Should aspirin be discontinued preoperatively in patients undergoing non-cardiac surgery?

·         If the patient is on aspirin for primary prophylaxis, then discontinue aspirin for 5 to 7 days before the surgery. Restart as soon as the perioperative risk of major bleeding has passed.

·         If the patient is on long-term aspirin for secondary prophylaxis, continue aspirin in patients with prior PCI with stenting and those undergoing carotid endarterectomy, unless the risk of major bleeding is thought to be high (POISE-2 trial) or the surgery involved is not likely to have bleeding controlled by homeostasis (prostate surgery, intra ocular surgery, intra cranial surgery).

·         Aspirin can be safely continued in most patients undergoing minor dental surgery or dermatologic procedures.

·         Guidelines from the American Society of Regional Anesthesia (ASRA) suggest that NSAIDs, including aspirin do not create a level of risk that will interfere with the performance of neuraxial blocks, and should not impact catheter techniques, timing of neuraxial catheter removal, or postoperative monitoring.

·         Discontinue cilostazol for at least 2 to 3 days prior to an elective surgery.

·         There is no data on the safety of dipyridamole if continued in the perioperative period. If discontinued, the drug should be stopped at least 2 days before surgery.

Dual antiplatelet therapy (DAPT) after PCI with stenting

·         Defer non-emergent noncardiac surgery for at least 6 months irrespective of stent type. In patients who must undergo non-emergent (time sensitive) noncardiac surgery prior to six months, attempt to defer surgery for at least three months after bare metal or drug-eluting stent placement. In patients for whom surgery before three months is in their best interest after weighing risks and benefits, refer patients as early as one month after stent placement.

·         For most patients undergoing noncardiac surgery who are taking DAPT after PCI with stenting because they have not reached the recommended minimum duration of such therapy, continue DAPT, as opposed to stopping it prior to surgery

·         In patients for whom the risk of bleeding is likely to exceed the risk of a perioperative event due to the premature cessation of DAPT, continue aspirin alone.

·         Stop both antiplatelet agents, in patients for whom a bleeding complication could be catastrophic, such as patients undergoing neurosurgical, prostate, or posterior eye procedures.

·         For patients taking DAPT after PCI with balloon angioplasty who are scheduled to undergo elective noncardiac surgery, wait at least 14 days after PCI

·         Clopidogrel, prasugrel, and ticagrelor when stopped should be stopped 5, 7 and 3-5 days, respectively, before surgery.

·         Clopidogrel, if stopped, should be restarted with a loading dose of 300-600 mg as soon as possible after surgery, perhaps even later in the day if postoperative bleeding has stopped.

·         Surgery be performed in centers with 24-hour interventional cardiology coverage

Dr KK Aggarwal

Padma Shri Awardee

Vice President CMAAO

Group Editor-in-Chief IJCP Publications

President Heart Care Foundation of India

Immediate Past National President IMA

Loneliness is a strong predictor of premature death

Loneliness has been shown to be a strong predictor of premature death due to cardiovascular events like heart attack, stroke. Loneliness and social isolation have been labeled as the new public health risks.

A meta-analytic review of social relationships and mortality risk published in PLoS Medicine in 2010 established that social relationships influences mortality risk. Data across 308,849 individuals, followed for an average of 7.5 years, indicate that participants with stronger social relationships had 50% increased chances of survival compared to those with poor or insufficient social relationships, which increased the risk of death by 50%. The study also suggested that the influence of social relationships on the risk of death is comparable with well-established risk factors for mortality such as smoking and alcohol consumption and exceed the influence of other risk factors such as physical inactivity and obesity.

In a more recent study published in July 2016 in Heart, poor social relationships or social isolation or loneliness was associated with a 29% increase in risk of incident CHD and a 32% increase in risk of stroke when compared with their peers who were either well connected or at least felt like they were well-connected.

Human behavior is governed by the needs of the individual. Every behavior is justified medically as every action is performed according to one’s own psyche, which in turn depends upon the needs. As per Vedic knowledge, human body is made up of physical body, mind, intellect, ego and the soul. The needs were classified as physical needs, emotional and social needs, intellectual needs, egoistic needs and the spiritual needs.

Inner happiness is attained when all these needs are met. This means that the person is in a parasympathetic state of mind, in which the mind is quiet and composed enabling rational and right conscious–based decisions and just the right frame of mind to tackle complications.  It is characterized by reduction in heart rate and blood pressure.

A sympathetic state of mind, on the other hand, releases stress hormones and may trigger panic or nervousness. The sympathetic system is predominant during acute stress evident by increase in heart rate and blood pressure. A person cannot take correct and decisive decision in a sympathetic state of mind.  He or she is likely to make mistakes which can often be detrimental to one’s living. Negativity of the mind also indicates a sympathetic state of mind.

A person who is lonely or socially isolated has unfulfilled needs. There is nobody to share emotions, intellectual conversations, give comfort or to lend a shoulder to cry on. A lonely person has to live alone with all his guilt and negative thoughts that stay within the subconscious mind. These individuals are also more likely to have anxiety and depression.

All these precipitate a sympathetic state, which may trigger an acute cardiovascular event such as high BP, heart attack, stroke and arrhythmias, which increase risk of death.

Dr KK Aggarwal

Padma Shri Awardee

Vice President CMAAO

Group Editor-in-Chief IJCP Publications

President Heart Care Foundation of India

Immediate Past National President IMA

Telephonic consultations: How safe are they?

In a recent judgment, the Bombay High Court turned down the anticipatory bail pleas of a doctor couple booked for the death of a woman patient under section 304 of Indian Penal Code (culpable homicide not amounting to murder) after the patient died earlier this year. The high court noted that there was no effort to refer the woman to another doctor in the absence of Deepa Pawaskar and she (Deepa) continued to prescribe medicines telephonically. “There was no resident medical officer or any other doctor to look after the patient in the absence of Dr Deepa and Sanjeev Pawaskar even when the couple knew that they would not be available in the hospital.” The accused couple, in their pleas, argued that they could not be charged with culpable homicide not amounting to murder and should, at the most, be booked under section 304 (A) (causing death due to negligence). However, the high court said that in the present case, the applicants took the risk of doing something with recklessness and indifference to the consequences. "An error in diagnosis could be negligence and covered under section 304 (A) of the Indian Penal Code. But this is a case of prescription without diagnosis and, therefore, culpable negligence." "When a doctor fails in his duty, is it not tantamount to criminal negligence? The courts cannot ignore the ethical nature of the medical law by liberally extending the legal protection to the medical professionals..." Thus, the Bench concluded that “Prescription without diagnosis would amount to culpable negligence. This amounts to gross negligence from the point of standard of care and recklessness and negligence, which is a tricky road to travel”.

In an earlier judgement in the matter of Martin F. D'Souza vs Mohd Ishfaq (3541 of 2002) dated 17.02.2009 in the Supreme Court of India, the Bench comprising of Justice Markandey Katju and GS Singhvi laid down precautions which doctor/hospitals/nursing homes should take to protect themselves from complaints of medical negligence. One amongst these relates to telephonic consultation, “No prescription should ordinarily be given without actual examination. The tendency to give prescription over the telephone, except in an acute emergency, should be avoided (54(b).”

The moral of the story is that telephonic consultations should be avoided as a routine.

However, if needed, consultations on phone can be given, provided there is an established relationship between the doctor and the patient. And, most importantly, the doctor is fully cognizant of the attendant risks, both medical and medicolegal.

If the concerned patient is under the treatment of a doctor, and the doctor is aware of the nuances of the case, then telephonic consultations can be given. For example, the patient may call the doctor to convey the results of lab tests or histopathology reports that he/she may been advised by the treating doctor. Opinion on an x-ray image may also be sought via a telephonic consultation.

A telephonic consultation for a patient means improved access and convenience. While doctors too would prefer the convenience, the issue of note for them is to recognize when this form of consultation is not sufficient to properly evaluate the patient and address the complaint, and to arrange a face-to-face consultation instead or provide timely and appropriate advice if the condition of the patient is deteriorating.

As a safeguard, the record of the consultation can be maintained with consent of the patient. Likewise, doctors should also be careful about any recordings being made by the patients without their consent. The doctors should be attuned to the tone and content of the speech in the conversation.

The confidentiality and privacy of the consultation and patient health information and other data should be maintained. No data should be shared without the prior consent of the patient.

Failure to abide by these rules could lead to a complaint of medical negligence filed against the doctor.

Dr KK Aggarwal

Padma Shri Awardee

Vice President CMAAO

Group Editor-in-Chief IJCP Publications

President Heart Care Foundation of India

Immediate Past National President IMA

Scrub typhus in India: Do not ignore fever with black patch on the skin

Scrub typhus, also known as Tsutsugamushi disease or Chigger borne typhus or Bush typhus, is an acute febrile illness caused by Orientia tsutsugamushi (earlier known as Rickettsia tsutsugamushi), an obligate intracellular Gram-negative bacterium.

Scrub typhus is endemic to a part of the world called the “tsutsugamushi triangle”, which extends from northeast Asia to Papua New Guinea and northern Australia in the southeast, Pakistan and Afghanistan in the northwest, and the Maldives and Réunion Islands in the southwest. However, evidence has shown that scrub typhus may not be restricted to the tsutsugamushi triangle and may be present outside this endemic zone also.

Scrub typhus is a re-emerging zoonotic disease in India. It is prevalent in many parts of India particularly in the sub-Himalayan belt, from Jammu to Nagaland. Outbreaks are frequent during the rainy season; but, in south India outbreaks occur during the cooler months of the year.

Here are some salient features about scrub typhus.

·         The trombiculid mite is the reservoir of infection. The larva (chigger) feeds on the vertebrate hosts and acquires the infection. The larval stage of the mite acts as both the reservoir and the vector for infecting the humans and rodents due to transovarial transmission of the bacteria.

·         Humans are accidental hosts in this zoonotic disease and acquire the infection through the bite of the infected larva of the trombiculid mite while walking, sitting, or lying on the infested ground. Human to human transmission does not occur.

·         The incubation period is 10-12 days.

·         The infection can range from a mild, self-limiting disease to a fatal infection, leading to multiorgan failure, if not diagnosed and treated in time.

·         Symptoms are acute in onset and non-specific in nature with high fever and chills, headache, malaise, myalgia, cough and breathlessness, diarrhea, vomiting and a nonpruritic maculopapular rash. The rash typically begins on the abdomen and spreads to the extremities. 

·         An eschar at the site of chigger bite is pathognomonic of scrub typhus. It is a punched out ulcer with a black necrotic center and an erythematous border on the exposed body parts like legs, neck, axilla, chest, abdomen and groin along with regional lymphadenopathy. It appears few days after the chigger bite, but before the disease presents clinically making it an important early sign associated with scrub typhus.  The eschar may be difficult to see in dark skinned people.

·         Differential diagnosis: Other febrile illnesses like dengue fever, malaria, chikungunya, typhoid

·         Lab diagnosis is by detection of IgM antibody on ELISA (positive within 3-4 days after the onset of illness), Weil Felix reaction (IgM titer ≥ 1:320 or a 4-fold rise in titer starting from 1:50), PCR from blood and eschar. Weil Felix test may be negative in the early stage of the infection as IgM antibodies appear only during the second week.

·         The gold standard test for serologic diagnosis of scrub typhus is immunofluorescence assay (IFA), but the cost, need for specialized lab and training limit its use.

·         Treatment: Doxycycline 200 mg / day in two divided doses for individuals above 45 kg for 7 days (orally or IV) is the drug of choice. Alternatively, azithromycin 500 mg single dose for 5 days (orally or IV), or tetracycline 500 mg in 4 divided doses for 7 days (orally or IV). In pregnant women, doxycycline is contraindicated. Azithromycin 500 mg in a single dose for 5 days is preferred.

·         Patients treated with appropriate antibiotics typically become afebrile within 48 hours of starting treatment. Failure of defervescence within 48 hours rules out scrub typhus.

·         Prevention: Chemoprophylaxis in endemic areas (doxycycline 200 mg single dose weekly, started before exposure to 6 weeks after exposure) and mite control (clearing the vegetation, application of insecticides to the ground and vegetation, application of insect repellents and miticide to both the exposed skin and clothing)

·         There is current no vaccine for scrub typhus.

Dr KK Aggarwal

Padma Shri Awardee

Vice President CMAAO

Group Editor-in-Chief IJCP Publications

President Heart Care Foundation of India

Immediate Past National President IMA

Ticks and mites: The differences we must know

Ticks and mites, like the fleas, bedbugs and lice are arthropods, the largest animal group. But, the similarity ends here. Fleas, bedbugs and lice are insects (Insecta group), while ticks and mites are arachnids (Arachnida group), which also includes spiders.

·         The most noticeable difference between ticks and mites is their size. Ticks are usually 1 mm long and can be seen with the naked eye. They can increase in length up to 3 centimeters after feeding. Mites, on the other hand, are less than one mm in size and hence, they cannot be seen with the naked eye i.e. they are microscopic. Ticks are usually acquired when walking through tall grass, shrubs and bushes.

·         Another important structural difference between the two lies in the hypostome, by which they attach to their hosts to feed. The hypostome in ticks is barbed and is inserted into the host allowing it to attach itself very effectively to the host. This is why it is difficult to remove a tick, especially when it is feeding as the hypostome may remain inside the host body. The hypostome in mites has no barbs and so mites can be easily be removed from their hosts.

·         Ticks have no hair on their bodies or have short hair, while mites have long hair on their bodies.

·         Ticks strictly live on animal hosts, while mites can feed on plants and animals.

Ticks and mites are external parasites of humans and are of public health importance as they are important vectors of diseases in humans (zoonoses).

Unlike ticks and mites, bedbugs, head lice and crab lice do not carry disease, though the bites caused by them can be bothersome. Only the body louse transmits infections to humans (Trench fever, epidemic typhus).

Rickettsiae (coccobacilli) and rickettsia-like bacteria are primary parasites of arthropods like lice, fleas, ticks and mites and usually spread to humans through the bites of ticks, mites, fleas, or lice that have previously fed on an infected animal.

Humans are accidental hosts in a chain of transmission between mites, ticks or fleas and animals (most commonly rodents).

·         Tick-borne illnesses include Lyme disease, Kyasanur forest diseases, Indian tick typhus, Rocky Mountain spotted fever, relapsing fever, tularemia, babesiosis, Q fever.

·         Scrub typhus and Rickettsial pox are mite-borne.

Rickettsial diseases are becoming common in India as a cause of acute febrile illness and are considered as emerging and re-emerging diseases. They are classically categorized into two: Typhus group and spotted fever group.

·         The Typhus group includes Epidemic typhus (louse), Murine typhus (flea) and Scrub typhus (mite).

·         The Spotted fever group includes Indian tick typhus (tick), Rocky Mountain spotted fever (tick) and Rickettsial pox (mite).

Then, there is another group of Rickettsial diseases, which includes Q fever and Trench fever.

The most commonly reported rickettsial diseases in India are scrub typhus (mite), murine typhus (flea), Indian tick typhus (louse) and Q fever (tick).

Other tick-borne diseases such as Kyasanur forest disease, Crimean Congo Hemorrhagic fever (CCHF), relapsing fever, Lyme disease and Q fever have also been reported in India.

Dr KK Aggarwal

Padma Shri Awardee

Vice President CMAAO

Group Editor-in-Chief IJCP Publications

President Heart Care Foundation of India

Immediate Past National President IMA

First practice guidelines for clinical evaluation of Alzheimer’s disease

The first practice guidelines for clinical evaluation of Alzheimer’s disease and other dementias has been released by the Alzheimer’s Association. The guideline addresses care of patients in both primary care and specialty care settings.

At their core, the guidelines recommend that all middle-aged or older individuals who self-report or whose care partner or clinician report cognitive, behavioral or functional changes should undergo a timely multi-tiered evaluation. Not just the patient and the doctor but, almost always, a care partner e.g., family member or confidant should always be involved.

Most importantly, concerns should not be dismissed as “normal aging” without a proper assessment. Not doing so delays the correct diagnosis and consequently, timely and appropriate care for persons with the disease.

The guidelines also emphasize on obtaining a history from the patient and also from someone who knows the patient well to:

·         Establish the presence and characteristics of any substantial changes, to categorize the cognitive behavioral syndrome.

·         Investigate possible causes and contributing factors to arrive at a diagnosis/diagnoses.

·         Appropriately educate, communicate findings and diagnosis, and ensure ongoing management, care and support

A broader category of “Cognitive Behavioral Syndromes” is described in the guidelines indicating that neurodegenerative conditions such as Alzheimer's disease and related dementias lead to both behavioral and cognitive symptoms of dementia. As a result, these conditions can produce changes in mood, anxiety, sleep, and personality together with interpersonal, work and social relationships, which become apparent earlier than the typical memory and thinking symptoms of Alzheimer’s disease.

The guidelines were previewed on July 22 at the Alzheimer's Association International Conference (AAIC) 2018, which concludes today in Chicago.

(Source: Alzheimer’s Association)