Tuesday, April 30, 2019

Loneliness in older adults: A new epidemic of society



Loneliness is the new epidemic of society today. Loneliness is particularly common in older adults, whose children have grown up and left the nest and are busy with their lives.

The amygdala in the brain plays a key role in regulating emotions and emotional responses.  The dorsal posterior insula regulates perception of pain; it becomes more active when we are lonely, so anything that happens to socially isolated people is more painful.

Cortisol is the fight or flight hormone. Oxytocin along with serotonin and dopamine constitute the happy hormones. Increase in dopamine, serotonin and oxytocin increase the positive emotions in the body.

Brain derived neurotrophic factor is another chemical, which helps the brain to remain plastic, or flexible, so that we can continue to hold on to past memories and create new ones. This chemical is present in low amounts in socially isolated people.

Loneliness is harmful socially; it is also bad for health, a fact which has been corroborated in studies. Loneliness is a strong predictor of heart disease, stroke or premature death.

A new article published April 29, 2019 in the Canadian Medical Association Journal has addressed the effect of loneliness on older patients. As per the article, loneliness is:

·         an emotional state of perceived isolation; it is not a mental disorder
·         common in older adults and linked to declines in health
·         as harmful as other risk factors for death, such as obesity and smoking
·         a significant predictor of health care usage
·         possibly alleviated by "social prescribing" to connect lonely adults with community supports and social networks


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


Eyeing Profits



Reproduced from India Legal, Published May 6, 2019, pg. 29

With hospitals and pharma companies charging heavily for medical devices, a PIL in the Delhi HC seeks direction to cap lens prices

Medical devices have often come under the scanner for being overpriced. A PIL filed in the Delhi High Court late last year challenged such overpricing with a specific plea that intraocular lenses, among the essential medical devices, be listed under the National Pharmaceutical Pricing Authority.

India has for long been known as the “blind capital” of the world. Around 15 million people here are blind, which is 50 percent of the world’s blind population. According to the data published by the National Programme for Control of Blindness and Visual Impairment, cataract alone accounts for 62.6 percent of all causes of curable blindness in India.

The cataract surgery rate is pinned at above one percent of the total population of the country every year. That means millions of people are getting intraocular lenses implanted each year. But there is a huge gap between the cost of procuring these lenses and the price a patient has to pay for correcting his vision.

The PIL came up for hearing in the Court last week and there was talk of the need for incorporating implantation of intraocular lenses into the definition of a “drug” in the National List of Essential Medicines (NLEM) and price capping it in the interest of public health. The National Pharmaceutical Pricing Authority (NPPA) was set up in August 1997 to act as an independent regulator for the pricing of drugs and ensure availability and accessibility of medicines at affordable prices. The Drug Price Control Orders (DPCO) are issued by the government to declare a ceiling price for essential and lifesaving medicines (as per a prescribed formula) so as to ensure that these medicines are available at a reasonable price to the general public.

The criteria for inclusion of a drug in NLEM includes, among other things—it should be approved/licensed in India; it should be useful in case of a disease which is a public health problem in India; it should have proven efficacy and a safety profile based on valid scientific evidence; it should be cost effective; and it should be stable under storage conditions in India.

The Union Ministry of Health and Family Welfare prepared and released the first NLEM in 1996, consisting of 279 medicines. This list was subsequently revised in 2003 and included 354 medicines. Later in 2011, the list was further revised and had 348 medicines. Till June 2018, 851 medicines (including four medical devices—cardiac stents, drug eluting stents, condoms and intra uterine devices) are regulated under the revised schedule.

Currently intraocular lenses, which fall under the ambit of notified devices and are widely used in cataract surgeries, are being priced ten times higher than the market at the point of care. Consumers are charged Rs 8,000 for a brand of intraocular lens which has a landing cost of Rs 800.

Medical experts have been insisting that intraocular lenses, catheters, orthopaedic implants, dental implants and ophthalmic medication be brought into the NLEM in order to make them affordable for the common man.

It is now the High Court’s turn to take a call.


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


Monday, April 29, 2019

All major heart hospitals in Delhi-NCR should take up the Mission Delhi project


On Thursday (25.4.19), the Indian Council of Medical Research (ICMR) has launched ‘Mission DELHI’, an emergency medical service, as part of which a motorbike-borne assistance unit can be quickly summoned for a person suffering heart attack or chest pain.

The pilot project has been launched in a radius of 3 kms around All India Institute of Medical Sciences (AIIMS), New Delhi and would be linked with Centralized Ambulance Trauma Services (CATS).

Under Mission DELHI (Delhi Emergency Life Heart-Attack Initiative), a pair of motorcycle-borne trained paramedic nurses would be the first responders for treating heart attack patients.

On getting a call, the pair would rush to the spot, gather basic information on the patient’s medical history, conduct a quick medical examination, take the ECG, and establish a virtual connect with the cardiologists at AIIMS and deliver expert medical advice and treatment.

While the emergency treatment is being provided, a CATS ambulance will arrive and take the patient for further treatment.

Even as the patient is on way to the hospital, doctors at AIIMS control center will evaluate the data received from the nurses to establish further course of treatment.

The attempt is to reach patients within 10 minutes. In this project, the clot buster will be given very soon even at home.

This project should not just be limited to ICMR and AIIMS.

Every major heart hospital in Delhi-NCR should take up this project and adopt area of 3 km around their hospital. All should be interlinked.

ICMR should provide them with the working model for implementation of the project for wider reach of this much-needed emergency medical assistance.


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


Belimumab, the first drug for lupus in children


The US Food and Drug Administration today approved belimumab (Benlysta) as intravenous (IV) infusion for treatment of children aged 5 years and older with active, autoantibody-positive, systemic lupus erythematosus (SLE) who are receiving standard therapy.

Belimumab, a human monoclonal antibody, is a B-lymphocyte stimulator (BLyS)-specific inhibitor.

While belimumab is approved for use in adults with SLE, this is the first time that it has been approved for use in children with SLE.

In Pediatric Lupus Trial of Belimumab Plus Background Standard Therapy (PLUTO) of children with SLE, belimumab IV + standard therapy reduced the risk of the patients experiencing a severe flare by 62% and also increased the duration of experiencing the first severe flare, from 82 days to 160 days.

The safety and pharmacokinetic profiles of the drug in pediatric patients were consistent with those in adults with SLE.

Side effects: Nausea, diarrhea and fever

Warning and precautions:  Mortality, serious infections, hypersensitivity and depression; it should not be co-administered with live vaccines. Patients also commonly experienced infusion reactions, so healthcare professionals are advised to pre-treat patients with an antihistamine.

(Source: US FDA)

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


Sunday, April 28, 2019

Syrup furosemide shortage: Will the DCGI Intervene?



Few days back I visited Satya Sai Heart Hospital in Ahmedabad. The hospital is doing a wonderful job of providing free heart surgeries to children. During the visit I came across a genuine issue: shortage of Furoped (syrup furosemide) in the market.

For children with heart failure, Furoped is a life-saving diuretic.

In an order in November 2017, the price of Furoped was reduced by 92% with the MRP coming down from Rs 106 to Rs 10/-. Then in June 2018, the National Pharmaceutical Pricing Authority (NPPA) increased the per unit price of Furoped from 29 p per ml to Rs 2.60 p.

A 30 ml bottle now costs around Rs 78/-.

Before the November price revision which was undertaken by NPPA without access to market data, the monthly sales of the drug were to the tune of approximately Rs 30- 35 lakh. Supplies dwindled to about 40% in the aftermath of that decision.

About two years back, there was a shortage of two drugs in the market, d-penicillamine (DPEN) and penicillin G potassium (Pentid-Abbott).

D-penicillamine is used to treat patients with Wilson’s disease (copper overload) with liver, neurological and psychiatric manifestations. And, patients have to be on this drug lifelong. The Indian Medical Association (IMA) had raised this issue and both drugs were freely available again.

There can be several reasons for drugs running short in supply. These can include manufacturing and quality problems, delays and discontinuations. 

In the United States, manufacturers provide the FDA with most drug shortage information. And, the agency works closely with them to prevent or reduce the impact of shortages.  All current and resolved drug shortages and discontinuations are reported to FDA at drugshortages@fda.hhs.gov, which are then compiled in a Drug Shortages Database.

But, unfortunately no such system exists in India to take care of drug shortages.

Furosemide is included in the National List of Essential Medicines (NLEM). All formulations of the drug (Tablet 40 mg, Oral liquid 10 mg/ml, Injection 10 mg/ ml) are to be available at all levels of healthcare - primary, secondary, tertiary, as per the NLEM. This means that it is under price control and profits are limited.

The continuing shortage of any life-saving or essential drug is a matter of concern.

All pediatric cardiologists, if they find that Furoped is still in shortage, should voice their concern.

All drug shortages can be reported on the platform of Medical Voice for Policy Change.

Read our earlier stories on this issue:

IMA is change maker: Medical voice is heard

Artamine shortage





An Open letter to the DCGI

To

The Drugs Controller General of India (DCGI)
Central Drugs Standard Control Organization
Directorate General of Health Services
Ministry of Health & Family Welfare
Government of India

Dear Sir

This is to bring to your kind attention that there is a shortage of Furoped (syrup furosemide), a diuretic drug, in the market. Furoped is a life-saving drug for children with heart failure.

All formulations of furosemide (tablet, oral liquid and injection) are included in the National List of Essential Medicines (NLEM) and are to be available at all levels of health care – primary, secondary and tertiary.

The continuing shortage of any life-saving or essential drug is a matter of concern.

We request you to look into the matter and ensure that the shortage is taken care of and that no similar shortages or of any other drug included in the NLEM occur in the future.

Warm Regards

Dr KK Aggarwal
President Heart Care Foundation of India


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

Stroke survivors should be screened and treated for osteoporosis


Results from the Ontario Stroke Registry suggest that recent stroke survivors are not always screened and treated for osteoporosis, which puts them at increased risk of fractures.  

The study examined data from more than 16,000 stroke survivors aged 65 years and older who either had visited the emergency department or had been hospitalized for strokes between 2003 and 2013 in Ontario, Canada.

Only a very small number of patients (5.1%) overall were screened for osteoporosis. One year after their stroke, only 15.5% of them had been prescribed medications to prevent fractures.

Female sex, pre-stroke osteoporosis and post-stroke falls and fractures were associated with increased rates of osteoporosis pharmacotherapy.

Stroke survivors are at high risk of falls, which may lead to fractures. This risk is up to four times greater than in healthy people. Hence, they should undergo screening bone mineral density test to identify those at risk of fractures after stroke and then be treated to prevent bone loss and fractures.

(Source: Stroke, April 25, 2019)

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

Saturday, April 27, 2019

NIH statement on World Malaria Day 2019



Statement of B.F. (Lee) Hall, M.D., Ph.D., and Anthony S. Fauci, M.D., National Institute of Allergy and Infectious Diseases

Eliminating malaria — one of the world’s oldest and deadliest diseases — remains a critically important public health and biomedical research challenge. Despite remarkable advances in reducing malaria incidence and deaths since 2000, recent progress has become stagnant and has even reversed in some regions. The World Health Organization (WHO) estimates that in 2017 about 219 million cases of malaria occurred worldwide and approximately 435,000 people died of the disease. Unfortunately, malaria cases increased from 2016 to 2017 in the 10 highest-burden countries in Africa, and the number of cases per 1,000 in populations at risk remained at 59 from 2015 to 2017.

Today, the National Institutes of Health recognizes World Malaria Day and commits to a reinvigorated malaria research program. This year’s World Malaria Day theme, “Zero malaria starts with me,” encourages governments, companies, academic institutions, philanthropies, and others to prioritize malaria, mobilize resources, and empower communities affected by malaria to lead and coordinate response activities. The National Institute of Allergy and Infectious Diseases (NIAID), part of NIH, is working toward “zero malaria” with coordinated global research projects to better understand the disease, improve diagnostics, treatments, and mosquito control interventions, and develop safe and effective vaccines.

NIAID works directly with scientists in malaria-endemic regions to build specialized local clinical research capacity. The NIAID-supported International Centers of Excellence for Malaria Research (ICEMR) program has more than 50 field sites in 17 endemic countries dedicated to multidisciplinary research on the complex interactions between the human host, mosquito vectors, and malaria parasites. ICEMR investigators share genomic and epidemiological data for parasites, mosquitoes, and human hosts through public databases such as PlasmoDB, VectorBase, and ClinEpiDB to assist researchers in developing drugs, vaccines and diagnostics, and in improving public health programs. 

ICEMR researchers are studying how the malaria-causing parasite adapts to antimalarial drug pressure and how that translates to the emergence and spread of drug resistance. Resistance to artemisinin drugs, used in most endemic areas, is emerging in Southeast Asia and appears to be spreading west. The ICEMRs are evaluating how asymptomatic malaria infections may contribute to persistent disease transmission and risk. Investigators also are studying how the behavior of malaria-transmitting mosquitoes is changing in response to insecticide use and environmental and ecosystem changes.

NIAID investigators and NIAID-supported scientists are helping to inform treatment policies in various countries by tracking genetic mutations in malaria parasites that indicate resistance to certain drugs. A team of experts recently identified a molecular marker of resistance to piperaquine (a combination therapy drug) in Cambodia (link is external) using publicly available genome sequence data.

Another international research team supported by NIAID created mutated versions of nearly all of the 5,400 Plasmodium falciparum (P. falciparum) parasite genes to determine which of the organism’s genes are essential to growth and survival. The information will help investigators prioritize targets for future antimalarial drug development. One investigational drug being evaluated, DM1157, is a modified form of the antimalarial drug chloroquine. Similar to chloroquine, it interferes with the malaria parasite’s metabolism; however, it inhibits the parasite’s ability to expel the drug, thereby avoiding the drug resistance seen with chloroquine. A Phase 1 clinical trial to evaluate the drug’s safety began in September 2018.

Cerebral malaria — a severe form of illness that can lead to brain damage, long-term neurological deficits, and death — remains a significant problem in sub-Saharan Africa. ICEMR investigators and their collaborators identified brain swelling as a potential contributor to the high mortality rate among children in Malawi with cerebral malaria. A clinical trial is underway to assess whether measures to reduce brain swelling can improve treatment outcomes. ICEMR investigators in India are studying whether the same findings are seen in adults with cerebral malaria, while NIAID researchers are working to develop novel adjunctive cerebral malaria treatments.

Certain populations, such as pregnant women, are at higher risk of developing severe disease upon contracting malaria. NIAID-supported researchers in Malawi recently found that administering the drug chloroquine as a weekly chemoprophylaxis may prevent malaria in pregnancy. NIAID-supported scientists also found that children with high levels of maternal antibodies to the malaria antigen PfSEA-1 at birth have decreased risk of severe malaria during infancy.

NIAID also supports the development of various investigational malaria vaccines. The Institute has conducted and supported multiple early-stage clinical trials of PfSPZ, a candidate malaria vaccine made of weakened immature malaria parasites. It is designed to prevent malaria infection and is now being evaluated in multiple clinical trials in malaria endemic regions, including in infants and children. Another candidate vaccine based on a recombinant protein is currently in a Phase 1 clinical trial.

NIAID researchers also are working on a vaccine designed to block transmission of the malaria parasite from infected humans to mosquitoes. Although a transmission-blocking vaccine would not prevent malaria infection, by limiting further spread it could reduce new malaria infections over time. Results from a clinical trial in Mali indicate that the investigational vaccine, when formulated with an immunity-boosting adjuvant, shows promise. Plans are underway to evaluate the efficacy of the vaccine in a Phase 2 clinical trial in Mali.

NIAID scientists recently developed a monoclonal antibody from a person vaccinated with PfSPZ that potentially could be used for seasonal control and elimination efforts as well as by tourists, health care workers, and military personnel to prevent malaria infection. A trial evaluating the antibody’s safety and efficacy against a controlled human malaria infection (human challenge study) is planned for early 2020. NIAID experts also are collaborating with Malian scientists to discover additional broadly protective monoclonal antibodies.

Although recent data indicate that malaria control efforts may have stalled, numerous historical examples indicate that with enough commitment and ingenuity malaria elimination can be achieved, even after significant setbacks. NIAID-supported investigators, researchers and their collaborators are accelerating progress toward malaria elimination every day. On this World Malaria Day, we reaffirm our commitment to advancing the best research to reach our goal of “zero malaria.”

(Source: NIH)


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


150-300 minutes physical activity offsets the harm from prolonged sitting


What bad food you eat may not matter, if you take enough amount of good food. And, if you sit for prolonged periods (6 or more hours daily), but replace the sitting time with exercise of at least moderate intensity, and with vigorous-intensity exercise, you can reduce the excess (CV) mortality risk.

The excess all-cause and CV mortality risks caused by regular, prolonged sitting is mainly seen in people who achieve less than 150 minutes of physical activity in a week. Those who maintain physical activity 150 to 200 minutes per week can considerably offset this excess risk; 300 minutes per week is even better.

It is not enough to replace sitting with standing. We need to be replacing sitting with movement. Even walking may do the trick in the case of all-cause mortality.

Some way outs

·    Increase physical activity to 150 to 299 min/week, or
·  Reduce sitting time from 8+ to <4 hours/day without increasing moderate to vigorous physical activity, or
· Increase moderate-to-vigorous physical activity to 150 to 299 min/week and reduce sitting to < 8 h/day.

Lesson: If you have to sit too much, make sure that you find ways to incorporate more moderate to vigorous physical activity into your life.

(Source: Journal of the American College of Cardiology, April 22)


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