Honorary Professor in Bioethics Awarded to Dr K K Aggarwal

Honorary Professor in Bioethics Awarded to Dr K K Aggarwal

Retired Justice of Supreme Court of Indian and Former Chairman Law Commission of India A R Lakshmanan delivered key note address on Bioethics during a National Conclave on the subject organized by Asia Pacific Network of UNESCO Bioethics organised at SRM University Potheri, Chennai.

Vice Chancellor of SRM University Doctor Dr T P Ganesan, Awarded "Honorary Professor in Bioethics" to incoming Indian Medical Association National President Dr A Marthanda Pillai and its incoming Honorary Secretary General Dr K K Aggarwal. Both of them are Recipients of Padma Shiri Awards.  They said IMA will educate all hits 2,50,000 members on Bioethics though IMA e-Connect program.

Dr N Dinesh Professor Psychiatry Amrita Institute of Medical Sciences Cochin also received the Honorary Professorship.

Tamilnadu State President of IMA Dr M Balasubramainan said that it is a great Honor for IMA Top Office Bearers to receive honorary professorships.

Dr Ruseell F D’ Souza Chairman of Asia Pacific network of UNESCO Bioethics said that UNESCO will join hands with IMA in the coming year to propagate the message of bioethics amongst the medical professionals with a standard curriculum.

Dr P Thangaraju SRM Pro Vice Chancellor, Dr Balakrishnan, Dean Medical Research, SRM University and Prof. Dr James Pandian, SRM Dean were present on the occasion and also deliberated on the subject.

Delegates from Tamilnadu, Kerala, Karnataka, Maharashtra, Delhi, Manipur & Nepal participated in the conclave.

Ebola can persist in the semen

Ebola in the semen

1. Ebola can be present in saliva, stool, semen, breast milk, tears, nasal blood, and a skin swab.

2. A study published in the Journal of Infectious Diseases (J Infect Dis. 1999 Feb;179 Suppl 1:S28-35) evaluated if convalescent body fluids contain Ebola virus and if secondary transmission occurs during convalescence. Twenty-nine Ebola hemorrhagic fever  convalescents and  their 152 house hold contacts were monitored for up to 21 months. Blood specimens were obtained and symptom information was collected from convalescents and their house hold contacts.  other body fluid specimens were also obtained from convalescents.  Joint and muscle pains were reported significantly more often by convalescents than house hold contacts. Evidence of Ebola virus was detected by reverse transcription-polymerase chain reaction in semen specimens up to 91 days after disease onset; however, these and all other non-blood body fluids tested negative by virus isolation.

 Among 81 initially antibody negative house hold contacts none became antibody positive.

Blood specimens of 5 house hold contacts not identified as Ebola hemorrhagic fever  patients were initially antibody positive. No direct evidence of convalescent-to- house hold contract transmission of Ebola fever was found, although the semen of convalescents may be infectious.

The existence of initially antibody-positive house hold contacts suggests that mild cases of Ebola virus infection occurred.

3. Who is a high risk Ebola Patient: Percutaneous (needle stick) or mucous membrane exposure to blood or body fluids (feces, saliva, sweat, urine, vomit, and semen) of a person with symptomatic Ebola virus disease and Exposure to the blood or body fluids (feces, saliva, sweat, urine, vomit, and semen) of a person with symptomatic Ebola virus disease without appropriate personal protective equipment (PPE). In both situations a person has to be symptomatic.

4. There is no identifiable risk when the contact is with an asymptomatic person who had contact with a person with Ebola and also contact with a person who is later diagnosed with Ebola virus disease, before the person developed symptoms.

5. Viral persistence — Virus can persist for some time in certain bodily fluids, such as semen and breast milk.

a     Follow-up studies of 40 survivors in the 1995 Kikwit, Democratic Republic of Congo outbreak showed that viral RNA sequences could be detected by RT-PCR in the semen of male patients for up to three months, and infectious virus was recovered from one individual 82 days after disease onset. [J Infect Dis. 1999;179 Suppl 1:S28.]

b  

         In only one known instance, during the 1967 Marburg outbreak, has viral persistence in semen led to virus transmission through sexual contact. [Curr Top Microbiol Immunol. 1999;235:49, Trans R Soc Trop Med Hyg. 1969;63(3):295.]

c     

      A study of patient samples collected during the outbreak of Ebola Sudan virus disease in Gulu, Uganda in 2000 detected virus in the breast milk of a patient, even after virus was no longer detectable in the bloodstream. Two children who were breast-fed by Ebola-infected mothers died of the disease. [J Infect Dis. 2007 Nov;196 Suppl 2:S142-7.]

d

         During the 2014 outbreak in West Africa, virus was cultured from a patient’s urine 12 days after the last positive culture was identified in plasma. [N Engl J Med. 2014 Oct]

6. Convalescent period of Ebola and Marburg virus disease is prolonged, and marked by weakness, fatigue, and failure to regain weight that was lost during illness. Extensive sloughing of skin and hair loss are commonly observed, possibly as a result of virus-induced necrosis of infected sweat glands and other dermal structures

7. There is no evidence that asymptomatic persons still in the incubation period are infectious to others.  But all symptomatic individuals should be assumed to have virus in the blood, and other body fluids, and appropriate safety precautions should be taken. [Arch Virol Suppl. 1996;11:141.]

8. Convalescence from Ebola Virus Disease is long and often associated with sequelae such as myelitis, recurrent hepatitis,  psychosis, or uveitis. Data on the post-recovery viraemic period are limited. As said above shedding of Ebola virus has been  reported in breast milk and semen after the virus has been cleared from blood. Viable virus has been isolated  from semen up to many weeks or months after recovery, and spermatogenic transmission of Marburg virus has been  documented. There is a paucity of data on Ebola virus in human egg cells. The risk of Ebola transmission should be considered in connection with reproductive cell donations, both for ‘partner’ and ‘other than partner’ donations.

However, the evidence that Ebola virus may persist for some time in the human body after recovery from Ebola Fever is  insufficient to define a specific deferral period for donors who have recovered from Ebola Fever. The current guidance  stipulates deferral for 12 months following recovery from a viral hemorrhagic fever and this recommendation  also applies to donors who have recovered from Ebola Fever. In addition, living or deceased donors of substances of human origin should be negative for Ebola virus by NAT testing

9. A deferral of donation for two incubation periods will provide a reasonable margin of safety for asymptomatic donors returning from Ebola affected areas. The longest incubation period for Ebola Disease has been 25 days. Thus, asymptomatic travelers or residents returning from Ebola Virus affected areas should be temporarily  deferred from donation of substance of human origin including blood for two months after leaving an area affected by Ebola virus.

10. Men who have recovered from the illness can still spread the virus to their partner through their semen for many months after recovery. For this reason, it is important for men to avoid sexual intercourse after recovery or to wear condoms if having sexual intercourse during this period after recovery.

[ Dr K K Aggarwal is Padma Shri, Dr  B C Roy National and National Science Communication Awardee, President Heart Care Foundation of India and Senior National Vice President, Indian Medical Association]

Zinc Phosphode the lethal killer in Chhattisgarh sterilization tragedy

New Delhi: After 13 women died in a sterilization programme in Chhattisgarh, a preliminary enquiry has revealed that the drug used during the procedure could have been contaminated with zinc phosphide, widely used as rodenticide and perhaps could be the cause of death of the victims.

Confirming these findings, Commission Bilaspur Division, Sonmani Borah, said traces of zinc phosphide have been found in Ciprocin 500mg tablets, manufactured by Mahawar Pharmaceutical Pvt Ltd. These tablets were distributed to all the women who underwent sterilizations at the three health camps - Takhatpur, Pendra and Marwahi - in Bilaspur district on last Saturday and Monday.

Mahawar Pharma Pvt Ltd's director Ramesh Mahawar and his son Sumit have been arrested under section 420 for cheating, based on a complaint lodged by Food and Drug Administration authorities.

All about Zinc Phosphide

Zinc phosphide can be prepared by the reaction of zinc with phosphorus; however, for critical applications, additional processing to remove arsenic compounds may be needed.

Zinc phosphide reacts with water to produce phosphine and zinc hydroxide. Metal phosphides is used as rodenticides.

A mixture of food and zinc phosphide is left where the rodents can eat it. The acid in the digestive system of the rodent reacts with the phosphide to generate the toxic phosphine gas.

Other pesticides similar to zinc phosphide are aluminium phosphide and calcium phosphide.

There is usually only a short interval between ingestion of phosphides and the appearance of systemic toxicity. Phosphine-induced impairment of myocardial contractility and fluid loss leads to circulatory failure, and critically, pulmonary edema supervenes, though whether this is a cardiogenic or non-cardiogenic is not always clear.
Metabolic acidosis, or mixed metabolic acidosis and respiratory alkalosis, and acute renal failure are frequent.

Other features include disseminated intravascular coagulation, hepatic necrosis and renal failure. There is conflicting evidence on the occurrence of magnesium disturbances.

There is no antidote to phosphine or metal phosphide poisoning and many patients die despite intensive care. Supportive measures are all that can be offered and should be implemented as required.

Depression linked to over 50% of heart blockages

Dr. Rick Levy from  Washington, DC who will be delivering a lecture on improving patient outcomes by treating stress, depression and  anxiety in the forthcoming Cardiological Society of India meet to be held at Hyderabad in early December said that depression, anxiety and ‘chronic worry’ correlate with a 2 to 5 times higher risk of developing heart blockages and 3 to 5 times higher morbidity and mortality  patients with established blockages.

Screening and treating heart patients for depression and anxiety  should be a standard practice. In the west over half of all heart patients suffer from depression or anxiety at some point, said Dr H K Chopra incoming President of National CSI.

A busy cardiologist can identify patients with clinical levels of depression and anxiety using an easy two-question Patient Health Questionnaire, or PHQ-2 – self-administered by the patient in less than a minute, and scored by a nurse or admitting staff member in less than 15 seconds.

The two questions to be asked are over the past two weeks how often have you been bothered by any of the following problems: Little interest or pleasure in doing things and Feeling down, depressed, or hopeless.

Give zero marks for not at all; 1 mark for several days, 2 marks for 50% of the days and 3 marks for every day. If the patient has a positive response to either question he or she needs a referral and treatment.  Maximum marks can be 6 and a cut off of 3 points can be taken a point for referral and treatment.

Commenting on the study Padma Shri, Dr B C Roy National and National Science Communication Awardee Dr K K Aggarwal Senior National Vice President Indian Medical Association said that Psychotherapy and regular meditation have been clinically proven to improve health outcomes for heart patients with depression and anxiety.

SSRIs are the only antidepressant proven relatively safe for heart patients.

Long-term use of mobile and cordless phones is associated with an increased risk for brain cancer

It's official: Long-term use of mobile and cordless phones is associated with an increased risk for glioma, the most common type of brain tumor as per the latest research published online on October 28 in Pathophysiology.

The new Sweden study by Dr Lennart Hardell, Professor of Oncology at University Hospital, shows that the risk for brain tumor is tripled among those using a wireless phone for more than 25 years and that the risk is also greater for those who had started using mobile or cordless phones before age 20 years.
The widespread use of wireless communications has resulted in greater exposure to radiofrequency electromagnetic fields and the brain is the main target of these radiations when these phones are used, with the highest exposure being on the same side of the brain where the phone is placed.
In the study an increased risk for brain tumor was associated with use for more than 1 year of both mobile and cordless phones and the highest risk was for those with the longest latency for mobile phone use over 25 years.

The precautions, include using hands-free phones with the "loud speaker" feature and text messaging instead of phoning.


Talking on mobile is risky when driving but talking to friend in the car is less risky when he can also see the road

Mobile conversations are an enemy to safe driving. A new Canadian study from University of Alberta in Edmonton finds that drivers do best when they don't talk and simply focus on the road, if they must talk, it's better if the person they are talking to has his or her eyes on the road, too. That could mean either sitting in the passenger seat or via a specially designed videophone.

The study, published recently in Psychological Science, tested driver safety in one of four conditions, using a driving simulator.

1. A silent driver alone in the vehicle.

2. The driver accompanied by a passenger, where they engaged in conversation.

3. The driver speaking to someone on a hands-free cellphone with a standard audio-only connection.

4. The driver speaking to someone remotely with a one-way video connection. That connection allowed the person on the other end of the line to see both the driver and the driver's perspective of the road ahead, much as if they were a passenger in the car.

The study found

1. Nothing was as safe as driving alone in peace and silence.

2. Talking to a fellow passenger in the car was less safe than driving alone, but it was still safer than being on a typical, audio-only cellphone call, which tripled the odds for a collision compared to silent driving.

3. The videophone call was safer than having an audio call, and almost as safe as having a talking passenger sitting beside you.

Chhattisgarh sterilization deaths: Accident or Negligence

To err is human; error of judgment is not crime; difference of opinion is not crime, failure of outcome is not crime; routine complications are not crime; mere deviation from standard practice may not be crime, BUT what a crime is " not taking standard precautions, neglecting the patient or not taking proper consent. This can only be found out after proper investigations.

I have written to MCI to take this case suo moto and investigate. Punish the doctors if he is guilty or protect him and restore the image of the medical profession if he is not guilty.

Following MCI ethics regulations clauses are applicable in such mishaps

2.4 The Patient must not be neglected: A physician is free to choose whom he will serve. He should, however, respond to any request for his assistance in an emergency. Once having undertaken a case, the physician should not neglect the patient, nor should he withdraw from the case without giving adequate notice to the patient and his family. Provisionally or fully registered medical practitioner shall not willfully commit an act of negligence that may deprive his patient or patients from necessary medical care.

7.16 Before performing an operation the physician should obtain in writing the consent from the husband or wife, parent or guardian in the case of minor, or the patient himself as the case may be. In an operation which may result in sterility the consent of both husband and wife is needed.

7.22 Research: Clinical drug trials or other research involving patients or volunteers as per the guidelines of ICMR can be undertaken, provided ethical considerations are borne in mind. Violation of existing ICMR guidelines in this regard shall constitute misconduct. Consent taken from the patient for trial of drug or therapy which is not as per the guidelines shall also be construed as misconduct.

Grass root facts

•             Camps are common, standardized and happen with the knowledge of government authorities.

•             Government pays incentives for patients, doctors and staff

•             Day care surgeries are done in conveyer belt fashion

Issues to decide negligence or accident

•             Proper consent

•             How many laparoscopes were used

•             Time taken for laparoscope sterilization

•             Time between two surgeries

•             Type of anesthesia given

•             Type of drugs used

•             How many surgeries are done in how much time

•             Qualification of the surgeon

•             Experience of the surgeon

•             Autopsy reports

•             CO2 used: quality

•             Quality of instruments used

Government steps on the tragedy

•             Meanwhile even as reports said that rusted equipment were used in the surgeries, a team of doctors from Delhi's premier AIIMS hospital is in Bilaspur to investigate what happened.

•             The medicines used have been sent to a lab in Kolkata for analysis

•             Autopsy reports are awaited

Media Trial

"Times Now"  TV channel news at 7-15 p.m. on 13-3-2014 equated Dr. R K Gupta, surgeon, of Chhattisgarh as "Doctor Death", "Butcher of Bilaspur" and "Merchant of Death".

Comments by fellow colleagues

•             "Till the results of the enquiry are released the doctors should not be harassed. The medic should not project the negative image of the profession" : Dr Narendra Saini Honorary Secretary general IMA

•             "It is for the IMA to digest it and to be blind to it and to ignore it or to launch  media blitz  against this channel and to send a legal notice demanding within 72 hours an unqualified apology to be prominently telecast on the same channel, failing which the IMA should initiate appropriate legal proceedings. Please note that IMA has full locus standi to move on these lines because it represents the whole medical profession and ought to preserve its dignity and respect. Dr M C Gupta"

•             " http://scdrc.up.nic.in/judgement/A-1893-2008.pdf: "Held that the tubectomy was done free at a primary health centre as part of government’s family planning programme without payment of any money and hence it was not within the ambit of consumer act…………………………………." M C Gupta

•             The government has announced a relief of Rs. 2 lakhs only ( Dr Mehra)

•             " Here in chhattisgarh government pay 1400 to the patient for sterilization operations and if operation fails than 30000 as compensation to be paid but they are not consumer still so many cases are going on in consumer court for the same and our treating surgeon keeps on attending the trials on behalf of govt. I don't understand why consumer court accepted these cases" Vicky bansal

•             " PAYING 30,000/- as compensation for failed tubectomy is in itself a wrong step as any procedure can fail. So what is the big deal?" Dr Sodhi

•             " We are talking of doctors & doctors alone. Please remember that this is a government programme, government doctors, government everything. There is something called vicarious responsibility. There is another thing which is "owning up responsibility". And finally there is something (though rare) called "shame". Another rare item is "moral ground"  Do you all not feel that the health minister should own up responsibility and resign on moral grounds? Dr Sodhi

Questions which need to be answered ( Dr Neeraj Nagpal)

1.            Is Surgeon responsible for deaths in family planning camp?

2.            Is setting of targets for family planning responsible for such mishaps?

3.            Is the team including nurses, helpers, OT assistants equally responsible ?

4.            Is the team including nurses, helpers, OT assistants equally responsible ?

5.            Should the nurses, OT technicians and helpers who were part of team also be arrested?

6.            Is arrest of Surgeon without finding cause of mishap correct?

7.            What are various reasons one can think as cause of 14 deaths in family planning camp?: Lack of sterilization of instruments by paramedical staff/ Reaction to medicines or anesthesia used/ Chemical contaminant in CO2 used for insufflation/ Poor skill of surgeon leading to bleeding/ Carelessness of surgeon while operating/ Carelessness of surgeon in preoperative and postoperative care/ Mischief by someone part of surgical team

8. Are Doctors pressurized to do more and more surgeries in Family Planning camps by their superiors?

 9. Does the concept of medical and surgical camps in sub optimal settings need to be abolished

10. Should those who pressurize doctors to achieve 'targets' also be punished ?

11. Should compensation awarded by Govt to deceased not be raised to 20 lacs or more in such a mishap ?

12. How should such tragedies be avoided in future ?: Reduce number of surgeries which can be done in one camp to 10; Use minimum 3 Laproscopes and instrument sets for one camp; Qualified nurses and OT assistants to accompany doctor on such camps; Penalize superiors if more than 10 tubectomies are done in one camp; Abolish family planning camps totally or Punish surgeon severely to make example of him

13. Should awards be given as incentive to surgeons who perform more surgeries in family planning camps?

14. Is labeling the Surgeon 'Killer' by our print and electronic media appropriate ?

15. After such media condemnation if it is found later the surgeon was not at fault ?   Should he be compensated by his employers / Should he be compensated by the Press/

Should he be compensated by his professional Associations who did not support him ?

The risk for coronary artery disease is two to four times higher in diabetic subjects

Indians get diabetes on average 10 years earlier than their Western counterparts

Being an Indian is a risk factor for diabetes; despite having lower overweight and obesity rates, India has a higher prevalence of diabetes compared to western countries and the risk for coronary artery disease is two to four times higher in diabetic subjects,  and in Indians, and it occurs prematurely are a few of the facts compiled by Heart Care Foundation of India to create awareness about how to control the diabetic menace in India.


All the public, private and government sector should fight the diabetic menace epidemic menace together, said Padma Shri, National Science Communication and Dr B C Roy National Awardee, Dr KK Aggarwal President Heart Care Foundation of India and Senior National Vice President Indian Medical Association.

Diabetes  challenges for India and Indians as compiled by the foundation

1.    Diabetes is a huge problem in India. The prevalence of diabetes increased tenfold, from 1.2% to 12.1%, between 1971 and 2000. It is estimated that 61.3 million people aged 20-79 years live with diabetes in India (2011 estimates). This number is expected to increase to 101.2 million by 2030. And, 77.2 million people in India are said to have pre-diabetes.


2.     Rough estimates show that the prevalence of diabetes in rural populations is one-quarter that of urban population for India and other Indian sub-continent countries such as Bangladesh, Nepal, Bhutan, and Sri Lanka.  An ICMR study has shown that a lower proportion of the population is affected in states of Northern India (Chandigarh 0.12 million, Jharkhand 0.96 million) as compared to Maharashtra (9.2 million) and Tamil Nadu (4.8 million). The National Urban Survey conducted across the metropolitan cities of India reported similar trend: 11.7 per cent in Kolkata (Eastern India), 6.1 per cent in Kashmir Valley (Northern India), 11.6 per cent in New Delhi (Northern India), and 9.3 per cent in West India (Mumbai) compared with (13.5 per cent in Chennai (South India), 16.6 per cent in Hyderabad (south India), and 12.4 per cent Bangalore (South India).


3.    Obesity is one of the major risk factors for diabetes, yet there has been little research focusing on this risk factor across India. Despite having lower overweight and obesity rates, India has a higher prevalence of diabetes compared to western countries suggesting that diabetes may occur at a much lower body mass index (BMI) in Indians compared with Europeans.


4.     A most disturbing trend is the shift in age of  onset of diabetes to a younger age. Indians get diabetes on average 10 years earlier than their Western counterparts.  An upsurge in number of early-onset diabetes cases is also responsible for the development of various diabetic complications due to longer disease duration. Diabetes control in individuals worsened with longer duration of the disease (9.9±5.5 years), with neuropathy the most common complication (24.6 per cent) followed by cardiovascular complications (23.6 per cent), renal issues (21.1 per cent), retinopathy (16.6 per cent) and foot ulcers (5.5 per cent).


5.     The risk for coronary artery disease is two to four times higher in diabetic subjects,  and in Indians, and it occurs prematurely. Indians are genetically predisposed to the development of coronary artery disease due to dyslipidaemia and low levels of high density lipoproteins; these determinants make Indians more prone to development of the complications of diabetes at an early age (20-40 years) compared with Caucasians (>50 years) and indicate that diabetes must be carefully screened and monitored regardless of patient age within India. The rate of cardiovascular disease mortality in India in the 30-59-year age group is double that in the U.S.


6.     Lifestyle changes have lead to decreased physical activity, increased consumption of fat, sugar and  calories, and higher stress levels, affecting insulin sensitivity and obesity. 86% of adults consume less than five servings of fruits and vegetables a day. 18.    Many Indians have insufficient physically activity (26.4% among males and 25.6% among females).


7.     Costs of diabetes care are alarmingly high. The annual cost for India due to diabetes was about $38 billion in 2011. According to the WHO, if one adult in a low-income family has diabetes, “as much as 25% of family income may be devoted to diabetes care.”   According to the World Economic Forum, cardiovascular disease, cancer, chronic respiratory disease,  diabetes and mental health conditions will cost India 126 trillion rupees between 2012 and 2030.


8.     While HbA1c is the gold standard test around the world for insulin initiation and intensification, it is not easily available to a large section of Indian population.


9.     There is a lack of “clinical inertia” for the commencement of insulin therapy in both the clinical and patient communities. The most common apprehensions are related to the complexities of the insulin regimen and concerns about weight gain, hypoglycaemic events, and fear of insulin prick.


10.     An inadequacy in Indian guidelines is also responsible for wide variation in treatment preferences across the country. The creation of simple and practical insulin guidelines that can be incorporated into routine clinical practice by primary health care physicians are desperately required to facilitate treatment and the initiation of insulin therapy throughout the country. Poor glycaemic control, a factor that has been observed in the Indian diabetic population, is responsible for micro- and macrovascular changes that present with diabetes