122 CMAAO CORONA FACTS and MYTH BUSTER: Myocardial injury

122 CMAAO CORONA FACTS and MYTH BUSTER:  Myocardial injury

Dr K K Aggarwal

President CMAAO

946: Myocardial Injury Among Hospitalised Patients With COVID-19 Associated With Higher Risk of Death

DG News Myocardial injury is prevalent among patients hospitalised with coronavirus disease 2019 (COVID-19) and is associated with higher risk of mortality, according to a study published in the Journal of the American College of Cardiology.

Anu Lala, MD, Icahn School of Medicine at Mount Sinai, New York, New York: “We found that 36% of patients who were hospitalised with COVID-19 had elevated troponin levels and were at higher risk of death. These findings, which are consistent with reports from China and Europe, are important for clinicians. If COVID-19-positive patients arrive in the emergency room and their initial test results show troponin levels are elevated, doctors may be able to better triage these patients and watch over them more closely, but this remains a testable hypothesis.”

Researchers analysed electronic health records of nearly 3,000 adult patients with confirmed positive COVID-19 admitted to 5 New York City hospitals within the Mount Sinai Health System between February 27, 2020, and April 12, 2020. The median age for patients analysed was 66 years and about 60% were male. One-quarter of all patients self-identified as African American and 27% self-identified as Latino. Roughly 25% of the patients had a history of heart disease and 25% had cardiovascular disease risk factors.

All patients had a blood test for troponin levels within 24 hours of admission, of which 64% had normal levels (0.00-0.03 ng/mL), 17% had mild elevation (>0.03-0.09 ng/mL), and 19% had higher elevation (>0.09 ng/mL). Higher troponin levels were more prevalent in patients who were aged older than 70 years old and had previously known conditions including diabetes, hypertension, atrial fibrillation, coronary artery disease, and heart failure.

Patients with milder forms of myocardial injury were associated with lower likelihood of hospital discharge and a 75% higher risk of death compared with patients with normal levels.

Patients with higher troponin concentrations were associated with a 3 times higher risk of death compared with those with normal levels. When adjusting for relevant factors such as heart disease, diabetes, and hypertension, troponin was independently associated with risk of death. More specifically, heart injury seems to be a more important indicator in predicting risk of death than a history of heart disease.

Reference: https://www.sciencedirect.com/science/article/abs/pii/S0735109720355522

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]

Welcome to the Silver Jubilee celebrations of the Perfect Health Mela

This year, we are celebrating 25 years of the MTNL Perfect Health Mela, scheduled to be held from 23th October to 27th October 2018 at the Talkatora Indoor Stadium, New Delhi. The theme for the Mela this year is “Affordable Healthcare”.

This year, the Mela promises to be bigger, better and more exciting for everyone as we have introduced many new features such as the ‘Evening Conclaves’, ‘Mini Melas’ and ‘HCFI CSR Awards’.

The Evening Conclaves are thematic conclaves, which will bring together experts from various fields for panel discussion on relevant issues such as antimicrobial resistance, IVF, Indoor pollution. The panel discussions will be followed by entertainment programs like a comedy night, concert night, qawwali and others.

Mini Melas are melas within the main Mela with five different themes each day of the Mela such as Math Mela, Art Mela, female adolescent health.

The HCFI CSR Awards, under various categories, will honor the best CSR initiatives by organizations and individuals that have revolutionized the way healthcare and other social initiatives are delivered.

The Mela will also undertake campaigns on two issues – “Indoor air pollution” and “Make in India” - to raise awareness on the fact that indoor air pollution can affect health as much as outdoor pollution; and to realize the goal of affordable healthcare through the Make in India for Cure in India movement.

We often talk of pollution outside our homes. Indoor air pollution often goes unnoticed and can be a major health hazard even in urban areas. However, indoor air pollution is an equally urgent issue that needs attention because a major part of our life is spent indoors in homes, schools, colleges, offices etc.

Make in India is imperative for Cure in India and it must be promoted to ensure that no one lacks access to timely treatment. This covers medical devices as well. The aim is to achieve the overall goal of affordable health care for all by making all critical and lifesaving medical devices available and accessible at affordable prices.

The Mela will showcase its usual activities across categories such as free health check-ups, entertainment programs, lifestyle exhibitions, lectures, workshops, CPR training, inter-school competitions (Harmony and EcoFest), a unique competition for specially-abled children (Anmol),  inter-college competitions (National Youth Fest) among others.

Entry to the Mela is free for all.

Join us as we celebrate the silver jubilee celebrations of the Perfect Health Mela.

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

Follow the four principles of Gandhian philosophy

The 150th birth anniversary of Mahatma Gandhi starts today and gives us an opportunity to recall the four fundamental principles that Mahatma Gandhi taught: Truth (satya), non-violence (ahimsa), welfare of all (sarvodaya) and peaceful protest (satyagraha). These principles can hold people together and hence form the backbone of dharma, which means “to hold together”.

Satya means oneness in your thoughts, speech and actions. Gandhi believed that “there is no religion higher than truth”. The Yoga-shastras as well as the Yoga Sutras of Patanjali propagate truthfulness as one of the main components for living a disciplined life.

Gandhi preached the concept of “experimenting with truth”, a phrase that also formed the subtitle to his autobiography. He taught how to learn through trial and error, often admitting to mistakes and changing one’s behavior accordingly. Non observance of truthfulness is the root cause of any corruption in the society.

Ahimsa teaches us the path of non violence. It should be practiced not only in actions but also in thoughts and speech. Ahimsa also forms the basis of Jainism and Hinduism as a religion.

The third principle is sarvodaya or welfare for all. The basic fundamental teaching of the Vedic science is also based on sarvodaya. It talks about “bahujan hitay-bahujan sukhay” - “the good of the masses, the benefit of the masses”. Gandhi found in it a composite concept of social welfare and economic justice. Any action, which is aimed and seems to be aimed at the welfare of the people will be accepted by all.

Satyagraha is protest based on satya (path of truthfulness) and non violence and includes peaceful demonstrations, prolonged fasts etc. i.e. a non violence-based civil resistance. It is based on the law of persistence. Satyagraha is formed by two Sanskrit words satya (truth) and agraha (holding firmly to or firmness). Gandhi said “Satyagraha is a weapon of the strong; it admits of no violence under any circumstance whatsoever; and it ever insists upon truth”. He said that if you are firm in the truth in the long run you are going to win.

These are basic principles that doctors should also follow as doctors not only need to be scientifically and legally correct, they also should be morally and ethically correct. Non-maleficence (do no harm) and beneficence (do good) are the pillars of medical ethics

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

Aim at achieving a parasympathetic state of mind

Every adversity is an opportunity to learn and therefore giving up is not the answer. 

A new research from the University of Portsmouth in the UK has found that people can die simply because they've given up, life has even beaten them, and they feel defeat is inescapable to them. The study is the first to describe the clinical markers for 'give-up-itis', a term used to describe what is known medically as psychogenic death. It usually follows a trauma from which a person thinks there is no escape, making death seem like the only rational outcome.

Although not akin to depression, the act of giving up on life and dying usually within days is a very real condition often linked to severe trauma. There are five stages leading to progressive psychological decline. Research indicates that give-up-itis could stem from a change in a frontal-subcortical circuit of the brain governing how a person maintains goal-directed behaviour.

The five stages of ‘give-up-itis’ are social withdrawal, apathy, aboulia (severe lack of motivation psychic akinesia (profound apathy) and psychogenic death.

Giving up is not the answer. Youngsters today are prone to get dejected by the smallest of sufferings. It is important to be self-motivated.

According to Hinduism, the very fact we are born means that in our last life, we did not get liberation or Moksha. It also means that some sufferings in our last birth remained. Therefore, the purpose of this birth is to face those sufferings. When the purpose of our life is to face sufferings, why suffer from them? They should be considered as ‘sukh’ and not ‘dukh’. As per Vedic literature, every adversity is an opportunity to learn or to do something different.”

The four notable principles of Buddhism also talk about the same. The first is that suffering exists, second that there is a reason for every suffering and third that it is possible to neutralize the suffering by understanding the 8 paths of cessation of suffering.

Remember that in every ‘dukh’ you think of ‘sukh’ and in every ‘sukh’ you think of a ‘dukh’. Positive thinking produces nearly a 30% drop in perception of pain. Next time you have a problem, think differently and learn to enjoy them. One should learn to disassociate from, both, external pain as well as pleasure, and only then can one acquire true internal happiness.”

Just as photon is the smallest unit of light and quantum is the smallest unit of energy, Qualia is the smallest unit of thought. Quantum teleportation is the transportation of quantum information via the phenomenon of entanglement. At the level of quantum, consciousness is the extreme parasympathetic state of mind or Samadhi. Those engaging in activities such as music and dance are able to achieve a parasympathetic state of mind.

The 25th Perfect Health Mela 2018 will explore some of these concepts during the cultural conclaves and programmes.

Celebrating its silver jubilee this year, the Mela will be held from 23rd to 27th October at the Talkatora Indoor Stadium, New Delhi.

The Board of Governors taking over was inevitable

The Niti Aayog had always wanted to change the structure of MCI for long. However, it was getting postponed either by pressure from the medical community including IMA or by the opposition political parties.

The NMC Bill had been put before the Parliament twice but had not been passed. It may not get passed in the winter session too. After that it will be National election time.

The bureaucracy is very adamant in making this change. The term of the MCI was getting over on 5th November. If the govt. had started the MCI re-election period, this would mean being elected for five years.

The Supreme Court had already consented to an overarching control of a 5-member committee.

So, the best way for the government was to not continue with the MCI beyond 5th November and run it with a 5-7 member Board of Governors as the Congress had done in the past with the same members who had been running it for the last one year with additional two members.

Most of these members nominated to the Board of Governors have proven integrity. Dr Sanjay Shrivastava, who has been appointed the Secretary General has a wide experience of the MCI.

The whole procedure has been advanced by one month with an idea that by the time the next parliament sits, they will have had enough time to adjust. The government is hoping to get the NMC Bill passed in November. If not, continue with the Board of Governors for the next one year.

Till the NMC comes, the present infrastructure and staff of MCI continues.

MCI Take-over: Malafide and Scheming (Team IMA 2018)

In an emergency session in Mumbai, the IMA Action Committee condemned the supersession of the Medical Council of India (MCI).

This action of the Government, at a juncture when the election to MCI has been announced, is unwarranted and malafide. The composition of the Board of Governors (BOG) itself is unacceptable. Directors of major National institutions would scarcely find time to administer more than 450 medical colleges and their UG and PG courses. Moreover, there is no representation to women and Registered Medical Practitioners.         

                                     

The Indian Medical Association (IMA) is convinced that supersession of MCI is only a smoke screen and ploy to prepare the ground for NMC and sabotage the democratic process of MCI. Why the Government was in a hurry to scuttle a democratic process needs an answer.     

                                        

 IMA’s concerns remain. Bringing MCI directly under the government control seems to be the plan to implementation of Bridge Courses, crosspathy and registration of non medical persons.

IMA demands that the BOG should refrain from taking any major policy decisions or amendments changing the character of the IMC Act.

IMA also demands that the election process in progress in MCI should be allowed to continue.   

    

IMA will continue its resistance to NMC Bill. Any intentions of the NMC Bill implemented through the appointed BOG will be fought with determination. 

• This is the fourth time that BOG is being appointed. All the previous attempts were an abject failure. 
• The eminent clinicians appointed have little exposure to the day-to-day administration of MCI. 
• The Government has not cited any reason for superseding MCI.                     
• MCI Election process is on.  It was inappropriate for the Government to supersede at this stage. This betrays a malafide intention. 
• BOG should conform to the basic tenets of IMC Act and refrain from tinkering with its fundamental structure. 
• Crosspathy, registration of non medical persons, bridge courses and mixing of syllabi are core concerns. The fidelity, identity and the privileges of the profession will be defended at any cost.       
• 184 private medical colleges are awaiting recognition due to strict norms of the outgoing MCI team.  IMA, media and the people should keep vigil in this regard.
• IMA foresees a highly difficult period ahead when checks and balances have been removed.
• A generation of substandard doctors will be the legacy of this action.
• IMA will keep its tryst with destiny and redeem the profession from dark forces. Every single challenge thrown at the profession will be repulsed with single minded. 

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

Saving a death when we cannot save a life in the intensive care unit

There are several situations and/or elective interventions in medicine where the patient is made unconscious, given anesthesia, surgery or sedation especially in terminally ill patients. In these situations, there is a chance that the patient may not wake up. Even though the intervention may have been necessary, it deprives them of their chance to share few last words with their families.

In the June 2018 issue of JAMA International Medicine, Michael E. Wilson - a critical care doctor - has written an account of a woman in intensive care in “Saving a death when we cannot save a life in the intensive care unit”, who was electively intubated for a procedure and then died, without ever having had the opportunity for her loved ones to say goodbye.

This can be somewhat likened to soldiers being sent off to war by their families with a puja and tika or families sending off their loved one on a pilgrimage or tirth yatra with a tika in ancient times as they may not come back alive.

This gives them an opportunity to talk to their families and express their wishes that they want to be fulfilled, knowing that this might be their last chance to hold this conversation.

When I was in Malaysia for the CMAAO general assembly, we went to the Port. There were three temples where fishermen prayed before going out to the sea and also when they returned.

The ritual of performing Shradh is to satisfy the unfulfilled, known or unknown, wishes and desires of the deceased person by the eldest son in the family. Shradhs are also for the unknown unfulfilled desires of our ancestors; unknown to the present family but maybe were known to the past family. These unknown wishes come back as dreams to their descendents through qualia or tanmatras. A mahashradha is performed when all the wishes of the ancestors are fulfilled. Once a mahashradha is performed, then there is no need to perform Shradh rituals thereafter.https://ssl.gstatic.com/ui/v1/icons/mail/images/cleardot.gif

 According to the Vedas, every individual has three debts to be paid off, firstly, the Devtas (Dev Rin), secondly of Guru and teachers (Rishi Rin) and, thirdly, of Ancestors (Pitra Rin). Devtas represent people with Daivik qualities; teachers the ones who have taught us and Pitra represent the three generations of our ancestors.

Therefore, it is always better to allow patients some time alone with their families and express their wishes, before any such intervention, or say goodbye in the worst case scenario.

 “My intubation checklist now includes this step…It’s a way to avoid stealing last words from a person”, as Michael E Wilson writes.

Always write down your wishes for your family…

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

Ordinance cleared to set up committee to run MCI until Parliament passes NMC

Just like it was 5 years back, a Board of Governors has taken over the MCI. Dr VK Paul has taken charge of MCI today evening.

The present MCI gets dissolved with immediate effect.

Proposed NMC is in Parliament and has nothing to do with present ordinance.

The ordinance is as below:

The Gazette of India

New Delhi, Wednesday, September 26, 2018/Asvin 4, 1940 (Saka)

MINISTRY OF LAW AND JUSTICE
(Legislative Department)

New Delhi, the 26th September. 2018/4svina 4, 1940 (Saka)

THE INDIAN MEDICAL COUNCIL (AMENDMENT)

ORDINANCE, 2018

No. 8 of 2018

Promulgated by the President in the Sixty-ninth Year of the Republic of India.

An Ordinance further to amend the Indian Medical Council Act. 1956.

WHEREAS Parliament is not in session and the President is satisfied that circumstances exist which render it necessary for him to take immediate action;

NOW, THEREFORE, in exercise of the powers conferred by clause (1) of article 123 of the Constitution, the President is pleased to promulgate the following Ordinance:-

1. (1) This Ordinance may be called the Indian Medical Council (Amendment) Ordinance, 2018.

(2) It shall come into force at once.

2. In section 3A of the Indian Medical Council Act, 1956,- --

(a) in sub-section (I), for the words, brackets and figures "Indian Medical Council (Amendment) Act. 2010", the words, brackets and figures "Indian Medical Council (Amendment) Ordinance, 2018" shall be substituted;

(b) in sub-section (2), for the words "three years", the words "one year" shall be substituted;

(c) in sub-section (4), for the words "and medical education", the words "and medical education or proven administrative capacity and experience" shall be substituted;

(d) after sub-section (7), the following sub-section shall be inserted, namely: — "

(7A) The Board of Governors shall be assisted by a Secretary General who shall be appointed by the Central Government on deputation or contract basis and he shall be the head of the secretariat in the Council.".

RAM NATH KOVIND,

 President.

DR. G. NARAYANA RAJU.

Secretary to the Govt. of India

(To be published in the Gazette of India, Extraordinary, Part – II, Section 3, Subsection (ii)] MINISTRY OF HEALTH AND FAMILY WELFARE (Department of Health and Family Welfare) NOTIFICATION New Delhi, the 26th September, 2018-09-26 S.O. – Whereas the President promulgated the Indian Medical Council (Amendment) Ordinance, 2018 (Ordinance 8 of 2018) on 26th September, 2018, which came into force on the said date; And whereas, on and from the date of commencement of Indian Medical Council (Amendment) Ordinance, 2018 (Ordinance 8 of 2018), the Medical Council of India shall stand superseded and teh President, Vice President adn other Members of the Council shall vacate their office and shall have no claim for any compensation, whatsoever; And whereas upon the supersession of the Council and until a new Council is reconstituted, a Board of Governors is required to be constituted by the Central Government to exercise the powers and perform the functions of the Council under the said Act; Now, therefore, in exercise of the powers conferred by sub-section (4) of section 3A of the Indian Medical Council (Amendment) Ordinance, 2018, the Central Government hereby constitutes the Board of Governors consisting of the following persons as its Chairperson and Members, namely: - Dr. VK Paul, Member, NITI Aayog                                      - Chairman Dr Randeep Guleria, Director, AIIMS, New Delhi               - Member Dr Jagat Ram, Director, PGIMER, Chandigarh                     - Member Dr BN Gangadhar, Director NIMHANS, Bangalore             - Member Dr Nikhil Tandon, Professsor, Department of                        - Member Endocrinology & Metabolism, AIIMS, New Delhi Dr S Venkatesh, Director General of Health Services            - Member ex-officio Ministry of Health & Family Welfare Prof Balram Bhargava, Secretary, Department of Health       - Member ex-officio Research & Director General Indian Council of Medical Research, New Delhi Further, in exercise of the powers conferred under section 7A of the Indian Medical Council (Amendment) Ordinance, 2018, the Central Government hereby appoint the Secretary General to assist the Board of Governors to the following person, namely:- Dr Sanjay Shrivastava, Ex-Deputy Director General, Directorate General of Health Services, Ministry of Health & Family Welfare, New Delhi

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