New WHO Guidelines on Housing and Health.

Dr KK Aggarwal & JK Jain

The WHO defines health as “not just the absence of disease, but a state of complete physical, mental and social well-being”. This means that the conditions, in which we live, learn, work and grow old, “the social contexts of health and disease” also influence our health and well-being. These social factors are called the social determinants of health.

Social gradient has been identified as one of the 10 social determinants of health, which also include stress, early life, social exclusion, work, unemployment, social support, addiction, food and transport.

Social gradient is measured by variables such as income, education, occupation or housing.

The quality of housing is becoming increasingly important to public health. To reiterate the significance of housing in health and well-being, on Tuesday, WHO released new guidelines on housing and health.

Healthy housing is not just the physical structure, which protects from extremes of temperature, injury hazards, animals/pests and provides adequate sanitation and illumination, it also means a feeling of home, which provides security, privacy and a sense of belonging.

Health housing is also determined by local community, which enables social interactions that support health and well-being. The immediate surroundings and the environment such as green space, access to services, transport options also influence health housing.

The new guidelines take into account the major health risks associated with poor housing conditions in four areas:

• Inadequate living space (crowding):
• Low and high indoor temperatures
• Injury hazards in the home
• Accessibility of housing for people with functional impairments.

The key recommendations are as follows:

• Crowding: Strategies should be developed and implemented to prevent and reduce household crowding.

• Indoor cold and insulation: Indoor housing temperatures should be high enough to protect residents from the harmful health effects of cold. For countries with temperate or colder climates, 18^oC has been proposed as a safe and well-balanced indoor temperature to protect the health of general populations during cold seasons. In climate zones with a cold season, efficient and safe thermal insulation should be installed in new housing and retrofitted in existing housing.

• Indoor heat: In populations exposed to high ambient temperatures, strategies to protect populations from excess indoor heat should be developed and implemented.

• Home safety and injuries: Housing should be equipped with safety devices (such as smoke and carbon monoxide alarms, stair gates and window guards) and measures should be taken to reduce hazards that lead to unintentional injuries.

• Accessibility: Based on the current and projected national prevalence of populations with functional impairments and taking into account trends of ageing, an adequate proportion of the housing stock should be accessible to people with functional impairments.

According to the WHO, “Improved housing conditions can save lives, prevent disease, increase quality of life, reduce poverty, and help mitigate climate change and contribute to the achievement of a number of Sustainable Development Goals, in particular those addressing Health (SDG 3) and Sustainable Cities (SDG 11).”

Housing is therefore a major entry point for intersectoral public health programmes and primary prevention.

(Source: WHO Housing and health guidelines, 2018)

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

Immediate Past National President IMA

Nicotine replacement therapy across the globe

Nicotine replacement therapy (NRT) is used to relieve nicotine withdrawal symptoms by providing nicotine without the use of tobacco, while the smoker breaks the behavior of cigarette smoking. NRT is effective for smoking cessation.

Many smokers worry that they will become dependent on NRT, but nicotine dependence rarely occurs, especially with the long-acting patch (USPSTF 2015).

Smokers may also worry that nicotine causes cancer, which it does not.

NRT is safe to use in patients with known stable cardiovascular disease. While there is limited information regarding its use after acute coronary syndrome, it is generally used to reduce nicotine withdrawal symptoms in the hospital when needed.

In randomized trials, individual NRT products were found to be superior to placebo, increasing quit rates up to twofold (1). One randomized trial among the NRT patch, gum, inhaler, and nasal spray found no difference in efficacy (2).

Single-agent NRT is less effective than combining the long-acting patch with a short-acting form such as gum, lozenge, or inhaler.

In a meta-analysis of nine randomized trials, use of a nicotine patch combined with a short-acting NRT product (gum, spray, or inhaler) was more effective than a single type of NRT (3). For smokers wishing to use NRT it is recommended to combine long- and short-acting NRT as initial therapy.

Differences in the bioavailability of nicotine replacement products provide a rationale for combining NRT products to increase efficacy for smoking cessation (4).

Each agent produces a lower blood nicotine level than does smoking one pack of cigarettes daily. In addition, smokers have experience titrating their nicotine intake to avoid both nicotine withdrawal and nicotine overdose, as they have done this titration throughout their years as cigarette smokers.

In general, NRT use is recommended for two to three months after smoking cessation, though NRT use for as long as a smoker is at high risk for relapse is acceptable because NRT is much safer than continuing to smoke. Some smokers may need to use the products indefinitely. NRT products can also be used while the smoker is still smoking.

Nicotine transdermal patch (long-acting): provides the most continuous nicotine delivery among all NRT products and is the simplest NRT to use. The patch has a long-acting, slow-onset pattern of nicotine delivery (5) but requires several hours to reach peak levels. The patch is available over the counter and by prescription in the United States. Dosing is determined by the number of cigarettes smoked daily when the patch is started: >10 cigarettes per day and weight >45 kg – Start with the highest dose nicotine patch (21 mg/day) for six weeks, followed by 14 mg/day for two weeks, and finish with 7 mg/day for two weeks; ≤10 cigarettes per day or weight < 45 kg – Start with the medium dose nicotine patch (14 mg/day) for six weeks, followed by 7 mg/day for two weeks.

Short-acting nicotine replacement therapy: (lozenge, gum, inhaler, or nasal spray) can be used as a single agent or can be added to daily nicotine patch therapy to help control cravings and withdrawal symptoms. However, short-acting forms require repeated use throughout the day, lead to more variable nicotine levels than the patch, and require more instructions for correct use. The nicotine patch, lozenge, and gum are available in the United States without a prescription; nasal spray and oral inhaler require a prescription. A nicotine mouth spray and sublingual tablet are available in some countries, though not in the United States.

Nicotine gum: Chewing the gum releases nicotine to be absorbed through the oral mucosa, resulting in peak blood nicotine levels 20 minutes after starting to chew. Nicotine gum is available in several flavors that most users find preferable to the original flavor. For those who smoke ≥ 25 cigarettes per day – 4 mg dose of gum is recommended; for those who smoke < 25 cigarettes per day – 2 mg dose of gum is recommended; chew at least one piece of gum every one to two hours while awake and also whenever there is an urge to smoke; up to 24 pieces of gum per day for six weeks. Gradually reduce use over a second six weeks, for a total duration of three months.

Nicotine lozenge is a commonly used short-acting NRT product, with pharmacokinetics similar to nicotine gum. Lozenges are easier to use correctly than nicotine gum and are also available in different flavors. Smokers who smoke within 30 minutes of awakening: 4 mg dose recommended; Smokers who wait more than 30 minutes after awakening to smoke: 2 mg dose recommended. Use up to one lozenge every 1 or 2 hours for six weeks. The maximum dose is five lozenges every 6 hours or 20 lozenges per day. Gradually reduce number of lozenges used per day over a second six weeks.

Nicotine inhalers consist of a mouthpiece and a plastic, nicotine-containing cartridge. The inhaler addresses not only physical dependence but also the behavioral and sensory aspects of smoking (having a cigarette between one's fingers and inhaling from the cigarette). When the smoker inhales through the device, nicotine vapor (not smoke) is released, deposited primarily in the oropharynx, and absorbed through the oral mucosa. Nicotine vapor does not reach the lungs to an appreciable extent. The ad lib use of the nicotine inhaler produces plasma nicotine levels that are roughly one-third of those that occur with cigarette smoking. The pharmacokinetics of the inhaler resemble those of nicotine gum. Use 6 to 16 cartridges per day for the first 6 to 12 weeks and gradually reduce dose over the next 6 to 12 weeks

Nicotine nasal spray results in peak nicotine levels 10 minutes after nasal spray use, which is a more rapid rise in plasma nicotine concentration than that produced by agents absorbed via the oral mucosa (gum, inhaler, or lozenge) (6). Dose is 1 or 2 sprays per hour. Use for about three months. The maximum dose is 10 sprays per hour, not to exceed 80 total sprays per day

Nicotine mouth spray: 1 mg nicotine is delivered per spray; use 1 or 2 sprays when cravings occur, up to four sprays per hour.

Nicotine sublingual tablet: One 2 mg tablet to dissolve sublingually (typically over 30 minutes) everyone to two hours. Patients who are heavily nicotine-addicted can use two tablets sublingually (4 mg total) for each dose (7).

ENDS: Electronic nicotine delivery systems are a new entry in the market.

References

1.    Cunningham JA, Kushnir V, Selby P, et al. Effect of mailing nicotine patches on tobacco cessation among adult smokers: a randomized clinical trial. JAMA Intern Med. 2016;176(2):184-90.

2.    Hajek P, West R, Foulds J, et al. Randomized comparative trial of nicotine polacrilex, a transdermal patch, nasal spray, and an inhaler. Arch Intern Med. 1999;159(17):2033-8.

3.    Cahill K, Stevens S, Perera R, Lancaster T. Pharmacological interventions for smoking cessation: an overview and network meta-analysis. Cochrane Database Syst Rev. 2013 May 31;(5):CD009329.

4.    Rigotti NA. Clinical practice. Treatment of tobacco use and dependence. N Engl J Med. 2002;346(7):506-12.

5.    Hartmann-Boyce J, Aveyard P. Drugs for smoking cessation. BMJ. 2016;352:i571.

6.    Hughes JR, Goldstein MG, Hurt RD, et al. Recent advances in the pharmacotherapy of smoking. JAMA. 1999;281(1):72-6.

7.    Glover ED, Glover PN, Franzon M, et al. A comparison of a nicotine sublingual tablet and placebo for smoking cessation. Nicotine Tob Res. 2002;4(4):441-50.

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

Immediate Past National President IMA

Harm reduction 5: Vaping is not the same as smoking

Dr KK Aggarwal & Dr Rajesh Chawla

Vaping is often considered synonymous with smoking. However, the two are not the same.

Smoking is a practice in which a substance is burned and the resulting smoke breathed is absorbed into the bloodstream. Most commonly, the dried leaves of the tobacco plant which have been rolled into a small square of rice paper to create a small, round cylinder called a "cigarette" are used. Smoking is primarily practiced as a route of administration for recreational drugs use.

Smoke is produced as a result of combustion (temperature > 800 degree C). When combustion occurs, new chemicals are formed via the process of oxidation. Hence, smoke contains thousands of new chemicals different from those initially burned. When a cigarette is smoked, there must be a fire to create the smoke.

Vaping is the act of inhaling and exhaling a vapor or an aerosol. E-cigarettes do not produce tobacco smoke, but an aerosol, which is commonly termed as “vapor” (1, 2).

Vapor: When a substance becomes gaseous, at a temperature that is lower than its point of combustion (180-250 degree C), it is considered as vapor. Unlike smoke, when vapor is produced, no new chemicals are formed. The chemicals that are in vapor are the same as those found in the vaporized substance.

The chemicals that are in a liquid are the same chemicals that are found in the vapor formed from the liquid. For instance, the e-liquid in e-cigarettes includes propylene glycol, food grade flavoring, vegetable glycerin (also called glycerol) and nicotine. All four of these chemicals are FDA approved for human consumption. (3)

Steam inhalation in medicine is also often advised as adjunctive treatment and may help to alleviate symptoms of lung diseases. Steam inhalation is nothing but the inhalation of water vapor.

Aerosol: Unlike vapor, which is simply a substance in gas form, aerosols contain tiny chemical particles. (4) In physics, a vapor is a substance in the gas phase, whereas an aerosol is a suspension of tiny particles of liquid, solid or both within a gas. Aerosol therefore is the state of the intermediate matter between the liquid and the gaseous state. It is composed of particles, which are neither as dispersed as the gas nor as concentrated as that of the liquid.

Nebulizers, both jet and ultrasonic, also produce aerosols from the respective liquid. Depending on the model, nebulizers generate droplets ranging in size from 1 µm to 5 µm.

Inhalation aerosol therapy in medicine uses bronchodilators and steroids as liquid particles suspended for therapeutic purposes.

The main point of difference of importance between smoke and vapor or aerosol is the presence of toxic tar and carbon monoxide in smoke. The smoke particulate matter, minus the water and nicotine, forms the portion of smoke known as tar, which contains most of the mutagenic and carcinogenic agents in tobacco smoke (5).

References

1.    www.centeronaddiction.org/e-cigarettes/recreational-vaping/what-vaping

2.    veppocig.com/pages/difference-between-smoke-and-vapor 

3.    veppocig.com/pages/difference-between-smoke-and-vapor

4.    truthinitiative.org/news/e-cigarettes-facts-stats-and-regulations

5.    de Angelo Calsaverini Leal RC. Inhalation devices: various forms of administration for therapeutic optimization. Open J Asthma. 2017;1(1):037-044.

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

Immediate Past National President IMA

Person Centric Medicine: Aspirin for primary prevention of cardiovascular disease and cancer

People Centric Approach in secondary prevention of cardiovascular disease: the absolute benefits of aspirin on occlusive events are greater than the absolute harm of major bleeding. All must get it.

Personal Centric Approach in primary prevention: the decision whether to use aspirin for primary prevention of cardiovascular disease and cancer be made based on shared decision-making, taking into account the probable benefits and harms of aspirin relative to the specific patient.

Three recent large randomized trials evaluating all-cause mortality associated with aspirin use indicate that the benefits and harms of aspirin for primary prevention are very closely balanced [1-5].

In both the ASCEND trial in patients with diabetes as well as the ARRIVE trial in patients with moderate CVD risk, the risk of all-cause death was similar with or without aspirin [1,5].

In the ASPREE trial of individuals 70 years or older, the risk of death was higher with aspirin (13 versus 11 percent) [2-4].

References

1.      ASCEND Study Collaborative Group, Bowman L, Mafhac approachm M, et al. Effects of Aspirin for Primary Prevention in Persons with Diabetes Mellitus. N Engl J Med 2018; 379:1529.

2.      McNeil JJ, Woods RL, Nelson MR, et al. Effect of Aspirin on Disability-free Survival in the Healthy Elderly. N Engl J Med 2018; 379:1499.

3.      McNeil JJ, Wolfe R, Woods RL, et al. Effect of Aspirin on Cardiovascular Events and Bleeding in the Healthy Elderly. N Engl J Med 2018; 379:1509.

4.      McNeil JJ, Nelson MR, Woods RL, et al. Effect of Aspirin on All-Cause Mortality in the Healthy Elderly. N Engl J Med 2018; 379:1519.

5.      Gaziano JM, Brotons C, Coppolecchia R, et al. Use of aspirin to reduce risk of initial vascular events in patients at moderate risk of cardiovascular disease (ARRIVE): a randomised, double-blind, placebo-controlled trial. Lancet 2018; 392:1036.

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

Immediate Past National President IMA

The high costs of healthcare: Necessary vis-à-vis unnecessary costs

An elderly patient with loss of consciousness was admitted in a corporate hospital in NCR. The patient’s hospital stay was for less than 48 hours and the total bill amounted to more than one lakh.

Let’s take a look at just a very small part of the bill – biochemistry. Among other lab investigations (and other modalities), the patient underwent kidney profile, liver function tests, lipid profile and thyroid profile. The total cost of these tests was Rs 9780/-.

Two questions arise:

1. Is this not overpricing?

2. Were they necessary?

The charges of IPD may sometimes be even much higher than the OPD charges, especially if they are billed as express charges.

The practice of doing “profiles” needs to be deliberated. Why do lipid profile at admission when the patient may not be fasting? Why do T3 and T4 when the screening test is TSH? Why do LFT when the screening test is SGPT?

Only those investigations that are essential should be done at first, bearing in mind the clinical signs and symptoms the patient presents with. The further investigations can then proceed in a stepwise manner.

This is the rationale of the Choosing Wisely initiative, a US-based health educational campaign, which calls upon leading medical specialty societies and other organizations to identify tests or procedures commonly used in their field whose necessity should be questioned and discussed with patients. More than 70 such societies have published more than 400 recommendations of overused tests and treatments that clinicians and patients should discuss. 

It was only last year that the case of exorbitant overcharging by Gurgaon Fortis hospital for the treatment of a seven-year-old dengue patient had hit the headlines and become the talk of the nation.

Much has been spoken about the high costs of health care since then.

Yet nothing seems to have changed.

The scenario has only worsened, it has not improved.

On the other hand, the hospitals have starting saying that ICU means Rs 50,000 per day cost and with ventilator, one lakh per day.

The cost of reagents in this case may not be more than few hundred rupees but the cost of corporate culture can be exorbitant.

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

Immediate Past National President IMA

Good news: Health ministry proposes social support of up to Rs 5 lakh to the dependents of organ donors

The Union health ministry has proposed providing “social support’’ of up to Rs 5 lakh to the dependants of an organ donor in cases of cadaver organ donation.

The social support will be provided not in the form of cash but by sponsoring medical treatment or education of dependents, said Dr Vasanthi Ramesh, director, National Organ and Tissue Transplant Organisation (NOTTO). The proposal under the National Organ Transplant Programme is currently under consideration of the finance ministry, Ramesh said.

The health ministry, she added, will provide Rs 1 lakh to hospitals for maintenance of the donor who has been declared brain dead till the organs are retrieved. Such patients, require to be infused with fluids and medication to maintain their organs

According to a senior health ministry official, the gap between the number of recipients and donors is very wide and thousands of people spend years hoping for a donor to give them a new lease of life. The official said that as per estimates, the annual requirement of kidney transplant for new cases is around two lakh with merely 8,000 transplants happening annually.

(Source: TOI, Nov 23, 2018)

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

Immediate Past National President IMA

Landmark PALISADE trial brings hope for children with peanut allergy

Peanut allergy is a severe and potentially life-threatening food allergy. But, the landmark phase 3 PALISADE trial published Nov. 22, 2018 in the New England Journal of Medicine has provided a breakthrough and brought hope for children and adolescents who have peanut allergy.

The trial showed that oral immunotherapy resulted in higher doses of peanut protein that could be ingested without dose-limiting symptoms and in lower symptom severity during peanut exposure at the exit food challenge than placebo.

Researchers from Evelina London Children's Hospital and King's College London screened 551 participants with peanut allergy for the trial; of these, 496 were aged 4 to 17 years, who were randomly assigned, in a 3:1 ratio, to receive placebo or AR101, a peanut-derived investigational biologic oral immunotherapy drug in an escalating-dose program. Doses were gradually increased every two weeks for a period of six months, before continuing on a "maintenance dose" of peanut for a further six months.

The results showed that 67.2% (250/372) of those on AR101 treatment were able to ingest a dose of at least 600 mg of peanut protein (a whole peanut kernel contains approximately 250–300 mg of peanut protein), without dose-limiting symptoms, at the exit food challenge as compared to only 4.0% (5/124) of the placebo-treated participants.

Adverse events were seen in 95% of participants in both groups.

AR101 also showed a favorable safety profile. The maximum severity of symptoms was moderate in 25% of those in the active-drug group and 59% of the participants in the placebo group and severe in 5% and 11%, respectively, during the exit food challenge.

A total of 34.7% of the participants in the active-drug group had mild events vs 50.0% of those in the placebo group; 59.7% and 44.4% of the participants, respectively, had moderate grade events and 4.3% and 0.8%, respectively, had severe grade events.

Efficacy was not shown in the participants 18 years of age or older.

(Source: PALISADE Group of Clinical Investigators. AR101 oral immunotherapy for peanut allergy. N Engl J Med. 2018 Nov 18. doi: 10.1056/NEJMoa1812856. [Epub ahead of print]

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

Immediate Past National President IMA

Reciprocal association between NAFLD and drug-induced liver injury

NAFLD may be a risk factor for DILI; drugs can cause NAFLD

Nonalcoholic fatty liver disease (NAFLD) is one of the most common causes of chronic liver disease globally. It is characterized by the presence of hepatic steatosis (fatty liver), when no other causes for secondary hepatic fat accumulation (heavy alcohol consumption) are present. Left untreated, it may progress to cirrhosis and is likely an important cause of cryptogenic cirrhosis.

The prevalence of this condition is higher among obese and diabetic patients.

Recently NAFLD has also been recognized as risk factor for drug-induced liver injury (DILI).

A study published in the November 2018 issue of the journal Alimentary Pharmacology and Therapeutics has shown a reciprocal association between NAFLD and DILI, which means that drugs can cause NAFLD by acting as steatogenic factors, and pre‐existing NAFLD could be a predisposing condition for certain drugs to cause DILI - intrinsic DILI (induced by acetaminophen, methotrexate and volatile anesthetics) more than idiosyncratic DILI.

Although the cause for this increased susceptibility is likely to be multifactorial, usually it is due to the triggering by the drug of similar steatogenic, inflammatory and/or fibrotic pathomechanisms that characterize NAFLD or changes in drug detoxification systems. 

“Drugs can induce macrovesicular steatosis by mimicking NAFLD pathogenic factors, including insulin resistance and imbalance between fat gain and loss. Other forms of hepatic fat accumulation exist, such as microvesicular steatosis and phospholipidosis, and are mostly associated with acute mitochondrial dysfunction and defective lipophagy, respectively. Drug‐induced mitochondrial dysfunction is also commonly involved in drug-induced steatohepatitis.”

The prevalence of NALFD is higher in obese patients. Polypharmacy is common in this patient group as they take multiple drugs to manage their weight or coexisting chronic conditions. Hence, they are more vulnerable to hepatotoxicity, whether or not they have an intrinsic higher susceptibility to DILI due to their liver disease.

The study cautions clinicians to restrict the number of prescribed medications in these patients, whenever possible and initiate pharmacotherapy in a stepwise manner. They should be closely monitored. Also, patients should be advised against OTC self-medication.

(Source: Bessone F, Dirchwolf M, Rodil MA, et al. Review article: drug-induced liver injury in the context of nonalcoholic fatty liver disease - a physiopathological and clinical integrated view. Aliment Pharmacol Ther. 2018 Nov;48(9):892-913). 

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

Immediate Past National President IMA