Wet vs dry winter: How temperature and humidity interact

The northern part of the country, including the national capital, is experiencing a severe cold wave.

Winter can be divided as either wet or dry winter.

Wet winter, or early winter, is characterized by fall in temperature along with high humidity. In cold weather, high humidity levels will make one feel colder.

The body cools itself by sweating. During summers, when the humidity is low, sweat evaporates easily and cools the body because the process of evaporation requires thermal (heat) energy. But, when humidity is high in summers, evaporation rate is reduced. The resulting limited evaporation in hot and humid conditions is not enough to cool the body. And, therefore, high humidity in hot weather makes one feel sticky and warmer. This combined effect of temperature and relative humidity is called heat index, which is experienced as the felt air temperature.

In winter, the cold air (low temperature) with high relative humidity "feels" colder. This is because the insulating effect of clothes decrease as the humidity rises. The moisture in the atmosphere is captured on the clothing, even though the clothes do not appear wet and results in greater heat loss from the body.

Another factor to be considered during winters is the sun. Cold days are more likely to be overcast, which reduces the amount of direct sunlight reaching the surface; whereas, on a dry sunny day, the body is warmed by radiant heating from the sun.

Fog and smog are common during wet winter.

Whenever the humidity is high, air movement is less and temperature is low, fog is the automatic result. It occurs when water droplets are suspended in the air.

When the level of pollutants is high in the atmosphere, the pollutants get mixed into the fog. This is called smog. Therefore, smog is the combination of smoke and fog and it further reduces the visibility. The smoke includes toxic emissions from vehicles and industries, dust and open burning of crops.

Dry winter, or late winter is characterized by absence of fog, smog and presence of chilly airy winds. Cold and dry air generally feels warmer than cold and humid air at the same temperature. 

Dr KK Aggarwal

Padma Shri Awardee

President Elect Confederation of Medical Associations in Asia and Oceania   (CMAAO)

Group Editor-in-Chief IJCP Publications

President Heart Care Foundation of India

Past National President IMA

Practice Changing: Non-invasive CT angio is a feasible alternative to the invasive conventional angiography for diagnosing complex CAD and decision-making

Coronary angiography is the gold standard diagnostic technique, which helps in therapeutic decision making in coronary disease. Coronary CT angiography is also a valuable aid to assess coronary heart disease. But, it has not been so widely used as the invasive coronary angiography.

But, the SYNTAX III REVOLUTION trial has now demonstrated that the non-invasive coronary CT angiography is non inferior to the invasive coronary angiography in diagnostic value.

The SYNTAX III Revolution trial for the first time randomised two separate Heart Teams (in six participating international centres) and not the patients, to quantify the anatomical complexity by using the SYNTAX score in patients with known de novo left main or three-vessel CAD in six participating international centres using information obtained from either coronary CTA or conventional angiography.

The primary goal was to assess the treatment decision, whether to decide on percutaneous coronary intervention (PCI), coronary artery bypass grafting (CABG) or equipoise between CABG and PCI.. The primary endpoint of this study was agreement between the two heart teams on the revascularization strategy.

Heart Team A had to make their decision on whether to perform revascularization with either PCI or surgery using information received strictly from the non-invasive multislice coronary computed tomography angiography (MSCT) from a GE Revolution multislice CT scan along with fractional flow reserve (FFR) CT assessment (HeartFlow).

Heart Team B also needed to make the same decision but using only conventional angiography.

·         No significant differences in the number of coronary stenoses > 50%, and SYNTAX score calculated by using coronary CTA and conventional angiography, were observed (1108 vs 1073 and 33.9 ± 12.0 vs. 30.3 ± 12.2, respectively).

·         CABG was recommended in 28% of patients by coronary CTA and in 26% of patients by invasive coronary angiography.

·         Equipoise CABG or PCI was suggested in 106 patients, with no difference between CTA and coronary angiography. Overall, the heart teams agreed on the coronary segments to be revascularized in 81.1% of cases.

FFRCT was available in 868 of the 1108 lesions and identified no flow-limiting stenosis in 116 lesions in 34% of the patients; thus, changing the treatment decision in 7% of the patients (the surgical procedure was changed to a percutaneous approach in 13 patients) and reducing the proportion of patients with haemodynamically significant three-vessel disease from 92.3 to 78.8%.

The European Society of Cardiology Guideline recommends coronary CTA as a class IIa indication in the presence of a low–intermediate pre-test probability risk of CAD.

These results from the SYNTAX III Revolution trial show that non-invasive multislice CT scans may well be the future in diagnostic imaging to assess the extent of coronary disease, whether it is a one-vessel or multivessel disease, and to guide decision-making accordingly regarding the revascularization strategy to adopt.

The results of the trial are published in the European Heart Journal. 

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

Winter pollution

Air pollution is here to stay ….it’s not just limited to a particular time of the year, but persists all through the year now. According to the WHO, in 2016, India had 14 out of world's 20 most polluted cities in terms of PM2.5 levels; Kanpur topping the list and New Delhi taking the sixth place.

Air quality particularly deteriorates during the winter season and drops to the “severe” or “hazardous” categories.

Pollution levels are increased during winters due to a combination of atmospheric (metereological) conditions and local pollution (emissions of air pollutants).

Generally, air is warmer near the earth surface and gets colder higher up as the altitude increases. During winters, this state is reversed i.e. the temperature is colder near the surface and the air is warmer higher in the atmosphere. 

This phenomenon is called “winter inversion” and is the reason why pollution levels increase during winters, especially in areas like Delhi where air pollutant levels are already higher. This warm air above the cold air acts like a lid and traps the pollutants and does not let them escape into the atmosphere. 

The effects of inversion are stronger at night, which is why air quality worsens overnight. This is also why people are asked to avoid morning walks especially during winters due to exposure to higher concentrations of pollutants at that time.

In summers, the air in the lower part of the atmosphere is warmer and lighter; so, it can rise up and carry pollutants away from the ground and mixes them with cleaner air in the upper layers of the atmosphere (”vertical mixing”).  

Another reason for high pollution levels during winters is a decrease in wind speed, which further slows down the dispersal of pollutants. The pollutants therefore remain close to the surface and worsen the air quality. The ‘trough like topography’ in North India, due to hills and mountain ranges coupled with stagnant air during winters also traps the toxic air over a large part of the country.

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

The doctor-patient relationship is a contract of service

Relatives of a patient ransacked a hospital in Hyderabad on Monday after she succumbed to her illness. They allegedly broke the glass, entrance gates of the hospital. The 45-year-old deceased woman was suffering from lung disease and swine flu. She was admitted to the hospital on Dec. 18 in a bad condition. On Dec. 24 she was put on ventilator but around 9:30 pm she succumbed to her illness. Reportedly, right after her death the family went on a rampage and began destructing the hospital property. Meanwhile, the hospital claimed that they have been trying to save the woman but she was not responding and her condition deteriorated. A case has been registered against the family for ransacking the hospital. And further investigation in the case is underway, as reported in Times Now.

This story once again puts back the spotlight on the widening gap in the doctor-patient relationship. Lack of communication is right in the center of such disputes.

Consent is the authorization or grant of permission by the patient for treatment or any diagnostic, surgical or therapeutic procedure to be carried out by the doctor. A valid consent has three components: Disclosure, capacity and voluntariness i.e. provision of relevant information by the doctor, capacity of the patient to understand the information given and take a decision based on the adequate information without force or coercion.

A doctor has to take consent from the patient before proceeding with his treatment. It is an ethical and legal requirement. And, therefore no doctor practices without taking consent.

While informed consent taking is important, this story also indicates that probably there is now also a need for another document to be signed by the doctor as well as the patient and/or the family, in addition to the informed consent. This document, which may be termed a “contract”, should disclose all information to the patient and/or his family regarding the treatment and the establishment.

Complications or adverse events may occur at any time during the course of treatment. What is important here is the competency of doctors, or of the hospital in managing these complications or untoward incidents. The information related to the ability to anticipate, recognize and quickly manage any complication should be included in the contract.

The need of services of a specialist e.g. neurosurgeon, or a nephrologist or cardiologist may arise any time during treatment. If the hospital does not have these specialty doctors on its staff, then subsequent delays in procuring their services will increase risk of violence.

The chances of complications, including unforeseen complications, type of complications, delayed or immediate, should be a part of the contract. Every possible complication should be defined.

Chances of death during treatment or on the table, due to anesthesia or after surgery should be defined.

A small set-up may not have all facilities as their bigger and better equipped counterparts. The patient and/or family members must be informed about the facilities.

And, information such as round the clock availability of staff / specialists or infrastructure and the chances of accidents or mishaps such as system failure, oxygen failure, electrical failure etc. should be a part of the contract.

This information should be made available right at the time of admission. And, will reduce the chances of disputes or acts of violence against the doctor and the hospital.

The doctor-patient relationship is a contract of service, which is signed by both, the doctor and the patient. A well-defined “contract” will help the patient choose the hospital. If not, then at least first aid should be administered and the patient can be referred to appropriately equipped hospital.  

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

High risk infantile hemangiomas should be promptly evaluated by hemangioma specialist

The American Academy of Pediatrics (AAP) has published new clinical practice guideline for the management of infantile hemangiomas.

Published online Dec. 24, 2018 in Pediatrics, the guideline says that “unlike many diseases, management of IHs is not limited to one medical or surgical specialty. A hemangioma specialist may have expertise in dermatology, hematologyoncology, pediatrics, facial plastic and reconstructive surgery, ophthalmology, otolaryngology, pediatric surgery, and/or plastic surgery, and his or her practice is often focused primarily or exclusively on the pediatric age group.”

Some key recommendations include:

·         Infantile hemangioma associated with life-threatening complications, functional impairment or ulceration or risk thereof, structural anomalies (e.g., in PHACE syndrome or LUMBAR syndrome), or permanent disfigurement is high risk. Once the hemangioma is classified as high risk, the patient should be evaluated by a hemangioma specialist as soon as possible.

·         Imaging should be done only when the diagnosis is uncertain, there are ≥5 cutaneous hemangiomas, or associated anatomic abnormalities are suspected. Ultrasonography is recommended as the initial imaging modality when the diagnosis of IH is uncertain. MRI may be done if associated structural abnormalities (e.g., PHACE syndrome or LUMBAR syndrome)

·         Oral propranolol (2-3 mg/kg/day) is the first-line agent for hemagiomas requiring systemic treatment; but, in the presence of comorbidities or adverse effects, a lower dose is recommended.

·         Propranolol is to be administered with or after feeding and doses be held at times of diminished oral intake or vomiting to reduce the risk of hypoglycemia.

·         Clinicians should evaluate patients for and educate caregivers about potential adverse effects of propranolol, including sleep disturbances, bronchial irritation, and clinically symptomatic bradycardia and hypotension.

·         When propranolol is contraindicated or response to propranolol is poor, oral prednisolone or prednisone may be used.

·         Intralesional injection of triamcinolone and/or betamethasone can be given to treat focal, bulky hemangiomas during proliferation or if they are located in  certain critical anatomic areas such as the lip.

·         In cases of thin and/ or superficial hemangiomas, topical timolol maleate may be prescribed.

·         Surgery and laser therapy may be indicated if the lesion has failed to improve with local wound care and/or pharmacotherapy; the lesion is well localized, and early surgery will simplify later reconstruction (e.g., a prominent hemangioma involving the ear or eyelid); the lesion is well localized in an anatomically favorable area or resection is likely to be necessary in the future, and the resultant scar would be the same

·         Clinicians should educate parents of infants with the hemangioma about the condition, including the expected natural history, and its potential for causing complications or disfigurement.

(Source: Krowchak DP, et al; Subcommittee on the Management of Infantile Hemangiomas. Pediatrics Dec 2018, e20183475; DOI: 10.1542/peds.2018-3475)

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

Consumer Protection Bill 2018: Implications for the practicing doctor

 On Thursday, the Lok Sabha passed the Consumer Protection Bill 2018, which will, if enacted, replace the current Consumer Protection Act 1986.

The bill, among other things, proposes setting up of the Consumer Disputes Redressal Commission and forums at the District, State and National levels to examine and decide on consumer complaints. 

It has also defined the pecuniary jurisdiction of the three fora, which have been increased from those provided in the Consumer Protection Act 1986.

Under the Consumer Protection Act 1986,

·         The District Forum can entertain complaints where the value of the goods or services and the compensation, if any, claimed is up to Rs 20 lakh.

·         The state commission can entertain complaints where the value of the goods or services and compensation, if any, claimed exceeds Rs 20 lakh but does not exceed Rs one crore.

·         The National commission can entertain complaints where the value of the goods or services and compensation, if any, claimed exceeds Rs one crore

Now, the new Consumer Protection Bill 2018 has substantially increased the pecuniary limits of the three disputes redressal agencies.

·      For District Forum, the jurisdiction has been increased to Rs one crore.

·      For State commission, the jurisdiction has been increased to between Rs one crore and up to Rs 10 crore.

·      For National commission, the jurisdiction has been increased to above Rs 10 crore.

This enhanced pecuniary jurisdiction of the Consumer Protection Commissions and Forums at District, State and National Level does have implications for practicing doctors.

District Forum would be most accessible to complainants; so, more and more cases will be filed before the District Forum.

Medical malpractice claims against doctors are becoming commonplace, so doctors will now have to increase their professional indemnity insurance up to Rs one crore. Because, the compensation claims now will be one crore at least and may even run into many crores.

The outcome of this would be an increase in the cost of treatment, which would mean a higher out-of-pocket spending on treatment costs. 

This should be of concern, especially for a country like ours, where patients pay most of their medical expenses out of their own pockets. 

The goal of providing quality and affordable healthcare to all then may seem more unreachable.

 Apart from the above amendments, the bill also proposes following other amendments as follows:

·         District, state and national fora do not require judicial members.

·         Not only persons but associations and other bodies can complain to consumer fora

·         Consumer Mediation cells at district, state and national level.

·         District, state and national councils, which are advisory in nature

·         A Central consumer authority which has judicial powers, can conduct investigations, search and make judgements 

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

Study supports guideline-recommended 10-year rescreening interval for colorectal cancer after a negative colonoscopy

Current guidelines recommend colonoscopy every 10 years, after a colonoscopy with normal findings (negative colonoscopy results, as the preferred screening strategy for colorectal cancer.

A study published Dec. 17, 2018 in JAMA Internal Medicine has provided evidence that corroborates this recommendation.

A retrospective cohort study was conducted in an integrated health care delivery organization serving more than 4 million members across Northern California. A total of 1 251 318 average-risk screening-eligible patients, aged 50-75 years, between January 1, 1998, and December 31, 2015, were included. The hazard ratios (HRs) for colorectal cancer and related deaths were calculated according to time since negative colonoscopy result (or since cohort entry for those unscreened).

The results showed that at 10 years after a negative colonoscopy, the risk for colorectal cancer and related deaths was 46% and 88% lower in patients who underwent colonoscopy, respectively, versus patients who were unscreened. A reduced risk of colorectal cancer and related deaths was also observed after at least 12 years of follow-up after the initial exam.

Lead author Jeffrey K. Lee, MD, Division of Research, Kaiser Permanente Northern California, Oakland, said that with the results of this study, physicians "can feel confident" about the guideline-recommended 10-year rescreening interval after a negative colonoscopy in which no colorectal cancer or polyps were found.

(Source: JAMA Intern Med. Published online December 17, 2018)

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