Friday, 30 September 2016

The medical voice works: the success: D Penicillamine comes back in the market

The medical voice works: the success: D Penicillamine comes back in the market Dear All September 13, we raised the issue of shortage of D Penicillamine. Patients with Wilson disease (copper overload) with liver, neurological and psychiatric manifestations are treated with D-penicillamine. D-penicillamine is an excellent chelator and patients have to be on this drug lifelong because of the genetic nature of the disease. Since the last 6 months 3-4 different companies in India that were producing the drug had stopped production of D-penicillamine (Brand names CILAMIN or ARTAMINE 250 mg). It appeared that the raw material that was coming from China was no longer available. Patients particularly children and adolescents and young adults are the most affected. Our voice was listened to . Panacea Biotec one of the manufacturer has ensured limited availability of Life Saving Drug Cilamin 250 Capsule (D-Penicillamine IP 250 mg) Cilamin 250 Capsule used for treatment of Wilsons disease, Rheumatoid Arthritis and other conditions witnessed short supply in the market during the last few months due to non-availability of raw material D-Penicillamine in India. Panacea Biotec, India's leading biotechnology company, has informed us that Cilamin 250 Capsules for treatment of above conditions has been made available in limited quantities in the retail market. Due to continuous efforts the company has resumed limited production of Cilamin 250 and have released limited quantities in the market from 26.9.2016. Some of the key initiatives taken by Panacea Biotec to ensure availability of Cilamin 250 to patients are as follows:- I. Delivered Cilamin 250 to approximately 300 patients so far by rationing safety stocks to all who could reach us through various forums. 2. Launched a website www.cilamin.com for emergency supplies to patients and for access to latest information on its availability. 3. Formed a WhatsApp Group Cilamin Support (+91 9350588528) of Patients, Doctors, Company Executives for monitoring and support. 4. Formed Twitter handler @Cilamin250 for real time communication 5. Formed Facebook page https://www.facebook.com/cilamin250 for real time communication. 6. Supply of new batches with limited quantities of Cilamin 250 have started from 26.9.16 As per the company it would take additional 2-4 weeks for access to additional quantities of raw material and additional 4 weeks for Cilamin 250 supplies to normalize. Dr K K Aggarwal National President Elect IMA

Nine preventable risk factors are responsible for 90% of heart attacks

Nine preventable risk factors are responsible for 90% of heart attacks New Delhi, September 29, 2016: One can prevent heart attacks. Nine preventable risk factors are responsible for 90% of heart attacks, said Padma Shri Awardee Dr KK Aggarwal – President Heart Care Foundation of India & National President Elect IMA on the occasion of World Heart Day. These are (in order of importance): 1. Increased LDL/HDL ratios (elevated bad LDL and low good HDL cholesterol levels) 2. Smoking 3. Diabetes 4. Hypertension 5. Abdominal obesity 6. Psychosocial (stress or depression) 7. Failure to eat fruits and vegetables daily 8. Failure to exercise 9. Failure to drink any alcohol The forthcoming MTNL Perfect Health Mela being organized from Health & F.W. Dept. NCT Delhi, MTNL, NDMC & other Central & Delhi state Government department by HCFI will focus on screening these nine risk factor added Dr K K Aggarwal One can prevent heart attack by following Dr KK’s Formula of 80. 1. Keep lower BP, bad cholesterol levels, resting heart rate, fasting sugar and abdominal girth levels all less than 80. 2. Keep kidney and lung functions more than 80%. 3. Engage in recommended amounts of physical activity (minimum 80 minutes of moderately strenuous exercise per week). Our recommendation is to walk 80 minutes a day and for 80 minutes per week the speed should be 80 steps per minute 4. Eat less and not more than 80 gm of ml of caloric food each meal. Follow a healthy diet (high fiber, low saturated fat, zero trans fat, low refined carbohydrate, low salt, high in fruits). Refined carbohydrates are white rice white maida and white rice. 5. Doing 80 cycles of pranayama a day 6. Spend 80 minutes with yourself every day (relaxation, meditation, helping others etc) 7. Do not smoke or be ready to dole out Rs 80,000/– for treatment. 8. Those who drink, do not want to stop and there is no contraindication, limit alcohol use to no more than 80 ml per day for men (50% for women) or 80 grams per week. 10 grams of alcohol is present in 30 ml or 1 oz of 80 proof liquor. Diabetes can be prevented by controlling five lifestyle factors. These are: 1. Follow a healthy diet 2. Maintain an optimal body weight (less than 23 × height in meters × height in meters) 3. Engage in recommended amounts of physical activity. 4. Limiting alcohol to recommended amount. 5. Not smoking. When and how to suspect a heart attack? 1. Chest pain, burning, discomfort, heaviness in the center of the chest lasting for over 30 seconds and not localized to a point. 2. First onset acidity after the age of 40 first rules out heart attack 3. First attack of asthma after the age of 40 may be heart asthma 4. Any symptom which is unusual, and appearing for the first time and cannot be explained: contact your doctors In heart attack what to do? 1. Do not panic 2. Chew a tablet of water–soluble 300 mg aspirin at the onset of chest pain. You will not die. 3. Call 42000565 or reach Moolchand Medcity within three hours of chest pain for a clot removal procedure. We will not let you die. If someone dies what to do? 1. The soul does not leave the body for 10 minutes 2. Within ten minute of death for the next 10 minutes do effective chest compression with a speed of 100 per minute. 80% people can be revived.

Early vasomotor menopausal symptoms linked to increased CVD mortality

Early vasomotor menopausal symptoms linked to increased CVD mortality 

Women who had vasomotor symptoms early in midlife and presented with signs and symptoms suggestive of myocardial ischemia were at a greater risk of dying due to cardiovascular disease than women in whom the menopausal symptoms occurred later, says a new study from the University of Pittsburgh School of Medicine in the United States.

The WISE (Women's Ischemia Syndrome Evaluation) of the National Heart, Lung, and Blood Institute (NHLBI) recruited 254 women older than 50 years, postmenopausal, with both ovaries, not on HRT who had been referred for coronary angiography for suspected myocardial ischemia.

Mortality due to cardiovascular disease was higher in women in whom vasomotor symptoms developed early compared to those who never had vasomotor symptoms. Early onset of vasomotor symptoms in these women was also associated with endothelial dysfunction with lower flow-mediated dilation (FMD) compared to women with later onset symptoms.

The findings of the study are published September 26, 2016 in the journal Menopause. 

Thursday, 29 September 2016

Can women get heart disease before pre- menopause?

Can women get heart disease before pre- menopause? New Delhi, September 28, 2016: Older women have been at a higher risk end for developing cardiovascular diseases. It is reported that more than 75 percent of women aged 40 to 60 have one or more risk factors for CVD. Heart disease is the leading cause of death in women over age 40, especially after menopause. Up until now the notion had been that menopause is the only phase during a woman’s life cycle during which she is prone to increased risk of CVD, but now the idea is being challenged by increasing incidences of coronary heart diseases in pre- menopausal women. Recently, evidence has emerged that even the pre- menopause phase in a woman’s life cycle is prone to developing cardiovascular complications because of exacerbated risk factors.
Complex hormonal and physiological changes take place during the transitory phase to menopause, the perimenopause. Estrogen and progesterone imbalance starts to set in, body fat starts getting redistributed, there are global changes in cholesterol levels and blood pressure starts to show a rise before menopause hits. It is seen that the risk factors associated with stroke and CVD increase more rapidly in the years leading up to menopause rather than afterwards. This is a result of a variety of physiological changes collectively known as the metabolic syndrome. The risk factors that together constitute the metabolic syndrome are a large waistline, high levels of blood fat (triglycerides), low levels of good cholesterol, high blood pressure and high fasting blood sugar
These changes are associated risk factors for CVD and if left unchecked, have the potential to develop into serious cardiovascular complications. This paradigm shift in the ‘at-risk’ population for heart disease is due to modern lifestyle. In today’s age of technology and modernization, there are a plethora of comforts available, but the cost of every comfort is some or the other form of compromised health.
According to a study conducted by Harvard Medical School, the major risk factors associated with modern lifestyle are smoking, high body mass index, a sedentary lifestyle, alcohol consumption and an unhealthy diet
“Lifestyle-related factors that increase the risk of heart disease are becoming increasingly common among girls, teenagers, and young adults. Physical activity drops sharply as girls approach teenage years and is significantly reduced by young-adulthood. Higher or lower than normal body mass index is an important determining factor for the course of cardiac complications in high risk individuals. The good news is that these hormonal and physiological changes during the pre-menopause period are reversible or in some cases, modifiable. Appropriate lifestyle changes can be incorporated to minimize the risk of developing heart disease during this period, ”said Padma Shri Awardee Dr KK Aggarwal – President Heart Care Foundation of India & National President Elect IMA.
“The notion that young adult women need not worry about heart health until they are ‘old enough’, needs to be abolished. Women approaching menopause need to be more proactive about following a heart-healthy lifestyle in order to minimize the effect of these associated risk factors. Your lifestyle is not only your best defense against cardiovascular diseases, it's also your responsibility towards yourself and your loved ones”, Dr KK Aggarwal added.
Follow these tips to reduce the toxic burden of these risk factors:
• Avoid active and passive smoking and alcohol, they are the most prominent risk factors associated with CVD. • Include about 80-160 minutes of exercise per week, may it be light workout or vigorous cardio routines. Simple exercises like dancing, walking, swimming and cycling are also sufficient if done regularly. • Follow a healthy balanced diet comprised of generous amounts of green leafy vegetables, fruits, nuts and whole grains. • Eating a diet rich in omega-3 fatty acids can also help ward off heart disease, eat plenty of fish products for this purpose. • Keep stress at bay and laugh out loud in your daily life, not just the social media. • Reduce salt intake, it will lower the chances of developing hypertension which can translate into CHD. • Manage pre- exiting medical conditions like diabetes, hypertension etc. • Avoid foods with added sugars and preservatives. • Get screened regularly for cholesterol and lipid profile. • Maintain a healthy blood pressure and body mass index

Wednesday, 28 September 2016

Women more at risk of heart disease today

Women more at risk of heart disease today

Heart disease is no longer exclusive to men as we now know. Women, especially urban women, are more at risk of developing heart disease today. And, a heart attack is usually more severe in women than in men.

An increasingly unhealthy lifestyle with a predominantly high trans fat, sugar and salt diet, more and more sitting, stress/depression, smoking, alcohol and cigarettes are some of the factors that have contributed to this rise in heart disease. Differences in the clinical presentation also make it difficult to establish a diagnosis in women.

·         Women generally present a decade later than men and with greater risk factor burden. They are less likely than men to have typical angina. Women with new onset of chest pain are approached and diagnosed less aggressively than man in the emergency department.
·         Established risk factors in women are: Presence of history of heart blockages; age over 55 years; high LDL (bad) or low HDL (good) cholesterol, diabetes, smoking, high blood pressure, peripheral artery disease or family history of heart disease.
·         Risk factors, which are more potent in women than in men are: Smoking is associated with 50% of all coronary events in women; diabetes confers more prognostic information in women than in men.
·         Symptoms of heart attack in women differ from those in men. Women may not know recognize these symptoms as due to a heart attack. Rather than the classical presentation of chest pain, women are more likely to have extreme fatigue, sleep disturbances, lightheadedness, nausea/vomiting, shortness of breathwith or without chest discomfort, indigestion, pain or discomfort in one or both arms, the back, neck, jaw or stomach.
·         Treadmill test in women has a higher false positive rate.
·         Small vessel disease is more common in women than in men.

New Form of Heart Failure on the Rise


A World Heart Month initiative

New Form of Heart Failure on the Rise

New Delhi, September 27, 2016: Heart failure is routinely described as the progressive loss of ability of the heart to pump blood. But, there is another form of heart failure where the blood–pumping ability of the heart remains near normal, said Padma Shri Awardee, Dr. KK Aggarwal, President HCFI & President Elect IMA. This second form of heart failure is too often overlooked and is just as lethal.
In this condition the heart muscle becomes thickened. The chamber inside gets smaller and the heart is unable to relax to accommodate the blood it needs to pump out. As there is no room for the heart to relax, the blood backs up into the lungs. This kind of anomaly is not picked up by standard measurements of "ejection fraction" –– the percentage of blood in the heart that goes out with every beat.
Quoting two studies published in the New England Journal of Medicine, Dr Aggarwal said that this form of the disease is called "diastolic heart failure" because the problem occurs during the diastole portion of heart activity, as the heart relaxes after a beat. Nearly one–third of these patients have an ejection fraction greater than 50 percent, which is very near normal. However, the death rate for this kind of heart failure matches that of patients with the more common form of heart failure, with more than 20% of all the patients dying within a year. There is a steady increase over 15 years of heart failure with normal or near–normal ejection fraction.

For patients, the symptoms of both types of heart failure are the same: Shortness of breath, difficulty exercising and fluid retention in the body. Physicians cannot make a diagnosis on the basis of symptoms or routine examinations. One has to have an echocardiogram and see the heart pumping and see if the ejection fraction is normal or reduced. Until now, relatively little attention has been paid to diastolic heart failure. Advances have been made against systolic heart failure, in which the ejection fraction falls below normal but not much has been done about diastolic heart failure.
Pacing for heart failure
For patients with advanced heart failure waiting for cardiac transplant, biventricular pacing not only improves the quality of life but also prolongs life. If the ejection fraction is low the combo device also gives an electric shock when the heart stops. It is said that all patients with low ejection fraction should ask their doctors for possible implantation of these devices.

Signals of heart failure
One of the commonest presentations is breathlessness on exertion, which is often confused as a part of aging or being obese. Not being able to climb stairs may be the earliest sign of hypertensive diastolic heart failure. Other signals are:
1.      Feeling extra tired even after a good night’s sleep. People with heart failure may limit activities they like to do or take naps to avoid feeling tired.
2.      Weight gain: Call your doctor if you gain weight for more than 2 days in a row or if you gain 2 or more pounds.
3.      Shortness of breath: Heart failure makes breathing harder, especially during exercise. Lying position may make it worse.
4.      Swollen ankles, legs, belly, and/or lower back, the swelling is often worse at the end of the day.

5.      Going to the bathroom more at night.

IMA Urges Banning Nuclear Weapons

IMA Urges Banning Nuclear Weapons World Medical Association, the global body representing more than nine million physicians today issued a strong plea to the governments of the world to work towards the elimination of all nuclear weapons. The WMA has warned that the current state of world affairs has made nuclear disarmament a more urgent issue than ever. To mark the International Day for the Total Elimination of Nuclear Weapons on September 26 WMA President Sir Michael Marmot said: It is vital that physicians around the world should reinforce about the abhorrence of nuclear weapons. The medical evidence about the consequences of using nuclear weapons is so horrific that nothing short of a total ban on nuclear weapons is acceptable. Physicians and national medical associations have a duty to speak out about the catastrophic consequences of deploying these weapons and Governments have a duty to make the world a safer place said WMA President. Development, testing, production, stock piling, transfer, deployment, threat and use of nuclear weapons must be condemned and must be halted all over the world said Padma Shri Awardee Dr KK Aggarwal, National President Elect Indian Medical Association. India can no longer afford to sit back and do nothing.

Eradicating rabies is a public health necessity

Eradicating rabies is a public health necessity The World Veterinary Association and the World Medical Association have joined forces to mark World Rabies Day (September 28) by calling for human rabies contracted from unvaccinated dogs infected with rabies to be totally eradicated by 2030 in collaboration with the “End Rabies Now” campaign initiated by the Global Alliance for Rabies Control. It has been estimated that rabies kills more than 60,000 people every year, about 40 per cent of whom are children less than 15 years old. It is a disease more prevalent in poor communities. As per Dr. RenĂ© Carlson, President of the World Veterinary Association, ‘Rabies is one of the deadliest diseases we know. Yet rabies is preventable if several measures are followed. Some of these measures include mass vaccination programs of dogs, humane population control of dogs through spay and neuter programs, community education about rabies and dog bite prevention, the importance of dog bite medical treatment and availability of rabies vaccine therapy after exposure. We currently have the tools to prevent this devastating disease and eliminate the suffering of both dogs and people who contract this essentially fatal disease. Eradicating rabies is not an option. It is a public health necessity.' She points out that when a person is bitten by a suspect rabid animal, that person must seek immediate medical care and be evaluated for rabies vaccine therapy. If possible the animal that bit the person should be examined, quarantined at an appropriate location, or euthanized for rabies virus infection verification by a qualified laboratory. Once symptoms of rabies appear, the disease is nearly always fatal. Canine vaccination and responsible pet ownership are essential measures to avoid this fate. Sir Michael Marmot, President of the World Medical Association, said ‘Many countries and communities have taken the right measures to prevent or eradicate rabies. But unfortunately the disease still kills many children in poor rural communities. Rabies is a disease that is very much dependent on living conditions. So improving living conditions and fostering public health services will save many lives.' Dr K K Aggarwal President-Elect Indian Medical association said that all doctors on the occasion of World Rabies Day 2016 should raise awareness about Rabies worldwide and be a part of “End Rabies Now” campaign to eradicate Rabies by 2030.

The Mosquito Menace: How to win over our collective failure

The Mosquito Menace: How to win over our collective failure

Dr K K Aggarwal
National President Elect and Honorary Secretary General IMA
President Heart Care Foundation of India
Napoleon Hill once said, “Most great people have attained their greatest success just one step beyond their greatest failure.” It’s time for all of us to convert our biggest failure of controlling the mosquito menace into success. We must all agree that collectively we have failed in controlling the mosquito menace and consequently, Delhi today is in the midst of an epidemic of Chikungunya with increasing numbers of dengue and malaria patients. This is a collective failure of Municipal Corporation, Delhi Government, Central Government, LG office, Medical Associations, CSR departments, Media, NGOs and Private sector. As per the current picture, the mosquito container index (the percentage of water-holding containers infested with larvae or pupae) in Delhi is over 40% and any index above 5% requires a community integrated cluster approach to reduce mosquito density together with effective anti-larval measures. But even today, 3 lakh mosquito repellent impregnated mosquito nets received by MCD as donations are not available to patients. Anti-larval measures, Temephos an organophosphate larvicide and/or mosquito fish or Gambusia, a freshwater fish are not available to a common man. What is the answer then? We need a paradigm shift in our thinking. We need to over report and act in time. There is no point acting when the cases have started. Often the civic bodies publically act in monsoon season. They may be planning ahead but public awareness and public involvement must start much ahead of time. Even the recent CAG report mentions that under reporting of dengue is disastrous to the society. We need to act against all the mosquitos, Aedes, Culex and Anopheles. Action against only the Aedes mosquito will not work. The campaign that Aedes mosquito is a day biter and only breeds in indoor fresh water will not work. Even if it is true, by killing Aedes you may end up in increasing the density of Culex and malaria causing Anopheles mosquitoes. Culex mosquito, which causes filarial and Japanese encephalitis is already rampant in the city. Even Aedes mosquito, which causes Chikungunya, West Nile, Zika and Dengue can spread by the bite of infected female indoor Aedes aegypti or outdoor Aedes albopictus mosquito. It is true that Aedes aegypti are more dangerous because they can fly up to 200 meters and only feed on human blood, whereas the Aedes albopictus that thrives outdoors can only fly as far as 80 meters and feed on animal blood other than human blood. The outdoor Aedes mosquito cannot be ignored. . The entire campaign up till now has been focused on a day biter, wearing long sleeves shirt and pants during the day and using night mosquito nets. But precautions needs to be taken throughout the day as the mosquitoes only recognize the light and not whether it is day or night. The fact that the mosquito only breeds in clear water also needs to be relearnt. The Aedes mosquito breeds in stagnant water anywhere inside or outside the house. Rain water is the most important source and can collect in any plastic container inside or outside the house. Even collected garbage in open areas can have left over plastic cups or tiny bottle caps with collected rain water collections providing an ideal atmosphere for mosquito breeding. It is true that disease spreading mosquitos do not make noise but the ‘noise-producing’ nuisance mosquitos unless addressed will not create a public movement. The law says that dengue or Chikungunya cases must be notified, but one can notify them within 7 days of diagnosis. Aedes mosquito takes up to three meals in a day and within 7 days will bite over 21 people in the vicinity. Municipal anti-mosquito and anti-larval actions must occur within hours of its detection. The very purpose of notification is lost if the disease is not notified within hours of even suspecting a diagnosis of Chikungunya. So, all suspected cases must be reported without waiting to confirm the diagnosis. We have failed because the government has been insisting that only ELISA-confirmed cases be notified. An SMS should be sent to all doctors practicing in that PIN code areas with a case so that they can become a part of the public health action chain. When the first case is suspected in a state, colony or house, all public health measure should start. An SMS should go to local councilor, MLA, MPs, all practicing doctors, local chemists, NGOs, RWAs, local IMA Branch, State IMA Branch, IMA Headquarters and other Specialty Organizations to join the public health chain efforts. It has taken over a decade for us doctors to understand that dengue 1 and 3 strains are not dangerous and cause only platelet deficiency with thinning of blood, while dengue 2 and 4 strains are dangerous as they destroy platelets and thicken blood due to capillary leakage and rise in hematocrit. Also, that platelet transfusion is not required in absence of active bleeding and it is the timely fluid resuscitation that is more important and not platelet resuscitation. Dengue becomes serious when the fever is subsiding. Earlier, dengue patients with high fever were hospitalized and there was always an urgency to discharge them when fever was subsiding. Now we know that the machine reading of platelet count can be defective. There can be an error of 20%. A platelet count of 10,000 by machine reading can mean it is actually 50,000. Hospital beds should be reserved only for severe dengue and severe Chikungunya cases. Just because one can claim reimbursement in Mediclaim or PSU, should not be the factor to decide on hospital admission. If it was US, Medicare by now would have come out with admission guidelines. The message has been going that fogging has no answer. But at this stage of container index of > 40, we need not only ground fogging but also aerial fogging. When Zika threat came up in Brazil they deployed the army to join and make it a public movement. All political parties reach every house during election process, then why can’t each one of them reach every house and make the anti-mosquito and anti-larval measures effective. Breeding checkers are only with Municipal Corporations and they also have regulatory powers to impose fine. We need breeding checker in private sector. The Skill development Ministry should start courses so that anyone can hire a breeding checker on weekly basis to check their premises. Community approach involves that 100% of the society talks about dengue. Every premise must write that their premises are mosquito-free. When you are invited to somebody’s place, you should ask “I hope your premises are mosquito-free” and when you invite somebody, write “Welcome to my house and it is mosquito-free”.’ Even today most hospitals do not provide mosquito nets to dengue or Chikungunya patients. While they may be having anti-larval mesh doors or mesh windows but for secondary prevention of dengue or Chikungunya, we need to ensure that medial establishments are certified mosquito-free. Many of us live in flats and the mosquitoes may be breeding on the roof top belonging to one of the owners of the flats and if he/she is out of station for a holiday, the anti-larval measures may remain deficient. RWAs should use their powers to check all unoccupied or closed premises including hostels, hotels and construction places in that premises. One of the five great vows of Jainism is Non-attachment/Non-possession or Aparigraha. It talks about not storing unwanted things. But in today’s era our roofs and verandahs are littered with left over tires, utensils, plastic utensils etc. We buy new car tires and keep the old ones on our roof top. We need to change this habit. We have forgotten to plant Tulsi and Peepal in our premises and stopped the daily Yagna, all of which have anti-mosquito properties. The new strategy has to focus on small collections of water such as bottle caps, finding mosquitoes lower in the room under the table or the bed, to look for them in all three parts of the house - roof tops, verandahs and inside the rooms including unused toilets accessories. Also the slogan “Check your house once a week” needs a change. One should be alert every day. It should be a part of your routine. You do not clean your premises once a week. Make it a habit to look for the breeding places. The new approach should be a war against indoor or outdoor mosquitoes; fresh stagnant or dirty water mosquitoes; small containers like bottle caps or large containers like overhead tankers; made of mud or plastic; throughout the day (early morning fogging when pupa hatch for Aedes, late night for malaria); scrubbing clean the utensils Slogan: Ghar ke ander or ghar ke bahar; din me or rat me, deewaron ke niche or upar, chote pani or bade pani ke collection me, eggs larve or mosquito, teeno ko maro.

Tuesday, 27 September 2016

IMA URGES BANNING NUCLEAR WEAPONS

IMA URGES BANNING NUCLEAR WEAPONS

World Medical Association, the global body representing more than nine million physicians today issued a strong plea to the governments of the world to work towards the elimination of all nuclear weapons. The WMA has warned that the current state of world affairs has made nuclear disarmament a more urgent issue than ever.

To mark the International Day for the Total Elimination of Nuclear Weapons on September 26 WMA President Sir Michael Marmot said: It is vital that physicians around the world should reinforce about the abhorrence of nuclear weapons. The medical evidence about the consequences of using nuclear weapons is so horrific that nothing short of a total ban on nuclear weapons is acceptable.

Physicians and national medical associations have a duty to speak out about the catastrophic consequences of deploying these weapons and Governments have a duty to make the world a safer place said WMA President.
Development, testing, production, stock piling, transfer, deployment, threat and use of nuclear weapons must be condemned and must be halted all over the world said Padma Shri Awardee Dr KK Aggarwal, National President Elect Indian Medical Association. India can no longer afford to sit back and do nothing.

Mosquito Menace: How to win over our collective failure

Mosquito Menace: How to win over our collective failure

Dr KK Aggarwal
National President Elect & Honorary Secretary General IMA
& President Heart Care Foundation of India

 Napoleon Hill once said that "Most great people have attained their greatest success just one step beyond their greatest failure."

It’s time for all of us to convert our biggest failure, to control mosquitos menace into success.

We all must agree that collectively we have failed in controlling the mosquitos menace and Delhi today is having an epidemic of chikungunya with rising cases of dengue and malaria.
It’s a collective failure of Municipal Corporation, Delhi Government, Central Government, LG office, Medical Associations, CSR departments, Media, NGOs and Private sector.

As per the current picture the mosquito container index in Delhi is over 40% and any index above 5% require community integrated cluster approach for mosquito density reduction together with effective anti-larval measures.

But even today the three lac mosquito repellent impregnated mosquito nets received my MCDs as donations are not available to patients.

Anti-larval measures, temephos an organophosphate larvicideteme and mosquitofish or Gambusia a freshwater fish is not available to a common man.

Then what is the answer. We need a paradigm shift in our thinking.

We need to over report and act in time. There is no point acting when the cases have started. Often the civic bodies publically act in monsoon season. They may be planning ahead but public awareness and public involvement must start much ahead of time. Even the recent CAG report mentions that under reporting of dengue is disastrous to the society.

We need to act on all the mosquitos, aedes, culex and anopheles; just acting on aedes will not work.

That campaign that aedes is a day biter and only breeds in indoor fresh water will not work. Even if it is true by killing aedes you may end up in increasing the density of Culex and malaria causing Anopheles mosquito. Culex mosquito which causes filarial and Japanese encephalitis is already rampant in the city. 

Even aedes which causes chikungunya, West Nile, Zika and Dengue can spread by the bite of infected female indoor Aedes aegypti or outdoor albipecto mosquito. 

It is true that Aedes aegypti are more dangerous because they can fly up to 200 metres and only feed on human blood whereas the Aedes albopictus that thrives outdoors can only fly as far as 80 metres and feed on animal blood other than human blood, but the outdoor aedes cannot be ignored. .


Whole campaign uptil, now has been focussed on a day biter, wear long sleeves shirt and pants during the day and no need to use night mosquito nets. But precautions needs to be taken throughout the day, the mosquito only recognise the light and not the day or night.

That the mosquito only breeds in clear water also needs to be relearnt. Aedes breed in stagnant water anywhere inside or outside the house. Rainy water is the most important source and can collect in any plastic container inside or outside the house. Even collected garbage in open areas can have left over plastic cups or tiny bottle caps with collected rainy water collections providing ideal atmosphere for mosquito breeding.

It is true that disease spreading mosquitos do not make noise but noise producing nuisance mosquitos unless addressed to will not create a public movement.



The law says that one must notify dengue or chikungunya but one can notify within seven days of diagnosis. Aedes mosquito takes upto three meals in a day and by seven days will bite over 21 people in the vicinity. Municipal anti mosquito and anti-larval actions must occur within hours of its detection. The very purpose of notification is lost if the disease is not notified within hours of even suspected cases.

One must report all the suspected cases and not wait for confirmation of the diagnosis. We have failed because the government has been insisting to notify only ELIESA confirmed cases. An SMS should be sent to all doctors practising in that PIN code areas with a case so that they can become a part of the public health action chain.

When the first case is suspected in a state, colony or house all public health measure should start. An SMS should go to local councillor, MLA, MPs, all practising doctors, local chemists, NGOs, RWAs, local IMA Branch, State IMA Branch, IMA Head-quarters and other Speciality Organisations to join the public health chain efforts.

It has taken over a decade for we doctors to understand that dengue 1 and 3 strains are not dangerous and causes only platelet deficiency with thinning of blood and dengue 2 and 4 strains are dangerous as they leads to platelet destruction along with thickening of blood due to capillary leakage and rise in haematocrit. That platelet transfusion is not required in absence of active bleeding. And that timely fluid resuscitation is more important and not platelet resuscitation.

That dengue becomes serious when the fever is subsiding. We used to admit dengue cases with high fever and always I urgency to discharge them when fever was subsidising.

Now we know that the machine reading of platelet count cab be defective. There can be an error of 20%. A platelet count of 10,000 by machine reading can mean it is actually 50,000.


Hospital beds should be reserved only for sever dengue and severe chikungunya cases. Just because one has a reimbursement in mediclaim or PSU one should not be admitted. If it was US, the Medicare by now would have come out with admitting guidelines.

The message has been going that fogging has no answer. But at this stage of container index of > 40 we need not only ground fogging but also aerial fogging.

When Zika threat came in Brazil they deployed army to join and make it a public movement. All political parties reach every house during election process then why can’t each one of them reach every house and make the anti-mosquito and anti-larval measures effective.

Breeding checkers are only with Municipal Corporation and they also have regulatory powers to put fine. We need breeding checker in private sector. The Skill development Ministry should start courses so that anyone can hire a breeding checker on weekly basis to check their premises.

Community approach involves that 100% of the society talks about dengue. Every premises must write that their premises are mosquito free. When you are invited to someone you should ask “I hope your premises are mosquito free” and when you invite write: welcome to my house and it is mosquito free’

Even today most hospitals do not provide mosquito nets to dengue or CHIKV patients. It is true they may be having anti- larval mesh doors or mesh windows but for secondary prevention of dengue or CHIKV we need to ensure that medial establishments are certified mosquito free.

In a flat oriented house the mosquito may be breeding in the roof top belonging to one of the owner and if he is out of station for a holiday, the anti-larval measures may remain deficient. The RWAs may use their powers to check all unoccupied or closed premises including hostels, hotels and construction places in that premises.
One of the five great vows of Jainism is Non-attachment/Non-possession or Aparigraha. It talks about not storing unwanted things. But in today’s era our roof and varandas are full of left over tyres, utensils, plastic utensils etc. We buy a new car tyre and keep the old one on our roof top. We need to change this habit.

We have forgotten to plant Tulsi and Pepaal in our premises and stopped the daily Yagna all which have anti mosquito properties.

The new strategy has to focus on small collection of water like in bottle caps, finding mosquitos lower in the room under the table or the bed, to look for them in all three parts of the house roof tops, varandas and inside the rooms including unused toilets accessories.

Also the slogan check your house once a week needs a change. One needs to be alert every day. It should be a part of your routine. You do not clean your premises once a week. Make it a habit to look for the breeding places.

The new approach should be a war against indoor or outdoor mosquitos; fresh stagnant or dirty water mosquitos; present in small containers like bottle caps or large container like overhead tankers;  made of mud or plastic; through out the day (early morning fogging when pupa hatch for aedes, late night for malaria); rub cleaning the utensils


Slogan: Ghar ke ander or ghar ke bahar; din me or rat me, devaro ki niche or upper, chote panui or bade pani ke collection me, eggs larve or mosquito, teno ko maro.

Dengue: Ads only after outbreak

Dengue: Ads only after outbreak
Durgesh Nandan JhaSep 27, 2016, 12.30 AM IST
New Delhi: The under-reporting of dengue cases, highlighted in the CAG report—carried in TOI on Monday—is merely a symptom of the chronic illness Delhi's government and civic bodies suffer from. An analysis of the audit reveals a rot at all levels of planning and action as far as containment of mosquito-borne diseases by the corporations is concerned. The state, too, wakes up only when the crisis hits home.

The CAG report says that dengue cases peak from June to November every year and publicity campaigns relating to prevention of the disease have to be released before that. However, the Delhi government issued advertisements worth Rs 10.04 crore between September and November over the past three years (from 2013-14 to 2015-16) only after the outbreak of dengue. Thus, the very objective of spending to create awareness of the measures to prevent an outbreak was defeated.

This year, too, epidemiologists point out the issuing of advertisements has followed a similar trend. The publicity campaigns of municipal corporations also started in the month of October in the past three years. CAG says launching of a public awareness campaign after monsoon has little justification.

But the story doesn't end here. The federal auditor has criticised the corporations for lack of effective surveillance, first critical element of dengue prevention. According to the audit, none of the civic bodies has a standard operating procedure for this purpose and only 287 out of 967 private and public health institutions report on dengue patients. This undermines the objective of meaningful surveillance to provide early warning of an impending outbreak. In November 2012, the Delhi government constituted a dengue task force under the chairmanship of the state health secretary to formulate an action plan for containment of dengue and other vector-borne diseases in the city. However, the CAG audit has revealed this task force did not meet even once in 2014 and 2015.

The lack of manpower is another key concern voiced by the federal auditor. The malaria department was formed in the early fifties. Though the inhabited area and the population of Delhi have increased manifold since then, points out the CAG report, the sanctioned posts in the malaria department have not been reviewed.

The corporations suffer from shortage of supervisory staff, ranging from 46% to 97%, and in the workmen cadre, from 20% to 36%. In NDMC, there is no sanctioned post of entomologist (scientists who study insects) while the sanctioned posts of epidemiologist and sanitation officers are lying vacant as of January 2016. There is a 12% shortage of anti-malaria jamadaars. The CAG points out that despite this situation, many malaria inspectors, assistant malaria inspectors and field workers are still deployed on ministerial work.


Chemical control measures of vector management are undertaken with the help of various types of pumps. The audit noted 26% of the available pumps/machines in the corporations were not working while 65% of the available pumps/machines in NDMC were non-functional.


The federal auditor has suggested constituting an inter-agency coordinating mechanism, given the multiplicity of agencies dealing with dengue prevention and control in Delhi.



"The CAG report exposes civic agencies, the state and the centre that often get into a blame game over the cause of such a crisis. They should now act on the gaps in dengue prevention mechanism to ensure that more lives are not lost," said Dr K K Aggarwal, president-election, Indian Medical Association.

Heart Disease in children

Heart Disease in children New Delhi, September 26, 2016: India is inching towards becoming the heart disease capital of the world. With the increasing lifestyle irregularities and stresses of the 21st century, heart disease is extremely common in the age group of 30+. However the incidence of the disease in young children is also very high. Heart disease in children can be of different kinds, congenital and acquired heart disease. Around one percent of children in India are born with congenital heart disease and some of them are often referred to blue babies. There was a time when there was a no cure for this and parents were just informed the inevitable fate of their child. However medical advancements over the past few decades have made it possible for most children suffering from congenital heart disease to live normal lives post timely surgical intervention.
Speaking on this topic, Padma Shri Awardee, Dr. KK Aggarwal, President HCFI & President Elect IMA said, Rheumatic heart disease on the other hand is common amongst school going children and develops post a strep throat infection. Given this it is always recommended that parents must never ignore a cough in a child who has no cough and sneezing since that is the most common indication of the bacterial infection which often leads to the development of heart disease affecting the child’s heart valves. While the sore throat, or swollen joints and fever, in the child may get okay and disappear, the valves of the heart run the risk of getting permanently damaged causing rheumatic heart disease. The affected children may require valve replacement, which if not done in time may even result in death. A large number of children with congenital heart disease and rheumatic heart disease die because of non-availability of operative facilities in the country, especially for complex congenital heart disease. Additionally the lack of funds for the usually expensive surgery forces parents to ignore the illness and accept the fate of their child. However what a lot of people do not realize is that there are ways to overcome this and help can be sought.
The following options are available for children with heart diseases who cannot afford treatment:
• Sameer Malik Heart Care Foundation Fund, an initiative by Heart Care Foundation of India provides assistance to the needy and underprivileged children suffering from heart disease in need of surgical intervention. Anyone can call the Helpline no. 09958771177, which is open from Monday to Saturday and ask for help • Various Rotary Clubs in the country provide free surgery to children with heart disease. • ‘Being Human’, the organization run by the actor Salman Khan also provides financial assistance to children with congenital heart diseases. • Most states provide assistance of up to Rs 1 lakh for congenital heart disease to children if they possess BPL or equivalent card in the state. • The Delhi State Government also provides free heart treatment to children whose parents have annual income of less than Rs 3 lakhs. • Parents can apply through legal counsel to municipal corporations for assistance, through their local MLA or through their MP to the Prime Minister Relief Fund. • Children can also approach Puttaparthi Heart Centre at Bengaluru, which provides free surgeries to such children. • Various NGOs and associations also provide free treatment; for example, Maheshwari Club provides free treatment to Maheshwari families. • People can also approach their religious organizations like Gurudwaras, Mosque committees and Hindu Mahasabhas etc. for free assistance in respective category. • Under Article 21 of the Constitution of India, people can also approach respective High Courts for directions to respective state heart departments to avail free surgeries. • In every state, there are government hospitals, which provide free surgeries; for example, GB Pant Hospital provides free surgery to everyone with heart disease. • Safdarjung Hospital, New Delhi provides free heart surgery to all BPL patients from across the country. • People can also approach various PSUs for assistance under their CSR policy. • People can also approach various large private companies for assistance under their CSR policy. • The end result is – no children in India should die of curable heart disease just because he or she cannot afford it.

Centralized entrance test followed by centralized state counselling by the State: SC Constitution Bench

Centralized entrance test followed by centralized state counselling by the State: SC Constitution Bench A five-Judge Constitution Bench comprising of: Anil R. Dave, J., A.K. Sikri, J., R.K. Agarwal, J., A.K. Goel, J., R. Banumathi, J in State of M.P. vs. Jainarayan Choukey and Ors., with I.A. No.83 in Civil Appeal (Nos.)4060 of 2009 pronounced on 23.09.2016 that Centralized entrance test be followed by centralized state counselling by the State Government only. The Bench observed “We have heard the Ld. Counsel for the parties at length. We observe that mandate of our judgment was to hold centralized entrance test followed by centralized state counselling by the State to make it a one composite process. We, therefore, direct that admission to all medical seats shall be conducted by centralized counselling only by the State Government and none else. If any counselling has been done by any College or University and any admission to any medical seat has been given so far, such admission shall stand cancelled forthwith and admission shall be given only as per centralized counselling done by the State Government. We may note at this stage that the State Government has done the first counselling. However, the Ld. Additional Solicitor General has made a statement at the Bar that the State Government is ready to undertake the entire process afresh and assure that it would be completed by 30th September which is the last date for admissions.”

Monday, 26 September 2016

Information on DGAT1 Deficiency, its Symptoms and Treatment

Information on DGAT1 Deficiency, its Symptoms and Treatment

The DGAT1 gene encodes an enzyme responsible for re-esterification of the triglycerides in enterocytes. Most medical research has been focused on suppressing the DGAT1 gene for treatment of obesity and related conditions.

Symptoms of DGAT1 Deficiency
Patients with deficiency in DGAT1 show an extreme intolerance to fat of any sort. There are only a handful of known cases globally, but all have shown clear symptoms within days post birth - extreme diarrhoea and vomiting. If left unmanaged, some potential symptoms include:
1. Diarrhea with protein loss
2. Malnutrition with hypophosphatemia
3. Multiple vitamin and mineral deficiencies (copper, zinc, iron, Vitamin D and E)
4. Hyperphosphatemia
5. Elevated transaminases
6. Iron deficiency anaemia
7. Failure to thrive

How do you test for DGAT1
Whole exome sequencing can provide insight into whether an individual has a deficiency of DGAT1. However, in some cases data labs have not picked up on the slight changes to DGAT1 in their reports, and diagnosis have been made post review of the underlying data by GI geneticists.

How do you treat DGAT1
The only known way to manage a DGAT1 deficiency is to almost eliminate all fat from the individual’s diet. Patients have been able to tolerate circa 10g of fat a day, spread across meals. Additional fat has caused explosive diarrhoea, and typically takes 2-3 days for the individual to return to normality.




A case study was done by Boston Children’s Hospital on DGAT1 mutation with reference to identical male twins of South Asian descent with a mutation of DGAT1 gene, 314T>C, p.L105P L105P, with congenital diarrhoea, outline their nutritional management and initial functional analysis.


Clinical Case:
·         Monochorionic male twins born at 36 weeks gestational age by scheduled c-section and developed watery diarrhea and acidosis shortly after birth.
·         Diarrhoea and poor weight gain persisted despite multiple formula changes and gastrostomy tube feeds.
·    Presented at 26-months old with failure to thrive, protein losing enteropathy, hypogammaglobulinemia, vitamin D, and iron deficiencies.
·         Twin A required hospitalization and total parenteral nutrition.
·         An extensive work-up culminated with whole exome sequencing (WES).


Genetics
·         WES sent from Twin A revealed a homozygous point mutation in the DGAT1 gene, c.314T>C, p.L105P.
·         Confirmation by Gene Dx sequencing and found both parents to be heterozygous for the same mutation.

Dietary Management

Twin A had improved growth and vitamin levels as expected on complete parenteral nutrition. He was transitioned to a low fat diet containing no more than 10% calories from fat. On this diet his protein losing enteropathy was resolved, as evidenced by normal stool alpha-1 antitrypsin and serum immune globulin levels. If his daily fat intake surpasses the 10%, he experiences loose stools. Similarly, his twin brother has improved growth and resolution of protein losing enteropathy on this regimen.