What caused the Muzaffarpur children deaths in June 2019. We still do not know.

To Sh Narendra Modi Ji
Hon'ble Prime Minsiter of India

Dear Sir

What caused the Muzaffarpur children deaths in June 2019. We still do not know. Four months left and we are not ready how to prevent  the same happening in 2020.

As per a TOI report almost half of children who died due to acute encephalitis syndrome in Bihar Muzaffarpur in mid-2019 had no history of Litchi consumption whereas majority of the rest were less than 2 years old and therefore not quite able to eat the fruit.

It is true that ICMR now has ordered for the investigations to ascertain the cause of sudden rise in deaths due to acute encephalitis syndrome in Bihar last year. But the the council will only start studying in April May with at the onset of Summer further possibilities.

In 2019 we had 125 deaths and more than 550 cases of AES.


Possible causes

1. Infective: Viral encephalitis, Cerebral malaria, scrub typhus
2. Non infective: malnutrition, refeeding syndrome (hypocalcaemia, hypoglycaemia, Hypophosphatemia and hypokalaemia) poor health infrastructure

In Muzaffarpur 48% of children under the age of five are stunted, 17.5% are wasted 42 % are underweight.

We need it to be managed the way we are managing the corona attack. This year the preparation should be such that no child dies of care. We must make shift hospital for such cases ready with all facilities  and all private nursing homes on board if need arises. We can not leave such disasters only on the states to manage.


Dr KK Aggarwal
Recipient of four National Awards (Padma Shri, Vishwa Hindi Samman, Dr B C Roy National Award and National Science Communication Award)
President Confederation of Medical Associations of Asia and Oceania
President Heart Care Foundation of India
Chairman HCFI Round Table on Health  wellness, Building Consensus
Past National President and Past Honorary Secretary General, Indian Medical Association

Cleveland Clinic's 2019 innovations

Cleveland Clinic's 2019 innovations

MSN and JDN: time to study these

Dr KK Aggarwal

President CMAAO, HCFI and Past National President IMA

1.     Newer drugs for treating diastolic heart failure, heart failure with a normal pumping function of the heart but still with elevated pressure inside the heart so you feel short of breath.

2.      Bempedoic acid is a new medication that has the same advantages of statins but does not cause muscle-related problems

3.      Newer drugs to treat cardiac amyloidosis

4.      Parp inhibitors in ovarian cancers

5.     E new device that sends electrical signals to the spinal cord to ease chronic back pain.

6.      Biologics in orthopedic injury

7.      An antibiotic envelope to prevent pacemaker infections.

8.      A pill for children with severe peanut allergy.

9.      Less invasive repair of the heart's mitral valve

10.  A new osteoporosis drug designed to reduce the risk of life-altering fractures.

Important 2019 take home heart messages

Important 2019 take home heart messages

Dr KK Aggarwal

President CMAAO, HCFI and Past National President IMA

•             Icosapent ethyl.  a prescription omega-3 fatty acid, reduced the risk for cardiovascular events by 25% in people with elevated triglyceride levels who were taking statins (REDUCE-IT led the US FDA to approve icosapent ethyl for CV risk reduction in December.

•             COMPLETE trial: STEMI heart attack with multivessel disease benefit from complete revascularization of any other angiographically significant lesions, rather than a strategy of intervention only in the culprit lesion.

•             DAPA-HF trial showed that the glucose-lowering drug dapagliflozin is beneficial in patients with heart failure, both with and without type 2 diabetes.

•             In a large-scale study of over 419,000 Apple Watch users, the device accurately detected atrial fibrillation in more than one third of the participants who received notifications of an irregular pulse.

•             EXTEND trial: it's possible to extend the window for thrombolysis out to 9 hours after ischemic stroke onset in some patients.

•             PARTNER 3 trial: patients with severe aortic stenosis at low surgical risk who had transcatheter aortic valve replacement using the SAPIEN 3 system (Edwards Lifesciences) had lower odds of stroke, rehospitalization, and death compared with those who had traditional surgery.

•             Five-year findings from the NOBLE trial demonstrate that percutaneous coronary intervention  is not as effective as coronary artery bypass grafting in reducing the risk of death, myocardial infarction, repeat revascularization, and stroke in patients with left main disease.

•             In children with familial hypercholesterolemia (FH) showed statin therapy beginning at a young age reduced incidence of CV events from 26% to 1% at age 39, and reduced death from CV causes from 7% to 1% at age 39.

•             In older women reducing sedentary time by just 1 hour each day equated to a 26% lower risk of heart disease and a 12% lower risk of CVD overall. The physical activity didn't have to happen all at once — it could be accumulated throughout the day.

•             Older women who engaged in light physical activity, such as gardening or walking, had a 42% lower risk of MI or coronary death than the least-active women.

•             Taking anti BP drug at bedtime led to a 45% reduction of CV events

•             SPRINT MIND study: intensive blood pressure lowering cuts the risk for mild cognitive impairment in adults aged 50 years and older.

•             Children exposed to second-hand smoke from their parents were at a higher risk for atrial fibrillation. For every pack per day increase in parental smoking, their children were 18% more likely to develop atrial fibrillation

 [Medscape]

18 Important Medical Research Outcomes of 2019

18 Important Medical Research Outcomes of 2019

Dr KK Aggarwal
President CMAAO< HCFI and Past national President iMA

1. New neurons proliferate in the hippocampus as we age, even into the ninth decade of life [Nature Medicine].

2. Novel protein-coding genes evolve on a de novo basis far more commonly than previously thought [Nature Ecology and Evolution].

3. Children's long bones grow with the help of a stem cell niche with a radical clonality switch that develops in the epiphyseal growth plate [Nature.]

4. 10,000 steps or less: Researchers who ran a study of nearly 17,000 women found the cutoff for mortality benefit was just 4400 [JAMA Internal Medicine.]

5. Comparing the DNA of primary colorectal cancer tumors and metastases in the liver or brain revealed that for 80% of the 21 patients in the study, metastases took root early [Nature Genetics].

6. Typhoid toxin may not be required for people infected with Salmonella Typhi to develop typhoid fever [Nature Medicine].

7. Assessing myocardial viability is not a helpful marker to predict the long-term outcome of coronary artery bypass grafting surgery [NEJM]

8. Rising BMI among people living in rural areas ― not cities ― is the main driver of the global obesity epidemic [Nature].

9. The brain microbiome: It might actually exist, and herpesvirus might play a role in Alzheimer disease, [Neuron in 2018]

10. Cardiac stem-cell therapy appears to work by stimulating the immunologic wound-healing process rather than generating new cells [Nature].

11. Even if patients with severe aortic stenosis have no symptoms, early surgery to replace the aortic valve lowers their risk for death [NEJM]

12. Could we inherit mitochondrial DNA from our fathers as well as our mothers? Yes [Proceedings of the National Academy of Sciences in December 2018]

13. Screen time: not so bad for kids' well-being after all? (Nature Human Behaviour)

14. The morning meal may not help people lose weight, according to a meta-analysis published in the BMJ.

15. Applying evolutionary game theory to cancer therapy, as researchers did in this paper in Nature Ecology and Evolution, challenges the traditional approach of blasting tumors with the maximum tolerable dose of chemotherapy.

16. type 2 diabetics and high Lp(a) levels was associated with a 3.5-fold higher risk for a cardiovascular event compared to having no diabetes or a low Lp(a) level (<24 nmol/L or approximately 10 mg/dL) (Jin JL et al. Diabetes Care . 2019;42:1312-1318)

17. In an observational registry study of Swedish outpatients with type 1 diabetes, those who had high plasma lipoprotein(a) [Lp (a)] levels — defined as >120 nmol/L or approximately 50 mg/dL — were more likely to have albuminuria, calcified aortic valve disease, or a composite measure of cardiovascular disease. And patients whose blood glucose level (A1C <6.9%) was well controlled had lower Lp(a) levels. [ December 18 in Diabetes Care].

18. Caloric restriction can reduce insulin resistance, weight, hepatic fat, and cardiovascular risk factors, regardless of carbohydrate content. To achieve caloric restriction one can go for fasting regimens as time-restricted eating (meals consumed within a limited number of hours), alternate-day fasting, and the 5:2 eating pattern (unrestricted eating for 5 days, followed by 2 days of restricted intake).
[source: Medsacpe]

Revisiting Healthcare in 2019

Revisiting Healthcare in 2019

Dr KK Aggarwal

President CMAAO , HCFI and Past National President IMA

The year 2019 saw a lot on new health promises. Let us review some of the important ones.

Disease Outbreaks

1.               As per Who list https://www.who.int/csr/don/archive/year/2019/en/ No major health outbreak in India in 2019.

2.               No case of Polio was noted.

3.               In June 2019, an outbreak of acute encephalitis syndrome occurred in Muzaffarpur and the adjoining districts in Bihar state of India, amidst the second-longest heatwave in the region, resulting in deaths of more than 100 children, mainly due to hypoglycemia.

4.               The index case of Nipah in Koci in June was contained the disease was controlled before it took off

5.               Congo fever: 17 cases were reported in Gujarat and three tested positive in Rajasthan.

6.               More than 67,000 people across India have been diagnosed with dengue so far this year, reports by the National Vector Borne Disease Control Programme (NVBDCP) show. By mid-October, reports show, the disease had claimed 48 lives.

7.               The number of HIV-infected people who go on to develop Tuberculosis (TB) is increasing in India, according to the India TB Report 2019, which was released by the government on September 25, 2019.Nearly 25 per cent of all deaths among PLHIV are estimated to be due to TB. The highest percentage of patients who tested positive for TB and were also infected with HIV came from Nagaland (15.6 per cent), followed by Karnataka (10 per cent), Chandigarh (9.1 per cent) and Manipur (8.9 per cent).

Major Concerns of the year

1.               Pollution in North India

2.               Rising AMR

Parliament Bills

1.               The parliament passed the National Medical Commission (NMC) Bill. The bill provided for setting up a National Medical Commission (NMC) in place of the MCI to develop and regulate all aspects of medical education, profession and institutions in India.

2.               The government in November referred a bill, which seeks to ban commercial surrogacy in India, to a 23-member select committee of Rajya Sabha.

3.               The government passed Prohibition of Electronic Cigarettes (Production, Manufacture, Import, Export, Transport, Sale, Distribution, Storage and Advertisement

4.               The draft bill Healthcare Service Personnel and Clinical Establishments (Prohibition of violence and damage to property) Bill, 2019 is pending to be passed

5.               The Allied and Healthcare Professions Bill, 2018 was introduced in Rajya Sabha by the Minister of Health and Family Welfare, Mr. J P Nadda on December 31, 2018. The Bill seeks to regulate and standardise the education and practice of allied and healthcare professionals. Jan 02, 2019 referred to standing committee

6.               The Occupational Safety, Health and Working Conditions Code, 2019 pending

Delhi

1.               Delhi health bill, which will replace Delhi Nursing Home act

2.               The Delhi Government will shift serious patient to private ICU. The payment will be done by DG if no bed is available with them

Major Courts Decisions

1.               Delhi high court on ‘courts in its own motion’ has asked the CDSCO to release a list of over the counter drugs

2.               Delhi high court on ‘courts in its own motion’ has asked the Railways to have emergency medical services at all major stations

Strikes

On 11 June 2019, following the assault of two junior doctors at Nil Ratan Sircar Medical College and Hospital (NRSMCH) the previous night, junior doctors in Kolkata began protesting and demanded the Chief Minister of West Bengal, Mamata Banerjee to intervene and provide adequate security to medical professionals, culminating into the collapse of healthcare facilities in the state. Despite attempts at mediation, protests continued through 13 June, finally resulting in the Chief Minister issuing an ultimatum to the protesting doctors, which was eventually defied by the protesting doctors who wanted the government to meet their demands for security and a public apology from the Chief Minister.

Life expectancy and Vital Statistics

1.               Life expectancy in India has increased from 49.7 years in 1970-75 to 68.7 years in 2012-16, as per the National Health Profile 2019. For the same period, the life expectancy for females is 70.2 years and 67.4 years for males.

2.               HIV virus now can be made untraceable undetectable and an HIV positive person will be able to live a normal married life on daily uninterrupted treatment

Major Campaigns

1.               Fit India Movement by Ministry of Sports GOI

2.               Perfect Health Mela by Heart Care Foundation of India

Economics

1.               The downfall in the economy was a major issue in 2019.

2.               In 2019, Fortis Healthcare announced that it has completed the acquisition of RHT Health Trust (RHT) assets for an enterprise value of Rs 4,650 crores.

3.               Rs 5,800 cr Medanta-Manipal deal falls through as sides disagree over valuation

Medical  Update

1.               For patients with heart failure and low heart pumping function with persistent symptoms and an elevated serum natriuretic peptide level on optimal pharmacologic and device therapy a new ray of hope came for better due to availability  of  a new drug dapagliflozin

2.               In patients with type 2 diabetes with kidney involvement (urine albumin excretion >300 mg per day and eGFR >30) the incorporation of an SGLT-2 inhibitor into the patient's glucose-lowering regimen has been shown to improve the diabetics complications.

3.               We expect in 2020 all patients with an LDL-C >100 mg/dL and a greater than 10 percent risk of a cardiovascular disease event within 10 years, will be put on statins. Also, All patients with  cardiovascular disease independent of the baseline low density lipoprotein cholesterol (LDL-C) level they will be put on lifelong high-intensity statin therapy (atorvastatin 40 to 80 mg or rosuvastatin 20 to 40 mg) rather than moderate intensity statin or no LDL-C lowering therapy.

Ayushman Bharat

As on 2^nd December 19590 hospitals empanelled, 6800774 patients benefitted via admissions and  11.46.69,820 cards issued

IMA

Dr Rajan Sharma took over as the National President 

New Drugs introduced in India in 2019

1.     Fenspiride hydrochloride film coated extended release tablet 80 mg and Fenspiride hydrochloride bulk for allergic asthma

2.     Bilastine tablets 20 mg and Bilastine Bulk for urticaria

3.     Iguratimod film coated tablets 25mg and Iguratimod Bulk for rheumatoid arthritis

4.     Fingolimod Capsules 0.5mg and Fingolimod hydrochloridebulk for multiple sclerosis

5.     Remogliflozin etabonate bulk and Remogliflozin etabonate film coated tablets 100 mg for diabetes

6.     Concentrate of Proteolytic enzyme enriched in Bromelain topical gel for eschar

7.     Menotrophin injection 600 IU/ml, 1 ml & 2 ml multi dose vial (Highly purified) for infertility

8.     Rifapentine 150mg film coated tablet for TB

9.     FDC of Bictegravir, Emtricitabine and Tenofovir alafenamide 50mg/200mg/25mg tablets for HIV

10.  Levomilnacipran ER capsules 20mg/40mg/80mg/120mg for depression

11.  Bosutinib bulk and Bosutinib tablets 100mg, 400mg, 5600 mg for cancer

12.  Algard HWS-256 (didecyl dimethyl ammonium chloride 10.14% w/w + n-Alkyl dimethyl benzyl ammonium chloride 6.76% w/w as disinfectant

13.  Algard - R-82 (octyldecyl dimethyl ammonium chloride 6.510 w/w + Dioctyl dimethyl ammonium chloride 2.604% w/w + Didecyl dimethyl ammonium chloride 3.906% w/w + Alkyl dimethyl benzyl ammonium chloride 8.680% w/w as disinfectant

14.  Safinamide methane sulphonate bulk drug and Safinamide tablets 50, 100mg for Parkinson disease for Parkinson disease

15.  Droxidopa bulk drug and Droxidopa capsules 200mg/300mg for postural hypotension

16.  Acalabrutinib 100mg capsules for multiple myeloma

17.  Abemaciclib 50mg, 100mg, 150mg and 200mg film coated tablets for breast cancer

18.  Ripasudil hydrochloride hydrate bulk drug and Ripasudil Eye drops 0.4% w/v for glaucome

19.  Diperoxochloric acid concentrate and Diperoxochloric acid topical solution for diabetic neuropathy ulcers

Practice-Changing Studies from American College of Gastroenterology 2019

Practice-Changing Studies from American College of Gastroenterology 2019

Dr KK Aggarwal
President CMAAO and HCFI

1. Oral Budesonide suspension 2 mg for 12 weeks shows Striking Efficacy for Eosinophilic Esophagitis

2. Avoidant/restrictive food intake disorder (ARFID) is increasingly being emphasized in adult gastroenterology. This is a diagnosis that's established by restriction or avoidance of food intake that is associated with weight loss, nutritional deficiencies, dependence on tube feedings or oral supplements, or significant psychosocial impairment.

3. Vedolizumab for Ulcerative Colitis: Shift from IOV to SC now. It is a monoclonal antibody targeting the alpha-4 beta-7 integrin.

4. Obeticholic Acid, a selective farnesoid X receptor agonist, which regulates bile acid homeostasis is effective in NASH

5. There is no apparent Increased Risk for Metachronous Lesions in Young Adults With Adenomas

6. Hyperbaric Oxygen is a new indication for refractory Pouchitis