for Ebola Disease has been 25 days. Thus, asymptomatic travelers or residents returning from Ebola Virus affected areas should be temporarily  deferred from donation of substance of human origin including blood for two months after leaving an area affected by Ebola virus.

10. Men who have recovered from the illness can still spread the virus to their partner through their semen for many months after recovery. For this reason, it is important for men to avoid sexual intercourse after recovery or to wear condoms if having sexual intercourse during this period after recovery.

[ Dr K K Aggarwal is Padma Shri, Dr  B C Roy National and National Science Communication Awardee, President Heart Care Foundation of India and Senior National Vice President, Indian Medical Association]

Monday, November 17, 2014

Zinc Phosphode the lethal killer in Chhattisgarh sterilization tragedy

New Delhi: After 13 women died in a sterilization programme in Chhattisgarh, a preliminary enquiry has revealed that the drug used during the procedure could have been contaminated with zinc phosphide, widely used as rodenticide and perhaps could be the cause of death of the victims.

Confirming these findings, Commission Bilaspur Division, Sonmani Borah, said traces of zinc phosphide have been found in Ciprocin 500mg tablets, manufactured by Mahawar Pharmaceutical Pvt Ltd. These tablets were distributed to all the women who underwent sterilizations at the three health camps - Takhatpur, Pendra and Marwahi - in Bilaspur district on last Saturday and Monday.

Mahawar Pharma Pvt Ltd's director Ramesh Mahawar and his son Sumit have been arrested under section 420 for cheating, based on a complaint lodged by Food and Drug Administration authorities.

All about Zinc Phosphide

Zinc phosphide can be prepared by the reaction of zinc with phosphorus; however, for critical applications, additional processing to remove arsenic compounds may be needed.

Zinc phosphide reacts with water to produce phosphine and zinc hydroxide. Metal phosphides is used as rodenticides.

A mixture of food and zinc phosphide is left where the rodents can eat it. The acid in the digestive system of the rodent reacts with the phosphide to generate the toxic phosphine gas.

Other pesticides similar to zinc phosphide are aluminium phosphide and calcium phosphide.

There is usually only a short interval between ingestion of phosphides and the appearance of systemic toxicity. Phosphine-induced impairment of myocardial contractility and fluid loss leads to circulatory failure, and critically, pulmonary edema supervenes, though whether this is a cardiogenic or non-cardiogenic is not always clear.
Metabolic acidosis, or mixed metabolic acidosis and respiratory alkalosis, and acute renal failure are frequent.

Other features include disseminated intravascular coagulation, hepatic necrosis and renal failure. There is conflicting evidence on the occurrence of magnesium disturbances.

There is no antidote to phosphine or metal phosphide poisoning and many patients die despite intensive care. Supportive measures are all that can be offered and should be implemented as required.

Sunday, November 16, 2014

Depression linked to over 50% of heart blockages

Dr. Rick Levy from  Washington, DC who will be delivering a lecture on improving patient outcomes by treating stress, depression and  anxiety in the forthcoming Cardiological Society of India meet to be held at Hyderabad in early December said that depression, anxiety and ‘chronic worry’ correlate with a 2 to 5 times higher risk of developing heart blockages and 3 to 5 times higher morbidity and mortality  patients with established blockages.

Screening and treating heart patients for depression and anxiety  should be a standard practice. In the west over half of all heart patients suffer from depression or anxiety at some point, said Dr H K Chopra incoming President of National CSI.

A busy cardiologist can identify patients with clinical levels of depression and anxiety using an easy two-question Patient Health Questionnaire, or PHQ-2 – self-administered by the patient in less than a minute, and scored by a nurse or admitting staff member in less than 15 seconds.

The two questions to be asked are over the past two weeks how often have you been bothered by any of the following problems: Little interest or pleasure in doing things and Feeling down, depressed, or hopeless.

Give zero marks for not at all; 1 mark for several days, 2 marks for 50% of the days and 3 marks for every day. If the patient has a positive response to either question he or she needs a referral and treatment.  Maximum marks can be 6 and a cut off of 3 points can be taken a point for referral and treatment.

Commenting on the study Padma Shri, Dr B C Roy National and National Science Communication Awardee Dr K K Aggarwal Senior National Vice President Indian Medical Association said that Psychotherapy and regular meditation have been clinically proven to improve health outcomes for heart patients with depression and anxiety.

SSRIs are the only antidepressant proven relatively safe for heart patients.

Saturday, November 15, 2014

Long-term use of mobile and cordless phones is associated with an increased risk for brain cancer

It's official: Long-term use of mobile and cordless phones is associated with an increased risk for glioma, the most common type of brain tumor as per the latest research published online on October 28 in Pathophysiology.

The new Sweden study by Dr Lennart Hardell, Professor of Oncology at University Hospital, shows that the risk for brain tumor is tripled among those using a wireless phone for more than 25 years and that the risk is also greater for those who had started using mobile or cordless phones before age 20 years.
The widespread use of wireless communications has resulted in greater exposure to radiofrequency electromagnetic fields and the brain is the main target of these radiations when these phones are used, with the highest exposure being on the same side of the brain where the phone is placed.
In the study an increased risk for brain tumor was associated with use for more than 1 year of both mobile and cordless phones and the highest risk was for those with the longest latency for mobile phone use over 25 years.

The precautions, include using hands-free phones with the "loud speaker" feature and text messaging instead of phoning.

Talking on mobile is risky when driving but talking to friend in the car is less risky when he can also see the road

Mobile conversations are an enemy to safe driving. A new Canadian study from University of Alberta in Edmonton finds that drivers do best when they don't talk and simply focus on the road, if they must talk, it's better if the person they are talking to has his or her eyes on the road, too. That could mean either sitting in the passenger seat or via a specially designed videophone.

The study, published recently in Psychological Science, tested driver safety in one of four conditions, using a driving simulator.

1. A silent driver alone in the vehicle.

2. The driver accompanied by a passenger, where they engaged in conversation.

3. The driver speaking to someone on a hands-free cellphone with a standard audio-only connection.

4. The driver speaking to someone remotely with a one-way video connection. That connection allowed the person on the other end of the line to see both the driver and the driver's perspective of the road ahead, much as if they were a passenger in the car.

The study found

1. Nothing was as safe as driving alone in peace and silence.

2. Talking to a fellow passenger in the car was less safe than driving alone, but it was still safer than being on a typical, audio-only cellphone call, which tripled the odds for a collision compared to silent driving.

3. The videophone call was safer than having an audio call, and almost as safe as having a talking passenger sitting beside you.

Friday, November 14, 2014

Chhattisgarh sterilization deaths: Accident or Negligence

To err is human; error of judgment is not crime; difference of opinion is not crime, failure of outcome is not crime; routine complications are not crime; mere deviation from standard practice may not be crime, BUT what a crime is " not taking standard precautions, neglecting the patient or not taking proper consent. This can only be found out after proper investigations.

I have written to MCI to take this case suo moto and investigate. Punish the doctors if he is guilty or protect him and restore the image of the medical profession if he is not guilty.

Following MCI ethics regulations clauses are applicable in such mishaps

2.4 The Patient must not be neglected: A physician is free to choose whom he will serve. He should, however, respond to any request for his assistance in an emergency. Once having undertaken a case, the physician should not neglect the patient, nor should he withdraw from the case without giving adequate notice to the patient and his family. Provisionally or fully registered medical practitioner shall not willfully commit an act of negligence that may deprive his patient or patients from necessary medical care.

7.16 Before performing an operation the physician should obtain in writing the consent from the husband or wife, parent or guardian in the case of minor, or the patient himself as the case may be. In an operation which may result in sterility the consent of both husband and wife is needed.

7.22 Research: Clinical drug trials or other research involving patients or volunteers as per the guidelines of ICMR can be undertaken, provided ethical considerations are borne in mind. Violation of existing ICMR guidelines in this regard shall constitute misconduct. Consent taken from the patient for trial of drug or therapy which is not as per the guidelines shall also be construed as misconduct.

Grass root facts

•             Camps are common, standardized and happen with the knowledge of government authorities.
•             Government pays incentives for patients, doctors and staff
•             Day care surgeries are done in conveyer belt fashion

Issues to decide negligence or accident

•             Proper consent
•             How many laparoscopes were used
•             Time taken for laparoscope sterilization
•             Time between two surgeries
•             Type of anesthesia given
•             Type of drugs used
•             How many surgeries are done in how much time
•             Qualification of the surgeon
•             Experience of the surgeon
•             Autopsy reports
•             CO2 used: quality
•             Quality of instruments used

Government steps on the tragedy

•             Meanwhile even as reports said that rusted equipment were used in the surgeries, a team of doctors from Delhi's premier AIIMS hospital is in Bilaspur to investigate what happened.
•             The medicines used have been sent to a lab in Kolkata for analysis
•             Autopsy reports are awaited

Media Trial

"Times Now"  TV channel news at 7-15 p.m. on 13-3-2014 equated Dr. R K Gupta, surgeon, of Chhattisgarh as "Doctor Death", "Butcher of Bilaspur" and "Merchant of Death".

Comments by fellow colleagues

•             "Till the results of the enquiry are released the doctors should not be harassed. The medic should not project the negative image of the profession" : Dr Narendra Saini Honorary Secretary general IMA
•             "It is for the IMA to digest it and to be blind to it and to ignore it or to launch  media blitz  against this channel and to send a legal notice demanding within 72 hours an unqualified apology to be prominently telecast on the same channel, failing which the IMA should initiate appropriate legal proceedings. Please note that IMA has full locus standi to move on these lines because it represents the whole medical profession and ought to preserve its dignity and respect. Dr M C Gupta"
•             " "Held that the tubectomy was done free at a primary health centre as part of government’s family planning programme without payment of any money and hence it was not within the ambit of consumer act…………………………………." M C Gupta
•             The government has announced a relief of Rs. 2 lakhs only ( Dr Mehra)
•             " Here in chhattisgarh government pay 1400 to the patient for sterilization operations and if operation fails than 30000 as compensation to be paid but they are not consumer still so many cases are going on in consumer court for the same and our treating surgeon keeps on attending the trials on behalf of govt. I don't understand why consumer court accepted these cases" Vicky bansal
•             " PAYING 30,000/- as compensation for failed tubectomy is in itself a wrong step as any procedure can fail. So what is the big deal?" Dr Sodhi
•             " We are talking of doctors & doctors alone. Please remember that this is a government programme, government doctors, government everything. There is something called vicarious responsibility. There is another thing which is "owning up responsibility". And finally there is something (though rare) called "shame". Another rare item is "moral ground"  Do you all not feel that the health minister should own up responsibility and resign on moral grounds? Dr Sodhi

Questions which need to be answered ( Dr Neeraj Nagpal)

1.            Is Surgeon responsible for deaths in family planning camp?
2.            Is setting of targets for family planning responsible for such mishaps?
3.            Is the team including nurses, helpers, OT assistants equally responsible ?
4.            Is the team including nurses, helpers, OT assistants equally responsible ?
5.            Should the nurses, OT technicians and helpers who were part of team also be arrested?
6.            Is arrest of Surgeon without finding cause of mishap correct?
7.            What are various reasons one can think as cause of 14 deaths in family planning camp?: Lack of sterilization of instruments by paramedical staff/ Reaction to medicines or anesthesia used/ Chemical contaminant in CO2 used for insufflation/ Poor skill of surgeon leading to bleeding/ Carelessness of surgeon while operating/ Carelessness of surgeon in preoperative and postoperative care/ Mischief by someone part of surgical team
8. Are Doctors pressurized to do more and more surgeries in Family Planning camps by their superiors?
 9. Does the concept of medical and surgical camps in sub optimal settings need to be abolished
10. Should those who pressurize doctors to achieve 'targets' also be punished ?
11. Should compensation awarded by Govt to deceased not be raised to 20 lacs or more in such a mishap ?
12. How should such tragedies be avoided in future ?: Reduce number of surgeries which can be done in one camp to 10; Use minimum 3 Laproscopes and instrument sets for one camp; Qualified nurses and OT assistants to accompany doctor on such camps; Penalize superiors if more than 10 tubectomies are done in one camp; Abolish family planning camps totally or Punish surgeon severely to make example of him
13. Should awards be given as incentive to surgeons who perform more surgeries in family planning camps?
14. Is labeling the Surgeon 'Killer' by our print and electronic media appropriate ?
15. After such media condemnation if it is found later the surgeon was not at fault ?   Should he be compensated by his employers / Should he be compensated by the Press/

Should he be compensated by his professional Associations who did not support him ?

Thursday, November 13, 2014

The risk for coronary artery disease is two to four times higher in diabetic subjects

Indians get diabetes on average 10 years earlier than their Western counterparts

Being an Indian is a risk factor for diabetes; despite having lower overweight and obesity rates, India has a higher prevalence of diabetes compared to western countries and the risk for coronary artery disease is two to four times higher in diabetic subjects,  and in Indians, and it occurs prematurely are a few of the facts compiled by Heart Care Foundation of India to create awareness about how to control the diabetic menace in India.

All the public, private and government sector should fight the diabetic menace epidemic menace together, said Padma Shri, National Science Communication and Dr B C Roy National Awardee, Dr KK Aggarwal President Heart Care Foundation of India and Senior National Vice President Indian Medical Association.

Diabetes  challenges for India and Indians as compiled by the foundation

1.    Diabetes is a huge problem in India. The prevalence of diabetes increased tenfold, from 1.2% to 12.1%, between 1971 and 2000. It is estimated that 61.3 million people aged 20-79 years live with diabetes in India (2011 estimates). This number is expected to increase to 101.2 million by 2030. And, 77.2 million people in India are said to have pre-diabetes.

2.     Rough estimates show that the prevalence of diabetes in rural populations is one-quarter that of urban population for India and other Indian sub-continent countries such as Bangladesh, Nepal, Bhutan, and Sri Lanka.  An ICMR study has shown that a lower proportion of the population is affected in states of Northern India (Chandigarh 0.12 million, Jharkhand 0.96 million) as compared to Maharashtra (9.2 million) and Tamil Nadu (4.8 million). The National Urban Survey conducted across the metropolitan cities of India reported similar trend: 11.7 per cent in Kolkata (Eastern India), 6.1 per cent in Kashmir Valley (Northern India), 11.6 per cent in New Delhi (Northern India), and 9.3 per cent in West India (Mumbai) compared with (13.5 per cent in Chennai (South India), 16.6 per cent in Hyderabad (south India), and 12.4 per cent Bangalore (South India).

3.    Obesity is one of the major risk factors for diabetes, yet there has been little research focusing on this risk factor across India. Despite having lower overweight and obesity rates, India has a higher prevalence of diabetes compared to western countries suggesting that diabetes may occur at a much lower body mass index (BMI) in Indians compared with Europeans.

4.     A most disturbing trend is the shift in age of  onset of diabetes to a younger age. Indians get diabetes on average 10 years earlier than their Western counterparts.  An upsurge in number of early-onset diabetes cases is also responsible for the development of various diabetic complications due to longer disease duration. Diabetes control in individuals worsened with longer duration of the disease (9.9±5.5 years), with neuropathy the most common complication (24.6 per cent) followed by cardiovascular complications (23.6 per cent), renal issues (21.1 per cent), retinopathy (16.6 per cent) and foot ulcers (5.5 per cent).

5.     The risk for coronary artery disease is two to four times higher in diabetic subjects,  and in Indians, and it occurs prematurely. Indians are genetically predisposed to the development of coronary artery disease due to dyslipidaemia and low levels of high density lipoproteins; these determinants make Indians more prone to development of the complications of diabetes at an early age (20-40 years) compared with Caucasians (>50 years) and indicate that diabetes must be carefully screened and monitored regardless of patient age within India. The rate of cardiovascular disease mortality in India in the 30-59-year age group is double that in the U.S.

6.     Lifestyle changes have lead to decreased physical activity, increased consumption of fat, sugar and  calories, and higher stress levels, affecting insulin sensitivity and obesity. 86% of adults consume less than five servings of fruits and vegetables a day. 18.    Many Indians have insufficient physically activity (26.4% among males and 25.6% among females).

7.     Costs of diabetes care are alarmingly high. The annual cost for India due to diabetes was about $38 billion in 2011. According to the WHO, if one adult in a low-income family has diabetes, “as much as 25% of family income may be devoted to diabetes care.”   According to the World Economic Forum, cardiovascular disease, cancer, chronic respiratory disease,  diabetes and mental health conditions will cost India 126 trillion rupees between 2012 and 2030.

8.     While HbA1c is the gold standard test around the world for insulin initiation and intensification, it is not easily available to a large section of Indian population.

9.     There is a lack of “clinical inertia” for the commencement of insulin therapy in both the clinical and patient communities. The most common apprehensions are related to the complexities of the insulin regimen and concerns about weight gain, hypoglycaemic events, and fear of insulin prick.

10.     An inadequacy in Indian guidelines is also responsible for wide variation in treatment preferences across the country. The creation of simple and practical insulin guidelines that can be incorporated into routine clinical practice by primary health care physicians are desperately required to facilitate treatment and the initiation of insulin therapy throughout the country. Poor glycaemic control, a factor that has been observed in the Indian diabetic population, is responsible for micro- and macrovascular changes that present with diabetes

Monday, November 10, 2014

Eating a healthy breakfast decreases the risk of developing type 2 diabetes

Eating a healthy breakfast decreases the risk of developing type 2 diabetes

New Delhi: World Diabetes Day is celebrated annually on November 14. Led by the International Diabetes Federation (IDF), World Diabetes Day was created in 1991 by IDF and the World Health Organization in response to growing concerns about the escalating health threat posed by diabetes.

Healthy Living and Diabetes is the World Diabetes Day theme for this year with focus on the importance of starting the day with a healthy breakfast to help prevent the onset of type 2 diabetes and effectively manage all types of diabetes to avoid complications.

"Eating a healthy breakfast decreases the risk of developing type 2 diabetes", said Padma Shri, National Science Communication and Dr B C Roy National Awardee, Dr KK Aggarwal president Heart Care Foundation of India and Senior National Vice President Indian Medical Association.

"A healthy diet is, more expensive than an unhealthy one. The wide availability of cheap energy dense low-nutrient food is contributing to the global epidemic of type 2 diabetes. Foods which reduce the risk of type 2 diabetes such as vegetables, fresh fruit, whole grains and unsaturated fats need to be more affordable and more widely available", added Dr Aggarwal.

A healthy diet containing leafy vegetables, fresh fruit, whole grains, lean meat, fish and nuts  can help reduce a person’s risk of type 2 diabetes  and avoid complications in people with diabetes.

Diabetes is a huge and growing burden: while 382 million people were living with diabetes  in 2013 that number is expected to balloon to  almost 600 million people by 2035. Diabetes is fast gaining the status of a potential epidemic in India with more than 62 million diabetic individuals currently diagnosed with the disease.
Up to 11% of total healthcare expenditure in every country across the globe could be saved by tackling the preventable risk factors for type 2  diabetes and over 70% of type 2 diabetes cases can be prevented or delayed by adopting healthier 

Saturday, November 8, 2014

Verapamil can reverse Diabetes

Verapamil can increase the beta cell mass: Verapamil, a drug used to control high blood pressure and arrhythmias has been shown by Dr Anath Shalev at University of Birmingham, Alabama to not only prevent type 1 diabetes in mice but reverse severe established diabetes. The drug down regulates a key promoter of type 1 diabetes (thioredoxin-interacting protein ) and bolster whatever dysfunctional beta cells remain in the pancreas. The treatment definitely creates an environment where beta cells are allowed to survive.

And now one year human trial, entitled, "The repurposing of verapamil as a beta-cell survival therapy in type 1 diabetes," is expected to begin early in 2015 by the same group.

Over a decade ago, the UAB team was able to identify a protein called thioredoxin-interacting protein (TXNIP), which is dramatically increased in human islet cells in response to high glucose levels. The researchers hypothesized that TXNIP might be involved in beta-cell death associated with diabetes. 

  Even short-term postprandial glucose excursions, as seen in pre-diabetes, may lead to a gradual, cumulative increase in TXNIP expression before any onset of overt diabetes. Furthermore, insulin resistance or any increased demand on the beta cell may also lead to elevated beta-cell TXNIP levels.
The team showed that TXNIP does indeed induce beta-cell death by apoptosis: in mice models in which TXNIP had been genetically deleted, for example, the animals were completely protected against diabetes.

Reduction of intracellular calcium inhibits the transcription and expression of TXNIP, so by using the calcium-channel blocker Verapamil to do this, they were able to mimic the effects of genetically deleted TXNIP in mice and preserve the insulin-producing beta cells.

Even after the animals had developed full-blown diabetes with high blood sugar levels, when treated with Verapamil, blood sugars normalized, and this was due to the reappearance and normalization of insulin-producing beta cells. [Mol Endocrinol. 2014:28:1211-1220]

Note: In India use of Verapamil in diabetes will be an off label use and hence will require consent. However those with high blood pressure or with hear blockages can be shifted to Verapamil.'

Friday, November 7, 2014

Non obstructive heart blockages not benign : Dr K K Aggarwal

In a retrospective study of patients undergoing elective coronary angiography, non-obstructive coronary artery disease (heart blockages), compared with no apparent coronary artery disease ( no blockages), was associated with a significantly greater 1-year risk of heart attack and all-cause mortality.

After risk adjustment, there was no significant association between 1- or 2-vessel non-obstructive coronary artery disease ( blockages in one or two arteries) and mortality, but there were significant associations with mortality for 3-vessel non-obstructive coronary artery disease (blockages in all three arteries).

Veterans with evidence of non-obstructive CAD on elective coronary angiography had a 2- to 4.5-fold greater risk for heart attack compared with those with no evidence of blockages and 1-year heart attack risk was found to increase progressively by the extent of blockages, rather than increasing abruptly when blockages became obstructive.
The results of this study are published in Nov. 5 JAMA.

Never tell your patients " that your coronaries are fine and they have nothing to worry about," but one should say " 'There is evidence of atherosclerosis and while there is no need to panic, we need to address it.'" Remember there is nothing like " mild coronary artery disease or mild blockages in the heart."

Up to 1 in 4 Angiograms Show Minimal Plaque or blockages.

Non-obstructive blockages mans presence of atherosclerotic plaque revealed during coronary angioplasty or angiography that does not appear to obstruct blood flow or result in angina symptoms.

These non-obstructive lesions occur in between 10% and 25% of patients undergoing elective angiography, and their presence has historically been characterized as "insignificant" or "no significant blockages  in the medical literature even though multiple studies have shown plaque ruptures leading to heart attack commonly come from non-obstructive plaques.

Thursday, November 6, 2014

Recurrent Kidney Stones: IMA Guidelines

Recurrent Kidney Stones: IMA Guidelines

Lifetime prevalence of kidney stones is approximately 13% in men and 7% in women. Without treatment, approximately 35% to 50% of those with kidney stones will experience recurrence within 5 years from the first stone.

Here are some guidelines

1. Increasing fluid intake to achieve at least 2 L of urine per day. "Increased fluid intake spread throughout the day can decrease stone recurrence by at least half with virtually no side effects. However, people who already drink the recommended amount of liquids, or when increased fluid intake is contraindicated, should not increase their fluid intake.

2. Available evidence shows no difference between intake of tap water or intake of a specific brand of mineral water in preventing kidney stones.

3. If drinking increased amounts of water is ineffective in preventing kidney stones, one may try pharmacologic monotherapy with a thiazide diuretic, citrate, or allopurinol.  These three types of drugs effectively reduced recurrence of composite calcium stones in patients who had a history of two or more stones. Combination therapy is no more effective than monotherapy.  All these drugs were associated with adverse events. For thiazides, these were orthostasis, gastrointestinal upset, erectile dysfunction, fatigue, and muscle symptoms. Citrates are associated with gastrointestinal symptoms and allopurinol with rash, acute gout, and leukopenia.

4. Patients should reduce intake of colas and other soft drinks acidified with phosphoric acid, as lower consumption is linked to lower risk for stone recurrence.

5. Fruit-flavored soft drinks can be taken as they are often acidified with citric acid.

6. Patients should reduce consumption of dietary oxalate, typically found in chocolate, beets, nuts, rhubarb, spinach, strawberries, tea, and wheat bran.

7. Patients should eat less dietary animal protein and purines.

8. Patients should maintain normal dietary calcium.

[ Contributor: Padma Shri, Dr B C Roy National Awardee and National Science Communication Awardee Dr K K Aggarwal, Honorary Secretary General IMA]

[Reference: November 4 issue of the Annals of Internal Medicine]

Wednesday, November 5, 2014

No heart patient should take antibiuotics without supervision: Dr K K Aggarwal

Antibiotic Cotrimoxazole when Combined With ACE Inhibitor or ARB can end up with Sudden Death

Trimethoprim-Sulfamethoxazole May Increase Risk for Hyperkalemia in the Elderly

New Delhi: In a study published in BMJ, the risk of sudden death went up by more than a third in older patients taking ACE inhibitors or angiotensin-receptor blockers (ARBs) who were also put on the antibacterial agent cotrimoxazole (sulfamethoxazole and trimethoprim), compared with those who were instead given amoxicillin.

The elevated risk was likely caused by its capacity for raising serum potassium, which became fatal on top of other medications known for causing hyperkalemia.

Patients who are on ACE inhibitors or ARBs, are at risk for hyperkalemia, should not take any antibiotic without medical supervision.

If given

1. One should give it at the lowest dose and for a minimum period of time
2. And keep a watch on potassium.

Diabetics are vulnerable

Patients with type 2 diabetes have a tendency for hyperkalemia because od silent kidny involvement
Heart failure patients if on potassium-sparing spironolactone are also at risk
Patients with both reduced left ventricular function and diabetes have the greatest risk.

The risk, he said, depends on the antibiotic's dosage and duration of use. Ten days of cotrimoxazole may be risky while three days not.
In the study data from patients aged 66 or older who received ACE inhibitors or ARBs in Ontario from 1994 to 2012, identified outpatients who died of sudden death within 7 days of being prescribed cotrimoxazole, amoxicillin, ciprofloxacin, norfloxacin, or nitrofurantoin. Those 1027 cases were matched to 3733 controls alive within that time frame relative to the antibiotic prescriptions, based on, among other things, age, sex, chronic kidney disease, and diabetes.

The adjusted odds ratios (95% CI) for sudden death within 7 days of an antibiotic prescription on top of an ACE inhibitor or ARB, by antibiotic, relative to amoxicillin (which does not pose a hyperkalemia risk itself or prolong the QT interval) were: 1.38 for cotrimoxazole; 1.29 for ciprofloxacin; 0.74 for norfloxacin and 0.64 for nitrofurantoin.

Ciprofloxacin can predispose to sudden death by prolonging the QT interval.

Tuesday, November 4, 2014

Type 2 diabetes can be delayed or prevented

Type 2 diabetes can be delayed or prevented, and both types 1 and 2 diabetes can be managed to prevent complications.

India is the diabetic capital of the world.

People with diabetes are nearly two times more likely than people without diabetes to die from heart disease, and are also at greater risk for kidney, eye and nerve diseases, among other painful and costly complications. Type 2 diabetes can be delayed or prevented, and both types 1 and 2 diabetes can be managed to prevent complications.

The National Diabetes Month, include World Diabetes Day on Nov. 14.

In type 1 diabetes, the body does not make insulin. In type 2 diabetes the body does not make or use insulin well. Gestational diabetes, occurs in some women during pregnancy. Though it usually goes away after the birth, these women and their children have a greater chance of getting type 2 diabetes later in life.

Type 2 diabetes has begun to affect young people.

Losing a modest 15 pounds of weight through diet and exercise can actually cut your risk of getting type 2 diabetes by as much as 58 percent in people at high risk.

In type 1 diabetes, tight control of blood sugar can prevent diabetes complications.

Diabetes Tips

·         Choose healthy foods to share.
·         Take a brisk walk together every day.
·         Talk with your family about your health and your family’s risk of diabetes and heart disease.
·         If you smoke, seek help to quit.
·         Make changes to reduce your risk for diabetes and its complications — for yourself, your families and for future generations.

Monday, November 3, 2014

Affecting over 127 lakh Indians, Artrial Fibrillation is the new growing epidemic of the country

Experts conclude at the 7th APHRS Scientific Session one of the largest International conferences on Heart Rhythm disorders in the World

Atrial Fibrillation, one of the most common Heart Rhythm disorders was concluded to be a growing epidemic in India affecting over 12.7 million Indians in 2013 as compared to 12.3 million in 2012. This was the main topic of discussion at the 7th APHRS Scientific Session, one of the largest gatherings of Cardiac Electrophysiologists in the world. In it’s in its 7th edition, the APHRS Scientific Session was jointly organized in India for the first time ever by the Asia Pacific Heart Rhythm Society (APHRS) and the Indian Heart Rhythm Society (IHRS). The topics of discussion included ECGs, Sudden Cardiac Death, Atrial Fibrillation, Heart Failure and Arrhythmia. The four-day conference was held between October 29 – Nov 1 simultaneously at Hotel Taj Palace and ITC Maurya in New Delhi.

A special focus was also given to technological development in the field of heart rhythm disorders through revolutionary technologies such as Leadless Pacemakers and Subcutaneous Implantable Cardioverter Defibrillator’s (ICD). According to the data presented in the APHRS 2014 white book, which was released on the closing ceremony of the conference, in 2013 over 23 lakh Indians suffered from heart failure and 6,27,000 died due to sudden cardiac death. The total number of pacemakers implanted in the year 2013 was 36,322 and ICD’s 1950. This showed the need for global platforms such as these to discuss the growing incidence of heart rhythm disorders and its treatment.

The highlight of the conference were the 200 scientific sessions conducted by 250 core leading National and International faculty including Dr Richard Fogel (President Heart Rhythm Society USA), Dr Young Hoon Kim (President APHRS), Dr Johnathan Kalman, Dr Kalyalam Shivkumar and Dr Mohan Nair (Organizing Committee Chairman APHRS Scientific Session 2014).

Speaking on the occasion Dr Mohan Nair, Chairman Organizing Committee, 7th Asia APHRS Scientific Session and Chairman Cardiology, Saket City Hospital said, “It is indeed a proud moment to have an International conference of such stature and scale being organized in India. With the increasing incidence of heart rhythm disorders in the country, it is extremely important that we make full use of the advancements in technology in the fields of arrhythmia and electro cardiology and educate the community about new and innovative treatment options available globally. I am happy to say that India today is at par with global and more and more innovations are being done in India in the field in line with our Prime Minister’s Make in India initiative”. 

Speaking on the occasion, Dr Young-Hoon Kim, President APHRS said, “Started in 2008, APHRS takes place every year in different countries of the Asia Pacific Region. The goal behind scheduling these conferences in different countries is to provide an exchange of information related to not only arrhythmia and electro cardiology but also to put forward an apt platform for the exposure to the local culture which is rewardingly educational and deeply enriching. I had a great time in India and look forward to coming back in the future. I am happy to announce that the next APHRS Scientific Session will take place in Melbourne, Australia in 2015”.

Giving a global perspective, Dr Jonathan KalmanProfessor at The Royal Melbourne Hospital in Melbourne, said, “Atrial fibrillation (AF) is the most common sustained heart rhythm disturbance and a major cause of stroke and death. Over recent decades, the incidence of AF has increased dramatically, positioning AF as one of the epidemics of the new millennium. Conferences like the APHRS Scientific Session like are extremely important platforms to discuss advancements in the field and provide adequate training to heart rhythm physicians to address this modern epidemic”.

Adding to this, Dr Richard Fogel, President, Heart Rhythm Society, USA said, “The treatment of arrhythmic disorders differs not just within different North American countries but also globally, making a platform such as this extremely beneficial and important. Technological advancement has now revolutionized treatment of heart rhythm disorders. For instance putting a three lead pacemaker is now an established non-drug therapy for end stage heart failure.”

      Key Highlights of the conference included

1.     Atrial fibrillation is the leading cause of stroke (paralysis) in the elderly
2.     Patient with atrial fibrillation need long-term blood thinners. Now safer blood thinners are available which do not require blood monitoring
3.     Sudden cardiac death is preventable. The general public should learn hands-only cardiopulmonary resuscitation (CPR)
4.     Patients who have low pumping action of the heart require a machine, implantable cardioverter-defibrillators (ICD), an internal electric shock device, which delivers an electric shock when the heart stops functioning due to the disturbed very high rhythm and thus restores normal rhythm
5.     Today it is possible to electrically burn (ablate) the electrical pathways of the heart that cause abnormal rhythm
6.     It is possible now to put a pacemaker without a lead
7.     It is now possible to put an internal electric shock device (ICD) subcutaneously below the skin bypassing the muscle
8.     All children going for competitive sports in school should be screened for chances of sudden cardiac death during sports
9.     All patients with low pumping action of the heart may require not only an internal electric shock device (ICD), but also a 3 lead pacemaker to improve pumping action of heart
10.  All patients with irregular rhythm, atrial tachycardia, should go for electric burning of accessory pathway of the heart (ablation), which is now practically a nonsurgical procedure
11.  All high risk patients should be screened for risk of sudden cardiac death so that necessary measures can be taken to prevent sudden cardiac death.
 12.   There is a need for a nationwide sudden cardiac death prevention program