Always enquire about chronic rhinitis in asthma and COPD patients

Patients hospitalized for either asthma or chronic obstructive pulmonary disease (COPD) have a higher risk of being readmitted for a hospital stay within 30 days of release if they also suffer from chronic rhinitis, says a new research from the University of Cincinnati.

The study, published in the Journal of Allergy and Clinical Immunology: In Practice, examined 4,754 asthmatic patients and 2,176 patients with COPD for a five-year period between 2012 and 2017. The 30-day asthma- and COPD-related readmissions of patients with allergic and non-allergic rhinitis with those patients without that diagnosis were compared using multivariate hazard models adjusted for relevant patient comorbidities.

Patients with asthma and allergic rhinitis were 4.4 times more likely to be rehospitalized within 30 days of discharge compared to those patients who did not have allergic rhinitis. Asthmatics with non-allergic rhinitis were 3.7 times more likely to be re-admitted within 30 days of discharge than asthmatics without non-allergic rhinitis.

Examination of COPD patients also revealed higher probability of rehospitalization when allergic rhinitis was also present.

COPD patients with allergic rhinitis may be readmitted 2.4 times the rate within 30 days of discharges compared to COPD patients without allergic rhinitis. Similarly, COPD patients with non-allergic rhinitis were 2.6 times more likely to readmitted within 30 days of discharge vs COPD patients without non-allergic rhinitis.

This study highlights the significance of a thorough history-taking, an art which many of us might have forgotten about, perhaps to meet the rush of the day.

Whenever treating a patient of asthma or COPD, one should always enquire about comorbid chronic rhinitis – allergic or non-allergic rather than treating or managing just the asthma or COPD. And, also treat it, if present.

Sir William Osler said, “Listen to your patient, he is telling you the diagnosis.”

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

Treating the Individual, Not the 'Average' Patient

Treating the Individual, Not the 'Average' Patient

The new trend is to strictly embrace evidence-based medicine (EBM) with the perception that the patients will do better and one can avoid legal consequences. In chart reviews, EBM looks easy: diagnosis A means use drug B and C.

Late David Sackett, MD, a pioneer in EBM, reveals the challenge: Evidence-based medicine is the conscientious explicit and judicious use of current best evidence in making decisions about the care of individual patients.

But in practice we do not treat patients but an individual patient.

Anyone with internet access can look up the guidelines or the results of a randomized controlled trial, but the challenge comes when deciding whether or not the patient in front of you is similar to those enrolled in the clinical trials underpinning the evidence.

Let’s take the example of the best blood pressure goal for a patient with multiple risk factors, hypertension and diabetes: Strict application of the evidence will be in ACCORD-BP trial, which showed that a systolic blood pressure target of 120 mm Hg, compared with a target below 140 mm Hg, did not reduce the rate of the composite outcome of fatal and nonfatal major cardiovascular events. And patients who received intensive treatment had more adverse effects. Evidence, therefore, points to the higher target.

But there is also the SPRINT trial, which showed that treatment to a lower BP goal resulted in serious reductions in cardiac events. But SPRINT excluded patients with diabetes

Is my patient closer to SPRINT or ACCORD? A trial's inclusion/exclusion criteria and the actual characteristics of enrolled patients may often differ greatly. The patient in the clinic might technically meet a trial's inclusion criteria but be poorly represented by the actual baseline characteristics of the patients enrolled in the study. Or, the patient might have a single exclusion criterion (e.g., diabetes) but resemble the trial population in many other ways.

My answer to this would be to treat the individual patient based on my experience of clinical practice.

When deciding on the line of management, I would take into consideration the social determinants of health, my past experience and not treat my patient as per the findings of any trial.

WHO has defined health has as “not just the absence of disease, but a state of complete physical, mental and social well-being”. This clearly indicates that the conditions we live in and work also affect our health.

So, it is not enough to address just the immediate presenting complaint, it is also important to treat the person as a whole in context of his/her social circumstances. Treatment has to be tailored to each individual patient taking into consideration their individual characteristics, culture, personal preferences, expectations etc.

Also many times I will use the harm reduction approach and keep the BP control on the higher side just to reduce the harm.

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

Weight cycling is associated with a higher risk of death

People often find it difficult to stick to to drastic changes in their diets along with exercise regimen to lose weight. So they start, stop and then restart. This sequence of events results in cyclical loss and gain of weight.

Weight cycling or ‘yo-yo dieting,’ as it is commonly called is the constant losing and gaining of weight (usually from diet). It is harmful to health in the long run. 

A new study published in the Journal of Clinical Endocrinology & Metabolism has also corroborated this and concluded that body-weight fluctuation was associated with mortality. A one-unit increase in average successive variability of body weight was associated with increase in mortality (HR 1.46, 95% CI 1.32−1.62, P < 0.001). 

The 16-year prospective cohort study examined 3,678 men and women from the Korean Genome and Epidemiology Study.

The study also made an interesting observation. People with obesity who experienced more weight cycling were less likely to develop diabetes than other study participants. The association between the ASV of body weight and incident diabetes mellitus seemed to be influenced by baseline body mass index (BMI); negative effect in subjects with BMI < 25 kg/m2 (HR 1.36) and protective effect in those with BMI ≥ 25 kg/m2 (HR 0.76). 

Harm reduction can also be applied to weight management. 

In the context of weight management, harm reduction means awareness about various options available and recognizing that moderate, individualized changes in eating or exercise habits can be beneficial, which can be in the form of either reducing the frequency of eating a particular food item, or reducing the quantity of a food item or adding exercise to the diet to manage weight.

(Endocrine Society, J Clin Endocrinol Metab. 2018 Nov 29. doi: 10.1210/jc.2018-01239)

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

Asian doctors should join the fight against climate change

Reversing climate change could be the greatest health accomplishment of the 21st century.

In an article in the US magazine ‘Fortune’ to coincide with the climate change summit in Poland, Dr. Eidelman President WMA writes that if doctors wanted to fully uphold the Declaration of Geneva’s creed that ‘the health and well-being of my patient will be my first consideration’, they needed to take an active role in defending their patients from the adverse effects of climate change.

Physicians are well suited to play this role. They often have close relationships with patients and their families and had an obligation not only to diagnose and treat the damage caused by climate change, but also to advice.

Patients should be told to become more conscious in their use of transportation, living in environmentally efficient housing and eating conscientiously—which means less meat, less wasting food, and using fewer single-use products and packaging.’

Doctors also should look at their own practice. High tech modern medicine was also high in energy and material consumption and this had a price in energy consumption, single-use products and abundant packaging of medical products.

The WMA supports physicians in investigating the environmental footprint of their practices with initiatives, such as ‘My Green Doctor’, a guide for doctors on implementing environmentally friendly practices.

Some medical organizations have commonly decided to divest from high carbon dioxide-producing industries and to boost our environmentally responsible investing.

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

Canada says Talc may be 'harmful to human health'

The government of Canada is considering prohibiting or restricting the use of talc in some products. The government "proposes that inhaling loose talc powders and using certain products containing talc in the female genital area may be harmful to human health." The announcement was made Wednesday on the Health Canada website.

The draft screening assessment will be published in the Canada Gazette, Part I, and will be open for public comment for 60 days, until February 6, 2019. The Risk Management Scope, which outlines the possible measures to manage the risks identified in the draft screening assessment, will also be open for public comment for the same 60-day period.

No action, such as warning labels or a ban, will be taken until this final assessment is published, according to news reports.

Draft assessment did not identify human health risks of concern from oral exposures, including talc in food and drugs; dermal exposures such as the application of talc-containing products to skin; or inhalational exposures from dry hair shampoo or pressed powder products, such as cosmetics like eye shadow and blush.  

However, the assessment did identify two exposure scenarios of potential concern to human health. 

One was inhalation of fine particles of talc during the use of loose powder, self-care products (eg, body powder, baby powder, face powder, foot powder), potentially resulting in damage to the lungs.   

The other scenario of concern was exposure of the female perineal area, which includes the genitals, to self-care products containing talc (e.g., body powder, baby powder, diaper and rash creams, genital antiperspirants and deodorants, body wipes, bath bombs), as this type of exposure has been associated with ovarian cancer in studies of the human population.

The controversy is over whether talc itself is a carcinogen, and the issue is complicated because talc is sometimes contaminated with asbestos (the two sometimes occur naturally together).  

The scientific community has not reached a consensus yet.

A recent review published in the European Journal of Cancer Prevention (Eur J Cancer Prev. 2008;17:139-146) concluded that “data collectively do not indicate that cosmetic talc causes ovarian cancer.”

Comments: For some, the controversy is on. The DCGI must come out with clear cut direction in this issue. But, in the meantime public should take their GP into confidence when using these products.

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

20 out of one lakh die in traffic accidents

Traffic deaths are now the leading global cause of deaths for children and young adults between 5 and 29 years old as per the recently released WHO Global Status Report on Road Safety 2018. People living in low-income countries have a risk that is three times higher than those in high-income countries. The rates are highest in Africa (26.6 per 100 000 population) and lowest in Europe (9.3 per 100 000 population). And, over twice as many patients die before they reach a hospital in low-income countries than in high-income countries.

Although, low-income countries account for only 1% of the world’s motor vehicle accidents, 13% of deaths due to road traffic accident occur in those countries. The lowest rates of road traffic deaths are in the Americas and Europe, with 15.6 and 9.3 deaths per 100,000 people, respectively. The highest death rates are in Africa and Southeast Asia: 26.6 and 20.7 deaths per 100,000, respectively.

More than half of all road traffic deaths are among vulnerable road users: pedestrians, cyclists and motorcyclists. Globally, 29% of deaths are car occupants, 28% are those using motorized two- and three-wheelers, 26% are pedestrians and cyclists and the remaining 17% are unidentified road users.

The United Nations has prioritized eight vehicle safety standards for implementation, which include frontal and side impact protection, electronic stability control, pedestrian front protection, advance braking. But, not all standards are implemented.

Five behavioral risk factors are speeding, drunken driving, not using motorcycle helmets, not using seat belts and not using child restraints. Head-on crashes, for example, occur on undivided roads while the lack of a footpath or a safe crossing presents a major risk for death and injury to pedestrians.

Speedbreakers are constructed in accident-prone areas as “safeguards”. But, in what can be called a paradox, they are also the cause of 30 crashes daily, killing at least nine people a day as per Road Transport ministry data (TOI).

The Indian Road Congress has laid down norms for speedbreakers and the required road markings. Speed breakers should be painted with alternate black and white stripes for visual warning besides suitable advance warning signs located 40 m in advance of the speed breaker.

One case titled as "Guru Hanuman Society versus Govt of NCT of Delhi & others” bearing WPC No 104/2015 is pending adjudication before the Hon'ble High Court of Delhi,  in which vide order dated 25.05.2016 the Hon'ble Court has passed some directions/guidelines wrt the speed beakers in Delhi. The Hon'ble Court has directed all the concerned authorities to follow the prescribed norms/rules and directions of the Court wrt building and maintenance of speed beakers.

Driving with high beam is another major cause of road accidents. High beams are to be used only in multiple laned highways where there is no chance of a motorist blinding driver travelling in the opposite direction. They are not meant for use inside the cities.

As stated in Rule 112(4)(a) of Delhi Motor Vehicles Act “the driver of a motor vehicle shall at all times, when the lights of the vehicle are in use, so manipulate them that danger or undue convenience is not caused to any person by dazzle”. 

On 26th September, 2018, Heart Care Foundation of India (HCFI) had filed a Right to Information application to Ministry of Road Transport and Highways thereby asking following questions:

1. Is there any law relating to “high beam lights in vehicles” in India?
2. Can a vehicle drive on high beam in colonies / cities in India?
3. If the answer to query no. 2 is “no”, then what is the punishment for a vehicle which is driving on high beam?
4. What actions / rules Government of India has made for stopping vehicles from driving on high beams in colonies?

5. How many accidents are taking place because of use of high beam by vehicles in colonies / cities in India? 

Vide reply dated 11.10.2018, the Transport Research Wing of Ministry of Road Transport & Highways had stated that: “Regarding query no. 1-4 of the application: TRW does not collect / compile information regarding high beam lights in vehicles and accidents because of use of high beam lights in vehicles in India. Thus, the information sought by you is not available in TRW”. 

This is indeed disturbing.

Recognizing the urgent need of enactment of stricter laws with respect to the use of high beam lights in vehicles, HCFI has filed a representation before the Hon'ble Prime Minister and Minister of Transport thereby requesting them to enact stringent laws on use of high beam lights in vehicles in cities, colonies, towns, etc. and the offenders should be punished for violating the same, awareness should be created among the public at large about the cons of using high beam lights in vehicles in inside the city. 

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

Should prophylactic PPI be given to intensive care patients at risk for GI bleeding?

Critically ill patients receiving intensive care are at risk of gastrointestinal (GI) stress ulceration. Hence, prophylactic therapy with either histamine H2–receptor antagonists or proton-pump inhibitors (PPIs) is recommended by guidelines. But, should prophylactic treatment (PPI) be given to these patients at risk for GI bleeding?

The findings of a new multicenter trial does not appear to think so, given its conclusion that giving PPI to ICU patients to prevent GI bleeding does not seem to affect mortality.

The European, multicenter SUP-ICU trial published in the New England Journal of Medicine (online Dec. 6, 2018) examined the risks and benefits of PPI treatment. The trial included 3298 patients who had been hospitalized to the ICU for an acute condition and who were at risk for gastrointestinal bleeding. They were randomized to receive 40 mg of intravenous pantoprazole (a PPI) or placebo daily during the ICU stay.

No between-group differences were observed with regard to mortality at 90 days (primary outcome) and the number of clinically important events.

• 510 patients (31.1%) in the pantoprazole group and 499 (30.4%) in the placebo group had died.
• At least one clinically important event (a composite of clinically important gastrointestinal bleeding, pneumonia, Clostridium difficile infection, or myocardial ischemia) had occurred in 21.9% of patients assigned to pantoprazole vs 22.6% of those assigned to placebo.
• 2.5% of patients in the pantoprazole group had clinically important GI bleeding vs 4.2% in the placebo group. 

In view of these findings, the authors recommend that “due to the lower incidence of clinically important upper gastrointestinal bleeding in the ICU, prophylaxis with a PPI, if initiated, should be reserved for seriously ill patients who are at risk for this complication”.

Source: Krag M, Marker S, Perner A, et al; SUP-ICU trial group. Pantoprazole in patients at risk for gastrointestinal bleeding in the ICU. N Engl J Med. 2018 Oct 24. doi: 10.1056/NEJMoa1714919. 

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