IJCP February 2018

ISSN 0971-0876 RNI 50798/1990 University Grants Commission 20737/15554

Indexed with IndMED Indexed with MedIND Indian Citation Index (ICI)

www.ijcpgroup.com

Volume 28, Number 9

Single Copy Rs. 300/-

February 2018, Pages 801–900

Peer Reviewed Journal

yy American Family Physician yy Anesthesiology yy Critical Care yy Clinical Physiology yy Drugs yy Gastroenterology yy Issue of the Month yy Neurology yy Obstetrics and Gynecology yy Imaging and Investigations

an i c i ys ians

yy Medicolegal

Phly Physic y l mi ami

yy Medifinance yy Conference Proceedings

Fademy of F n ica Aca

yy Around the Globe

er merican m A eA

yy Spiritual Update

ingurnal of th t a or d Jo

yy Lighter Reading

rp-reviewe o c In eer AP

Full text online: http://ebook.ijcpgroup.com/ijcp/ IJCP Publications | https://goo.gl/j2nXQQ

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Online Submission

IJCP Group of Publications Volume 28, Number 9, February 2018

Dr Sanjiv Chopra Group Consultant Editor

From the desk of THE group editor-in-chief

Dr Deepak Chopra Chief Editorial Advisor

Dr KK Aggarwal Padma Shri Awardee Group Editor-in-Chief Dr Veena Aggarwal Group Executive Editor

IJCP Editorial Board Obstetrics and Gynaecology Dr Alka Kriplani, Dr Thankam Verma, Dr Kamala Selvaraj Cardiology Dr Praveen Chandra Paediatrics Dr Swati Y Bhave Diabetology Dr CR Anand Moses, Dr Sidhartha Das, Dr A Ramachandran, Dr Samith A Shetty, Dr Vijay Viswanathan, Dr V Mohan, Dr V Seshiah, Dr Vijayakumar ENT Dr Jasveer Singh, Dr Chanchal Pal Dentistry Dr KMK Masthan, Dr Rajesh Chandna Gastroenterology Dr Ajay Kumar, Dr Rajiv Khosla, Dr JS Rajkumar Dermatology Dr Hasmukh J Shroff, Dr Pasricha, Dr Koushik Lahiri, Dr Jayakar Thomas Nephrology Dr Georgi Abraham Neurology Dr V Nagarajan, Dr Vineet Suri, Dr AV Srinivasan Oncology Dr V Shanta Orthopedics Dr J Maheshwari

Anand Gopal Bhatnagar Editorial Anchor Advisory Bodies Heart Care Foundation of India

805 Patient Communication Made Easy

American Family Physician

807 Diagnosis and Management of Nephrotic Syndrome in Adults

Charles Kodner

813 Practice Guidelines 814 Photo Quiz ANESTHESIOLOGY

818 Anesthetic Challenges for Functional MRI in Pyopagus Conjoined Twins Under TIVA

Ankesh Gupta, Sushil C Verma, Yawar R Rather, Ajit Gupta

CRITICAL CARE

821 Inadvertently Lost Cannula Sheath in External Jugular Vein: A Rare Incident

Sanjiv K Goyal, Sandeep Singh Maavi, Ashish Garg, Vijay Jagad

CLINICAL PHYSIOLOGY

823 Some Facts About Cellular Oxygenation and Daily Life

KK Aggarwal, S Sharma

Drugs

830 Nitrofurantoin as a First-line Drug in the Treatment of “Escherichia coli Causing Community-acquired Urinary Tract Infection”

Shashi Chopra, Gomty Mahajan

GASTROENTEROLOGY

836 Hepatic Granulomas: A Clinician’s Perspective

Mayank Jain, Joy Varghese, Jayanthi Venkataraman

Issue of the Month

842 IMA Clarifications on FAQs by Ministry of Health, Government of India Regarding National Medical Commission

Non-Resident Indians Chamber of Commerce & Industry World Fellowship of Religions

This journal is indexed in IndMED (http://indmed.nic.in) and full-text of articles are included in medIND databases (http://mednic.in) hosted by National Informatics Centre, New Delhi.

Dr KK Aggarwal

Ravi Wankhedkar, RN Tandon, A Marthanda Pillai, Vedprakash Mishra KK Aggarwal

NEUROLOGY

858 Dyke-Davidoff-Masson Syndrome

Sasi Sekhar Tvd, A Gopala Krishna Rao, Satish P Sashidhar Reddy G, Sarat M

OBSTETRICS AND GYNECOLOGY Published, Printed and Edited by Dr KK Aggarwal, on behalf of IJCP Publications Ltd. and Published at E - 219, Greater Kailash Part - 1 New Delhi - 110 048 E-mail: editorial@ijcp.com

861 Heterologous Malignant Mixed Mullerian Tumor of Uterus: An Uncommon Tumor with Uncommon Presentation

Bhavana S

865 Subseptate Uterus Presenting as Unstable Lie at Term

Printed at New Edge Communications Pvt. Ltd., New Delhi E-mail: edgecommunication@gmail.com

Shikha Singh, Saroj Singh, Ankita Kumari, Ruchita Sinha

IMAGING AND INVESTIGATIONs

Copyright 2018 IJCP Publications Ltd. All rights reserved.

867 Mid-cavity Obstruction of Right Ventricle Without Any Other Congenital Anomaly

The copyright for all the editorial material contained in this journal, in the form of layout, content including images and design, is held by IJCP Publications Ltd. No part of this publication may be published in any form whatsoever without the prior written permission of the publisher.

Sr Mittal

MEDICOLEGAL

869 Case Study on Whether a Doctor can Suffix His Name Other Qualifications Undertaken by Him Which are not Recognised by MCI or Not

Editorial Policies The purpose of IJCP Academy of CME is to serve the medical profession and provide print continuing medical education as a part of their social commitment. The information and opinions presented in IJCP group publications reflect the views of the authors, not those of the journal, unless so stated. Advertising is accepted only if judged to be in harmony with the purpose of the journal; however, IJCP group reserves the right to reject any advertising at its sole discretion. Neither acceptance nor rejection constitutes an endorsement by IJCP group of a particular policy, product or procedure. We believe that readers need to be aware of any affiliation or financial relationship (employment, consultancies, stock ownership, honoraria, etc.) between an author and any organization or entity that has a direct financial interest in the subject matter or materials the author is writing about. We inform the reader of any pertinent relationships disclosed. A disclosure statement, where appropriate, is published at the end of the relevant article.

Kk Aggarwal, Ira Gupta

Medifinance

871 Medifinance

KK Aggarwal, Arun Kishore

CONFERENCE PROCEEDINGS

872 69th Annual Conference of Cardiological Society of India (CSI 2017) 880 58th Annual Conference of the Indian Society of Gastroenterology (ISGCON 2017) AROUND THE GLOBE

884 News and Views Spiritual Update

Note: Indian Journal of Clinical Practice does not guarantee, directly or indirectly, the quality or efficacy of any product or service described in the advertisements or other material which is commercial in nature in this issue.

893 You are Born with a Quota, Use it Judicially

KK Aggarwal

Lighter reading

894 Lighter Side of Medicine

IJCP’s Editorial & Business Offices Delhi

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Dr Veena Aggarwal 9811036687 E - 219, Greater Kailash, Part - I, New Delhi - 110 048 Cont.: 011-40587513 editorial@ijcp.com drveenaijcp@gmail.com Subscription Dinesh: 9891272006 subscribe@ijcp.com Ritu: 09831363901 ritu@ijcp.com

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from the desk of THE group editor-in-chief

Dr KK Aggarwal

Padma Shri Awardee President, Heart Care Foundation of India Group Editor-in-Chief, IJCP Group

Patient Communication Made Easy

S

hould be simple, positive, one liner with full meaning called sutra, field tested, facts based and not fear based, communicated at a time when iron is hot and through the mouth of medical celebrities.

ÂÂ

Pulmonary embolism is like lung heart attack.

ÂÂ

EEG is the ECG of brain.

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Honking of a car is angina of the heart.

Here are some examples

ÂÂ

Car stopped with engine off means cardiac arrest.

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PCOD: is the diabetes of the ovary.

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Car stopped with engine on is heart attack.

ÂÂ

Stroke: is the heart attack of brain.

ÂÂ

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Erectile dysfunction means angina of the male organs.

Stopped car can run by pushing the car similarly stopped heart can be revived by cardiac compressions.

ÂÂ

Fever is a good sign: when police (WBC) and thieves (bacteria) fight there will always be heat produced because of destruction.

ÂÂ

Traffic congestion can be corrected by widening the roads similarly blocked arteries can be handled by balloon angioplasty.

ÂÂ

A weak heart cannot win Olympics: a low EF heart cannot present with LVF with accelerated hypertension and similarly a critical aortic stenosis can nor present with accelerated hypertension.

ÂÂ

Widened road needs railing to prevent encroachment similarly blocked opened arteries needs a stent with current to prevent re blockages.

ÂÂ

Heart bypass means building flyovers.

ÂÂ

Beating bypass means building a flyover without stopping the traffic.

ÂÂ

First encroachment on the road occurs in pavement and the same is intima media thickness of carotid arteries in atherosclerosis.

ÂÂ

Osteoarthritis means rusting of joints.

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Rheumatoid arthritis means termite infestation of the joint and joint pain will improve on movements.

ÂÂ

Rusted joints of a door will make a noise on movement, similarly rusted osteoarthritis of joints will be painful on movements.

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If tobacco was good then insects, birds and animals would have eaten tobacco crops.

ÂÂ

Heart is a four-bedded room house.

ÂÂ

Heart artery blockages means the plumbing system of the heart is chocked.

ÂÂ

Heart electrical blockages means the electrical wiring system of the heart is bad.

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In heart attack pain is a good sign: means some of the heart muscle is still alive.

ÂÂ

Heart pacemaker means putting an inverter.

ÂÂ

Mini brain attack means angina of brain.

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Stroke in evolution means unstable angina of the brain.

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Cerebral atrophy is like heart cardiomyopathy.

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Brain seizures are like heart arrhythmias.

IJCP Sutra 1: In the setting of a mumps outbreak individuals who completed a two-dose series of a mumps virus-containing vaccine >2 years prior to the outbreak should receive a third MMR dose. MMWR Morb Mortal Wkly Rep. 2018;67:33.

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Indian Journal of Clinical Practice, Vol. 28, No. 9, February 2018

ÂÂ

If God wanted, you to eat mangoes in winter he would have grown them in winter.

ÂÂ

If GOD wanted, you to have coconuts in noncoastal areas he would not have grown then only in coastal areas.

ÂÂ

Gangrene of the leg means heart attack of the legs.

ÂÂ

Thoughts are like monkeys, wandering all the time.

ÂÂ

Bull means uncontrolled sexual desires.

ÂÂ

Cobra means uncontrolled ego.

ÂÂ

Tortoise means the art of withdrawal.

ÂÂ

Ganga means the positive flow of thoughts.

ÂÂ ÂÂ

ÂÂ

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Health and good humor are to the human body like sunshine to vegetation.

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Body is like a machine and it also requires annual maintenance contract.

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Body is like a machine and requires insurance.

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Body is like a machine and requires preventive servicing.

ÂÂ

Jungle animals do not get heart attack because they live in accordance with the laws of nature.

ÂÂ

Oil which is liquid at room temperature will remain liquid in body.

Apoptosis means patjhad of plant leaves.

ÂÂ

Hunan body is also made up of five elements and is influenced by these elements.

Oils which are solid at room temperature will solidify in the heart arteries and cause blockages.

ÂÂ

A man too busy to take care of his health is like a mechanic too busy to look after his tools.

Seasonal vegetables will be in abundance in the market and will be cheaper.

ÂÂ

If nature wanted you to eat sugar he would not have made it as fourth generation item (sugar cane, jaggery, khand and then sugar).

Health is like money, we never have a true idea of its value until we lose it.

■■■■

806

IJCP Sutra 2: In HIV-infected women who become pregnant while on an elvitegravir-cobicistat-containing regimen switch to a different regimen.

7th International Workshop on HIV and Women. Seattle, WA. February 11-12, 2017.

American Family Physician

Diagnosis and Management of Nephrotic Syndrome in Adults CHARLES KODNER

Abstract Nephrotic syndrome (NS) consists of peripheral edema, heavy proteinuria, and hypoalbuminemia, often with hyperlipidemia.

Patients typically present with edema and fatigue, without evidence of heart failure or severe liver disease. The diagnosis of NS is based on typical clinical features with confirmation of heavy proteinuria and hypoalbuminemia. The patient history and selected diagnostic studies rule out important secondary causes, including diabetes mellitus, systemic lupus erythematosus, and medication adverse effects. Most cases of NS are considered idiopathic or primary; membranous nephropathy and focal segmental glomerulosclerosis are the most common histologic subtypes of primary NS in adults. Important complications of NS include venous thrombosis and hyperlipidemia; other potential complications include infection and acute kidney injury.

Spontaneous acute kidney injury from NS is rare but can occur as a result of the underlying medical problem. Despite a lack of evidence-based guidelines, treatment consisting of sodium restriction, fluid restriction, loop diuretics, angiotensinconverting enzyme inhibitor or angiotensin receptor blocker therapy, and careful assessment for possible disease complications is appropriate for most patients. Renal biopsy is often recommended, although it may be most useful in patients with suspected underlying systemic lupus erythematosus or other renal disorders, in whom biopsy can guide management and prognosis. Immunosuppressive treatment, including corticosteroids, is often used for NS, although evidence is lacking. Routine prophylactic treatment to prevent infection or thrombosis is not recommended. A nephrologist should be consulted about use of anticoagulation and immunosuppressants, need for renal biopsy, and for other areas of uncertainty.

Keywords: Nephrotic syndrome, peripheral edema, heavy proteinuria, hypoalbuminemia, hyperlipidemia, renal biopsy

N

ephrotic syndrome (NS) consists of peripheral edema, heavy proteinuria, and hypoalbuminemia, often with hyperlipidemia.

Patients typically present with edema and fatigue, without heart failure or severe liver disease. Although there is limited evidence to guide management decisions, recent expert consensus guidelines and systematic reviews provide updated recommendations. This article focuses on diagnosis and management of NS in adults, which is different from that in children.

Epidemiology The annual incidence of NS in adults is three per 100,000 persons. Approximately 80% to 90% of NS cases in adults are idiopathic. Membranous nephropathy is the most common cause in whites, and focal segmental glomerulosclerosis is most common in blacks; each of

these disorders accounts for approximately 30% to 35% of NS cases in adults. Minimal change disease and immunoglobulin A nephropathy each account for approximately 15% of cases. The remaining 10% of cases are secondary to an underlying medical condition.1 Causes Assessing the cause of NS is important in guiding management decisions. Many underlying systemic conditions can cause NS, although type 2 diabetes mellitus and systemic lupus erythematosus are most common. NS may not present as a primary diagnosis, but instead as one of multiple disease manifestations, particularly in systemic lupus erythematosus.

AÂ published case report of a 29-year-old pregnant woman with lupus nephritis, preeclampsia, NS, and hemolytic anemia illustrates this scenario.2 Secondary causes of NS are listed in Table 1.1,3 Pathophysiology

CHARLES KODNER, MD, is an associate professor in the Department of Family and Geriatric Medicine at the University of Louisville (Ky.) School of Medicine.

Source: Adapted from Am Fam Physician. 2016;93(6):479-485.

The mechanism of edema formation in NS is unclear.

The primary defect seems to be increased glomerular

IJCP Sutra 3: For patients undergoing angiography who are at increased risk for contrast nephropathy do not give acetylcysteine, either orally or intravenously.

N Engl J Med. 2017.

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Indian Journal of Clinical Practice, Vol. 28, No. 9, February 2018

Table 1. Secondary Causes of Nephrotic Syndrome Metabolic

Medication/drug use

Infection (continued)

Amyloidosis

Heroin

Viral

Diabetes mellitus

Interferon alfa

Epstein-Barr virus

Immunologic

Lithium

Hepatitis B and C

Cryoglobulinemia

Nonsteroidal anti-inflammatory drugs

Herpes zoster

Erythema multiforme

Pamidronate

Human immunodeficiency virus

Henoch-Schönlein purpura

Infection

Allergic

Microscopic polyangiitis

Bacterial

Antitoxins

Polyarteritis nodosa

Infective endocarditis

Insect stings, venomous snake bites

Sjögren syndrome

Leprosy

Poison ivy or oak

Systemic lupus erythematosus

Syphilis

Genetic syndromes

Idiopathic/primary

Protozoan

Congenital nephrotic syndrome (Finnish type)

Neoplastic

Filariasis

Familial focal segmental glomerulonephritis

Carcinoma (e.g., bronchus, breast, colon, stomach, kidney)

Helminthiasis

Hereditary nephritis (Alport syndrome)

Malaria

Other

Leukemia, lymphomas

Schistosomiasis

Castleman disease

Melanoma

Chronic allograft nephropathy

Multiple myeloma

Malignant hypertension Preeclampsia Sarcoidosis

Information from references 1 and 3.

permeability to albumin and other plasma proteins.

Primary renal sodium retention and decreased oncotic pressure from hypoalbuminemia lead to increased extravasation of fluid from the intravascular space into the interstitial space, resulting in edema.4 The pathophysiology of thrombogenesis in NS is also not completely understood but seems to be multifactorial, involving loss of coagulation regulatory proteins and a shift in the hemostatic balance toward a prothrombotic milieu.5 Patients with NS and prothrombotic genetic mutations have a further increased risk of thrombosis.

Diagnostic Evaluation New-onset edema, particularly in the lower extremities, is the most common presenting symptom of NS. Depending on disease severity, patients may have edema extending to the proximal lower extremities, lower abdomen, or genitalia. Ascites, periorbital edema, hypertension, and pleural effusion are also possible presenting features. Patients may report foamy urine, exertional dyspnea or fatigue, and significant fluidassociated weight gain.1,3

808

The diagnostic criteria for NS are listed in Table 2.1 Confirmation of proteinuria via 24-hour urine collection is cumbersome for patients, and the specimen can be collected incorrectly. The protein-to-creatinine ratio from a single urine sample is commonly used to diagnose nephrotic-range proteinuria. Although this spot test has limited accuracy in patients who exercise heavily, are gaining or losing muscle mass, or have similar factors, in general, it is sufficient for diagnosing heavy proteinuria.1 Further diagnostic assessment of patients with NS has three goals: to assess for complications, identify underlying disease, and potentially determine the histologic type of idiopathic NS. The role of renal biopsy in patients with NS is controversial, and there are no evidence-based guidelines regarding indications for biopsy. Whether biopsy is performed often depends on the preferences of consulting nephrologists. In patients with NS from a known secondary cause and who are responding to treatment appropriately, biopsy will likely add little to treatment. Biopsy may be more useful for treatment and prognosis in patients with idiopathic NS of an unknown histologic disease type or with suspected underlying systemic lupus erythematosus or other renal disorders.

IJCP Sutra 4: For individuals with iron deficiency who are treated with oral iron, the dose be taken every other day rather than every day. Lancet Haematol.

2017;4:e524.

American Family Physician Complications Various systemic complications are commonly associated with NS. These are thought to result from overproduction of hepatic proteins and loss of low-molecular-weight proteins in the urine, although the specific mechanisms have not been fully described.5 It is generally not necessary to screen otherwise asymptomatic patients for these complications. Figure 1 is an algorithm for the diagnosis and management of NS.1

Venous Thrombosis Venous thrombosis is one of the most important complications of NS, but the true incidence and risk are difficult to determine because of the heterogeneity of the clinical manifestations and causes of NS. The most

common sites of venous thrombosis in adults are in the deep veins of the lower limbs, although thrombosis can also occur in the renal veins and can cause pulmonary embolism. Arterial thrombosis is rare in patients with NS.1 In a historical case series of patients with NS, venous thrombosis of the lower limb occurred in 8% of patients, and renal venous thrombosis occurred in up to 25% of patients. However, more recent data suggest a much lower risk of venous thrombosis in patients with NS.6 In a retrospective study, deep venous thrombosis occurred in 1.5% of adults with NS, and renal venous thrombosis occurred in 0.5% of adults with NS.6 Venous thrombosis is much more common in adults than in children and is more common in adults with membranous nephropathy than other histologies,5 with an incidence of up to 7%.7

Diagnosis of Nephrotic Syndrome in Adults

Step 1: Confirm nephrotic syndrome

Positive result on urine dipstick testing (2/3/4+) Early morning urinary protein measurement; protein-to-creatinine ratio is typically > 3 to 3.5 mg protein/mg creatinine (300 to 350 mg/mmol) in nephrotic syndrome Serum albumin measurement

Step 2: Assess for common causes

Urinalysis: Hematuria or casts suggest nephritis Blood counts and coagulation panel: Abnormal results may suggest a bleeding disorder Renal function and electrolytes: An elevated creatinine level may indicate acute kidney injury and indicates reduced GFR Liver panel: Elevated transaminase levels may suggest viral hepatitis Glucose tests for diabetes mellitus

Step 3: Assess for underlying conditions

Focused testing for disorders suggested by history and physical examination Antinuclear antibody, anti–double-stranded DNA antibody, and complement values (C3 and C4) if connective tissue disorder is suspected Chest radiography if pleural effusion is suspected Echocardiography if heart failure is suspected Abdominal ultrasonography if ascites is suspected Renal ultrasonography if GFR is reduced Viral hepatitis panel if transaminase levels are abnormal

Step 4: Assess for disease complications

Consideration of focused testing for disorders suggested by history and physical examination Renal ultrasonography if GFR is reduced Lower extremity Doppler ultrasonography, chest computed tomography, or lung ventilation/perfusion scan if venous thrombosis or pleural effusion is suspected

Step 5: Consider renal biopsy

Nephrologist consultation if biopsy is considered Renal biopsy should be considered if it will inform management, or for severe disease, lack of response to treatment, or steroid resistance

Figure 1. Algorithm for the diagnosis of nephrotic syndrome in adults.

GFR = Glomerular filtration rate.

Information from reference 1.

IJCP Sutra 5: Patients ≥60 years of age with new onset dyspepsia should undergo an upper endoscopy. Am J Gastroenterol. 2017;112:988.

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Indian Journal of Clinical Practice, Vol. 28, No. 9, February 2018

Unless the patient’s history suggests a thromboembolic complication, screening otherwise asymptomatic patients for thromboembolic events is not indicated.

Infection

disease process is believed to improve or resolve the dyslipidemia.1,10 Management

Bacterial infections, especially cellulitis, are a potential complication of NS. A Cochrane review found no relevant studies of infections in adults with NS.8 There are no reliable data on the incidence of infection as a complication of NS and no current guidelines for the use of prophylactic antibiotics in adults with NS.

Management of NS is limited by a lack of clear evidencebased guidelines, although recent expert consensus guidelines provide useful recommendations.11 In addition to correction of treatable causes, management includes general measures to treat symptoms such as edema and, in some cases, immunosuppressant treatment of the renal pathology.

Renal Failure

General Treatment Measures

Acute kidney injury is considered a rare spontaneous complication of NS. It can coexist with NS when it is caused by the same factors that lead to edema and proteinuria, such as lupus nephritis and drug-induced interstitial nephritis.1,9 Although acute kidney injury is uncommon in NS, tests for renal function, quantification of proteinuria, serum chemistry, and lipid profile are appropriate to assess renal function and determine the degree of hyperlipidemia. Table 3 shows the differential diagnosis of acute kidney injury in patients with NS.3

Because of the possible pathophysiologic role of sodium retention, some experts recommend that routine treatment of patients with NS include restricting dietary sodium to less than 3 g per day and restricting fluid to less than 1,500 mL per day.1

Hyperlipidemia Elevated lipid levels (potentially markedly elevated) are a common feature of NS. Any subtype of lipoprotein concentrations can be elevated. There are no recent epidemiologic data to indicate how common or severe this complication is, and no recent data regarding the impact of treatment for dyslipidemia associated with NS. However, resolving proteinuria and any underlying Table 3. Differential Diagnosis of Acute Kidney Injury in Nephrotic Syndrome Acute allergic interstitial nephritis secondary to use of various drugs, including diuretics Acute tubular necrosis caused by volume depletion or sepsis Adverse effects of drug therapy Hemodynamic response to nonsteroidal anti-inflammatory drugs, angiotensin-converting enzyme inhibitors, or angiotensin receptor blockers Intrarenal edema Prerenal failure caused by volume depletion Renal venous thrombosis Transformation of underlying glomerular disease (e.g., crescentic nephritis superimposed on membranous nephropathy) Information from references 3.

810

Treating Edema Patients with nephrosis are resistant to diuretics, even if the glomerular filtration rate is normal. Loop diuretics act in the renal tubule and must be protein-bound to be effective. Serum proteins are reduced in NS, limiting the effectiveness of loop diuretics, and patients may require higher-than-normal doses.3 Other mechanisms for diuretic resistance are also possible. Oral loop diuretics with twice-daily administration are usually preferred because of the longer duration of action. However, with severe NS and edema, gastrointestinal absorption of the diuretic may be uncertain because of intestinal wall edema, and intravenous diuretics may be necessary. Diuresis should be relatively gradual and guided by daily weight assessment, with a target of 2 to 4 lb (1 to 2 kg) per day.3 Furosemide at 40 mg orally twice daily or bumetanide at 1 mg twice daily is a reasonable starting dosage, with approximate doubling of the dose every one to three days if there is inadequate improvement in edema or other evidence of fluid overload.3 An approximate upper limit for furosemide is 240 mg per dose or 600 mg total per day,12 but there is no clear evidence or rationale for this limit. If there is still an inadequate clinical response, patients may be treated by changing to intravenous loop diuretics, adding oral thiazide diuretics, or giving an intravenous bolus of 20% human albumin prior to an intravenous diuretic bolus.3

Anticoagulation for Venous Thrombosis Despite the known risk of venous thrombosis in patients with NS, there are no randomized controlled trials to

IJCP Sutra 6: For patients <60 years, upper endoscopy is reserved for those with clinically significant weight loss, overt gastrointestinal bleeding, more than one alarm feature, or rapidly progressive alarm features. Patients <60 years of age should be tested and treated for H. pylori infection. Am J Gastroenterol. 2017;112:988.

American Family Physician guide whether prophylactic anticoagulation should be used and for how long.1 Adult patients with NS should be assessed individually for underlying disease. Additional considerations are the severity of NS (i.e., serum albumin less than 2.0 to 2.5 g per dL [20 to 25 g per L] may be more likely to prompt anticoagulation prophylaxis7), preexisting thrombophilic states, and the overall likelihood of serious bleeding events from the use of oral anticoagulation. The decision to treat with anticoagulants should be made individually.13 Although the benefits of anticoagulation may outweigh the risks in selected patients at high risk of venous thrombosis (e.g., those with known prothrombotic tendency or a history of venous thrombosis), anticoagulation is not routinely used for primary prevention of thrombotic events in patients with NS.6

Treating and Preventing Infection Infection has been reported in up to 20% of adults with NS, although it is unclear if NS is causative or if the infection is a result of hospitalization, corticosteroid use, or other factors.1 A Cochrane review found no strong evidence to recommend a specific intervention to prevent infection in adults with NS.8

Treating Dyslipidemia A recent Cochrane review found insufficient evidence to determine if lipid-lowering agents are helpful in managing dyslipidemia in adults with NS and no other indications for treatment based on previously obtained lipid levels.10

Antiproteinuric Treatment Treatment with angiotensin-converting enzyme inhibitors or angiotensin receptor blockers appears to reduce the risk of venous thrombosis, although this has not been confirmed.14 Treatment with angiotensinconverting enzyme inhibitors or angiotensin receptor blockers is often recommended for patients with NS because of their known antiproteinuric effects. However the degree of benefit for specific outcomes, such as renal failure or recovery, improvement in edema, or need for dialysis, is unproven, and the evidence supporting the routine use of these medications is conflicting.

Immunosuppressive Therapy Corticosteroids are often used in the treatment of NS despite an absence of supporting data. In recent years, corticosteroids and other immunosuppressive treatments have been investigated for use in NS (Table 4).15

Table 4. Potential Immunosuppressive Agents for Nephrotic Syndrome Due to Idiopathic Membranous Nephropathy Adrenocorticotropic hormone Alkylating agents (chlorambucil, cyclophosphamide) Azathioprine Biologics (rituximab, eculizumab) Calcineurin inhibitors (cyclosporine, tacrolimus) High-dose immune globulin Mycophenolate mofetil Tripterygium wilfordii (thunder god vine; traditional Chinese immunosuppressive therapy) Information from references 15.

A Cochrane review showed that combining an alkylating agent with a corticosteroid has short- and long-term benefits for membranous nephropathy in adults with NS.15 In general, immunosuppressive treatment has no proven benefit for most adults with idiopathic NS, and the potential risks may outweigh any benefits. The role of such treatment and specific treatment decisions, such as type and duration of therapy, depend on clinical factors and potentially on the histologic diagnosis identified on biopsy. If NS is steroid-resistant or does not improve, other immunosuppressive treatments should be considered in cooperation with a nephrologist. Immunosuppressive therapy for NS secondary to systemic lupus erythematosus is highly effective and supported by multiple studies, and may lead to partial or complete remission in patients with minimal change disease or primary focal segmental glomerulosclerosis.

Prognosis The prognosis for NS is highly dependent on the underlying cause, the disease histology, and patient clinical factors. Although many patients improve with appropriate supportive care and do not require any specific therapy, others worsen despite aggressive, specific therapy and may require dialysis.

In one study, routine treatment with an angiotensinconverting enzyme inhibitor or angiotensin receptor blocker, plus selective use of corticosteroids or other immunosuppressants, led to a remission rate of 76%, with 12% of patients requiring hemodialysis.16 Idiopathic membranous nephropathy is one of the most common forms of primary NS in adults, and has

IJCP Sutra 7: For patients with suspected multiple myeloma prefer cross-sectional imaging (low-dose CT, PET/CT, or MRI scan), rather than a skeletal survey, as the imaging modality to detect bone involvement. Blood Cancer J. 2017;7:e599.

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Indian Journal of Clinical Practice, Vol. 28, No. 9, February 2018

a generally favorable prognosis.15 The prognosis for this illness roughly follows a “rule of thirds”: about one-third of patients have a benign course with a high rate of remission; one-third have ongoing evidence of proteinuria or edema but maintain normal renal function; and somewhat less than one-third of patients progress toward end-stage renal disease within 10 years.15 Adults with primary focal segmental glomerulosclerosis, however, tend to have a poorer prognosis, and the degree of proteinuria is a significant prognostic factor.

Although about one-half of patients with nephroticrange proteinuria progress to end-stage renal disease over five to 10 years, patients with very heavy proteinuria (10 to 14 g per day) will develop end-stage renal disease on average within two to three years.17 Subspecialist Consultation Consultation with nephrologists should guide decisions about use of anticoagulation and immunosuppressants, need for renal biopsy, and for other areas of uncertainty.

thromboembolic disease. Clin J Am Soc Nephrol. 2012; 7(3):513-520.

6. Kayali F, Najjar R, Aswad F, Matta F, Stein PD. Venous thromboembolism in patients hospitalized with nephrotic syndrome. Am J Med. 2008;121(3):226-230.

7. Pincus KJ, Hynicka LM. Prophylaxis of thromboembolic events in patients with nephrotic syndrome. Ann Pharmacother. 2013;47(5):725-734.

8. Wu HM, Tang JL, Cao L, Sha ZH, Li Y. Interventions for preventing infection in nephrotic syndrome. Cochrane Database Syst Rev. 2012;(4):CD003964.

9. Koomans HA. Pathophysiology of acute renal failure in idiopatic nephrotic syndrome. Nephrol Dial Transplant.

2001;16(2):221-224.

10. Kong X, Yuan H, Fan J, Li Z, Wu T, Jiang L. Lipid-lowering agents for nephrotic syndrome. Cochrane Database Syst Rev. 2013;(12):CD005425.

11. Radhakrishnan J, Cattran DC. The KDIGO practice guideline on glomerulonephritis: reading between the (guide)lines—application to the individual patient. Kidney Int. 2012;82(8):840-856.

Note: For complete article visit: www.aafp.org/afp.

12. Furosemide dosage. Drugs.com. http://www.drugs. com/ dosage/furosemide.html. Accessed January 13, 2016.

REFERENCES

13. Glassock RJ. Prophylactic anticoagulation in nephrotic syndrome. J Am Soc Nephrol. 2007;18(8):2221-2225.

1. Hull RP, Goldsmith DJ. Nephrotic syndrome in adults.

BMJ. 2008;336(7654):1185-1189.

2. Williams WW Jr, Ecker JL, Thadhani RI, Rahemtullah A. Case records of the Massachusetts General Hospital.

Case 38-2005. A 29-year-old pregnant woman with the nephrotic syndrome and hypertension. N Engl J Med. 2005;353(24):2590-2600.

3. Floege J. Introduction to glomerular disease: clinical presentations. In: Johnson RJ, Feehally J, Floege J, eds.

Comprehensive Clinical Nephrology. 5th ed. Philadelphia, Pa.: Elsevier Saunders; 2015.

4. Siddall EC, Radhakrishnan J. The pathophysiology of edema formation in the nephrotic syndrome. Kidney Int. 2012;82(6):635-642.

5. Kerlin BA, Ayoob R, Smoyer WE. Epidemiology and pathophysiology of nephrotic syndrome-associated

14. Mahmoodi BK, Mulder AB, Waanders F, et al. The impact of antiproteinuric therapy on the prothrombotic state in patients with overt proteinuria. J Thromb Haemost.

2011;9(12):2416-2423.

15. Chen Y, Schieppati A, Chen X, et al. Immunosuppressive treatment for idiopathic membranous nephropathy in adults with nephrotic syndrome. Cochrane Database Syst Rev. 2014;(10):CD004293.

16. McQuarrie EP, Stirling CM, Geddes CC. Idiopathic membranous nephropathy and nephrotic syndrome.

Nephrol Dial Transplant. 2012;27(1):235-242.

17. Korbet SM. Treatment of primary FSGS in adults. J Am Soc Nephrol. 2012;23(11):1769-1776.

18. Kodner C. Nephrotic syndrome in adults: diagnosis and management. Am Fam Physician. 2009;80(10): 1129-1134.

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ÂÂ ÂÂ

ÂÂ ÂÂ

812

Formula of 80 for Managing Lipids Keep HDL ‘good’ cholesterol below 40 mg/dL (half of 80) Keep TG below 160 mg/dL (twice of 80) Formula of 1 for Diabetes 1% reduction in cholesterol reduces chances of heart attack by 2% 1% reduction in HDL ‘good’ cholesterol increases chances of heart attack by 3%

IJCP Sutra 8: For patients age ≤60 years with an embolic-appearing cryptogenic ischemic stroke who have a patent foramen ovale (PFO) with a rightto-left shunt detected by bubble study do percutaneous PFO closure in addition to antiplatelet therapy, rather than antiplatelet therapy alone. N Engl J Med. 2017;377:1022.

American Family Physician

Practice Guidelines American Academy of Pediatrics Releases Report on Infantile Hemangiomas Infantile hemangiomas, the most common tumors of childhood, are vascular neoplasms characterized by abnormal proliferation of endothelial cells and aberrant blood vessel architecture. The incidence of infantile hemangiomas is approximately 5%. Congenital hemangiomas are biologically and behaviorally distinct from infantile hemangiomas because they are fully grown at birth and can be rapidly involuting or noninvoluting. The American Academy of Pediatrics has published this report to provide an update on diagnosing and managing infantile hemangiomas.

Clinical Presentation Infantile hemangiomas usually appear by four weeks of age and stop enlarging by five months of age. During the involution phase, which is usually complete by four years of age, the lesions flatten, shrink, and fade.

Up to 70% of infantile hemangiomas lead to residual skin changes, including telangiectasia, fibrofatty tissue, redundant skin, atrophy, dyspigmentation, and scarring.

Management Complications can include ulceration, bleeding, feeding problems if there is a perioral or digestive lesion, and visual impairment including ptosis, amblyopia, and astigmatism. Segmental hemangiomas are more likely to lead to complications, and facial hemangiomas are more complicated than nonfacial hemangiomas.

Imaging is not usually necessary, but ultrasonography is the preferred initial modality if indicated.

Interventions are needed if the patient has a lifethreatening condition, an existing or imminent functional impairment, pain, or bleeding. Patients should be evaluated for structural anomalies. Elective treatment may be performed to reduce the likelihood of disfigurement. The management of ulcerative infantile hemangiomas focuses on wound care, controlling pain, controlling growth, and preventing and treating secondary infections.

Medical Therapy Systemic corticosteroids were the mainstay of treatment until 2008 when improvement with beta-blocker therapy was reported. The U.S. Food and Drug Administration has approved the oral beta blocker propranolol for the treatment of infantile hemangiomas. A consensus report recommends initiating propranolol in a clinical setting, with cardiovascular monitoring every hour for the first two hours and repeated monitoring with dosage increases of more than 0.5 mg per kg per day for infants older than eight weeks. Inpatient initiation should be considered for infants younger than eight weeks or with a postconceptual age of less than 48 weeks and for infants with risk factors.

Corticosteroids are an alternative therapy if propranolol cannot be used or is not effective. Most studies support oral prednisolone or prednisone, 2 to 3 mg per kg per day as a single morning dose. Several months of corticosteroid therapy are often needed, and treatment is usually more successful when initiated during the proliferative phase. Intralesional steroid injections can be effective for small, bulky, well-localized infantile hemangiomas.

Surgery Laser therapy may be useful in treating early lesions or residual telangiectasia. Resection of a proliferating infantile hemangioma generally is not recommended in infancy because younger patients have a higher risk of surgery complications. Delaying surgery until after infancy also allows for involution and better outcomes. Most infantile hemangiomas do not improve significantly after four years of age; therefore, surgery by this age allows for correction before self-esteem and long-term memory are well established. Indications for resection in infants include failure of other therapy for a critical infantile hemangioma, a focal lesion in a favorable location, or elective surgery leaving a scar that would be the same if the lesion were removed after involution.

Source: Adapted from Am Fam Physician. 2016;93(6):526-527.

IJCP Sutra 9: For patients with mild to moderate treatment resistant major depression, augment the initial antidepressant with a second drug and/or psychotherapy, rather than other strategies such as switching antidepressants or switching from pharmacotherapy to psychotherapy. JAMA. 2017;318:132.

813

American Family Physician

Photo Quiz Diffuse, Hyperpigmented Rash in an Adult A 58-year-old man presented with generalized pruritus and an erythematous rash across his trunk, back, and extremities, including his palms and soles. The rash was not painful. Because of memory difficulties, he could not recall when the rash first appeared. He had no recent illness or fever. He had recently been evaluated for ataxia, upper extremity tremors, and hearing loss, and was presumed to have Parkinson disease. His medical history was significant for past alcohol abuse and placement of a pacemaker. He did not use intravenous drugs, and his wife was his only sex partner over the previous 16 years. He had areas of hypopigmentation across his distal extremities that were previously diagnosed as vitiligo.

On physical examination, he was confused and had difficulty hearing. He was afebrile. The skin examination revealed an erythematous, flat, maculopapular rash (Figures 1 and 2). There was no involvement of the gingiva or oral mucosa. Excoriations were present with areas of desquamation on the buttocks.

Figure 1.

Question Based on the patientâ&#x20AC;&#x2122;s history and physical examination findings, which one of the following is the most likely diagnosis?

A. Erythema multiforme.

B. Neurocutaneous manifestation of syphilis.

C. Septic emboli from infective endocarditis.

D. Stevens-Johnson syndrome.

E. Subacute cutaneous lupus erythematosus.

Figure 2.

See the following page for discussion.

Source: Adapted from Am Fam Physician. 2016;93(6):513-514.

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IJCP Sutra 10: For patients with chronic HCV genotype 1 infection who have not been previously treated with sofosbuvir or an NS5A inhibitor, give ledipasvir-sofosbuvir, sofosbuvir-velpatasvir, or glecaprevir-pibrentasvir. 52nd Annual Meeting of the European Association for the Study of the Liver (EASL), Amsterdam, The Netherlands, April 19-23, 2017.

American Family Physician Discussion The answer is B: neurocutaneous manifestation of syphilis. Neurologic and cutaneous manifestations are consistent with secondary syphilis. The clinical findings of secondary syphilis can vary greatly, but skin manifestations are most common.1 They are typically well-defined, small, erythematous, and hyperpigmented macules that may become generalized. The presentation evolves to include a more widespread papulosquamous eruption that can involve the trunk, extremities, and palmar and plantar surfaces.2 Acral involvement of papulosquamous lesions should be considered features of secondary syphilis until proven otherwise.2 The cutaneous findings of secondary syphilis typically occur two to eight weeks after the appearance of a painless primary genital chancre3 and result from dissemination of the infective spirochete. There has been an increase in prevalence of primary and secondary syphilis in recent years because of coinfection with human immunodeficiency virus.

Other symptoms of secondary syphilis include lowgrade fever, malaise, headaches, painless adenopathy, conjunctivitis, and arthralgias.2 The central nervous system may become involved in 40% of cases because of early spirochetemia.3 Diagnosis is made through a combination of serologic testing, with nontreponemal antigen testing and treponemal antigen confirmation.4 This patientâ&#x20AC;&#x2122;s presentation of a rash with recent neurologic changes suggests syphilis. Laboratory results included positive findings on plasma reagin and human immunodeficiency virus antibody testing. A lumbar puncture was also performed and revealed Venereal Disease Research Laboratories titers of 1:128, which is consistent with neurosyphilis.

Erythema multiforme is an acute inflammatory reaction that typically presents as targetoid or ringlike lesions on the extremities with occasional involvement of the palms and soles. It may also include mucocutaneous erosions or bullae. The target lesions usually appear within approximately a 72-hour period, remain fixed, and then show signs of healing. Erythema multiforme usually occurs after an infection and has a benign course.5 Septic emboli are most commonly associated with vegetations on the mitral valve and typically present with fever. Skin findings may include palpable purpura, petechiae, and nodular lesions (Osler nodes and Janeway lesions). These are considered pathognomonic for bacterial endocarditis.6

Summary Table Condition

Characteristics

Erythema multiforme

Targetoid or ringlike lesions on the extremities, with occasional involvement of the palms and soles; various stages of healing

Secondary syphilis

Maculopapular rash involving the trunk and extremities, including the palms and soles; rash develops after the appearance of the painless primary genital chancre

Septic emboli

Palpable purpura, petechiae, and nodular lesions (Osler nodes and Janeway lesions)

Stevens-Johnson F u l l - t h i c k n e s s d e s q u a m a t i o n a n d syndrome mucocutaneous blistering; purpuric papules that progress to epidermal necrosis Subacute cutaneous lupus

Erythematous macules or plaques on sunexposed skin; progression to hyperkeratotic papulosquamous or annular plaques, with gray-white hypopigmentation and telangiectasis

Stevens-Johnson syndrome is a severe, acute mucocutaneous eruption often caused by use of medications, such as sulfonamide antibiotics, allopurinol, nonsteroidal anti-inflammatory drugs, and antiepileptic drugs (phenytoin, carbamazepine, and lamotrigine). The syndrome causes pruritic papules on the face, neck, and central trunk,7 and the palms and soles may be involved. The hallmark is full-thickness epidermal necrosis with resultant desquamation and mucocutaneous blistering. If skin detachment involves more than 30% of the body surface area, the reaction is called toxic epidermal necrolysis.8 Subacute cutaneous lupus erythematosus is a subtype of lupus erythematosus with erythematous macules or plaques on sun-exposed skin (upper back, shoulders, extensor aspects of the arms). These lesions can evolve into hyperkeratotic papulosquamous or annular plaques, with gray-white hypopigmentation and telangiectasis.9 REFERENCES 1. Pleimes M, et al. Malignant syphilis with ocular involvement and organism-depleted lesions. Clin Infect Dis. 2009;48(1):83-85.

2. Balagula Y, Mattei PL, Wisco OJ, Erdag G, Chien AL. The great imitator revisited. Int J Dermatol. 2014;53(12): 1434-1441.

3. Ahsan S, Burrascano J. Neurosyphilis: an unresolved case of meningitis. Case Rep Infect Dis. 2015;2015:634259.

IJCP Sutra 11: For patients with a presumptive diagnosis of acquired TTP administer rituximab as a component of initial therapy. Blood Adv. 2017;1:1159.

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Indian Journal of Clinical Practice, Vol. 28, No. 9, February 2018 4. Workowski KA, Bolan GA. Sexually transmitted diseases treatment guidelines, 2015 [published correction appears in MMWR Recomm Rep. 2015;64(33):924]. MMWR Recomm Rep. 2015;64(RR-03):1-137.

5. Roujeau JC, Stern RS. Severe adverse cutaneous reactions to drugs. N Engl J Med. 1994;331(19):1272-1285.

6. Pierce D, Calkins B, Thornton K. Infectious endocarditis: diagnosis and treatment. Am Fam Physician.

2012;85(10):981-986.

7. Fritsch PO, Sidoroff A. Drug-induced Stevens-Johnson syndrome/toxic epidermal necrolysis. Am J Clin Dermatol.

2000;1(6):349-360.

8. Usatine R, Sandy N. Dermatologic emergencies. Am Fam Physician. 2010;82(7):773-780.

9. Pai VV, et al. Subacute cutaneous lupus erythematosus presenting as erythroderma. Indian J Dermatol.

2014;59(6):634.

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Make sure During Medical Practice

Situation:

A hypertensive patient on a diuretic had high serum uric acid levels >7 mg/dL.

© IJCP GROUP

Stop diuretic and start losartan.

Lesson:

Make sure to remember that losartan is a safe and efficacious agent to lower serum uric acid levels in patients with hyperuricemia. It is the only ARB that has consistently demonstrated a significant reduction in serum uric acid levels.

Ther Adv Chronic Dis. 2015;6(6):339-46.

816

IJCP Sutra 12: For patients with an asymptomatic solid or subsolid (pure ground glass or part-solid) solitary pulmonary nodule (SPN) <6 mm, no routine follow-up is required. For patients with solid SPNs that have been stable on serial CT over a two year period, or with subsolid SPNs that have been stable over a five year period do no further diagnostic testing. Radiology. 2017;284:228.

ANESTHESIOLOGY

Anesthetic Challenges for Functional MRI in Pyopagus Conjoined Twins Under TIVA ANKESH GUPTA*, SUSHIL C VERMA†, YAWAR R RATHER‡, AJIT GUPTA¥

Abstract Conjoined twins are a rare clinical presentation with an incidence of 1 in 2,50,000/live births, encountered by anesthesiologists/ clinicians is associated with challenging management. Cross-circulation, sharing of organs and other physiological aspects are to be investigated before definitive treatment is undertaken. Availability of magnetic resonance imaging (MRI) compatible twin sets of anesthesia machine are rarely available in MRI rooms in developing countries, making separate general anesthesia technique for each baby challenging. We undertook total intravenous anesthesia (TIVA) for anesthesia with oxygen supplementation of both babies with single anesthesia machine.

Keywords: Conjoined twins, pyopagus, MRI, TIVA

C

onjoined twins, especially pyopagus (1:2,50,000/ live births), a rare presentation is encountered in clinical practice with anatomical, physiological, sharing of circulation/organs and makes definitive treatment a challenge. The surgical team including an anesthesiologist have a challenge to investigate the problems before surgery/separation procedure.

Anesthesiologist has to induce anesthesia to babies on several occasions like computed tomography (CT) scan and magnetic resonance imaging (MRI), etc. Anesthetizing two babies at one go in an MRI room makes procedure dangerous and challenging since getting two MRI compatible sets of anesthetic equipment is very difficult.

In usual practice, general anesthesia with intubation is method of choice, but this case was done under total intravenous anesthesia (TIVA) with separate facemask (Fig. 1) oxygenation using single MRI compatible

anesthesia machine which through was challenging but was carried out safely and without any complication, hence this case report.

Case Report One and half month old male conjoined twins having combined weight of 6.14 kg, fixed at lower lumbar and sacral region were scheduled to undergo MRI (Fig. 2 a and b).

On examination: Babies were evaluated in preanesthetic clinic, found to have heart rate - 120/min in baby 1 and heart rates - 134/min in baby 2, having no medical comorbidity with separate external genitalia, anal openings and separate extremities. All routine preoperative investigations were within normal limits for each baby.

*Senior

Resident Indira Gandhi Institute of Medical Sciences, Patna, Bihar †Senior Resident Dr Ram Manohar Lohiya Hospital, New Delhi ‡Postgraduate Student Sri Aurobindo Institute of Medical Sciences, Indore, Mahya Pradesh ¥Professor and Head Indira Gandhi Institute of Medical Sciences, Patna, Bihar Address for correspondence Dr Ajit Gupta Professor and Head Dept. of Anesthesiology Indira Gandhi Institute of Medical Sciences, Patna, Bihar E-mail: ajpta_igims@yahoo.co.uk

818

Figure 1. Separate facemask for intravenous anesthesia using single MRI compatible anesthesia machine.

IJCP Sutra 13: For women with postpartum hemorrhage diagnosed within three hours of delivery administer tranexamic acid as a component of overall treatment. When more than three hours have elapsed since delivery add tranexamic acid. Lancet. 2017.

ANESTHESIOLOGY TIVA was planned with atropine 0.01 mg/kg i.e., (0.3Â mg), midazolam 0.05 mg/kg i.e., (0.15 mg) and ketamine 2 mg/kg i.e., (6 mg), which were taken in separate labeled syringe diluted adequately.

Babies were oxygenated with facemask and especially assembled circuit using Y-connector through open circuit of MRI compatible machine, babies breathing spontaneously. The drugs were injected separately to each baby and vitals monitored during whole procedure. There was slight change with increased heart rate and systolic blood pressure, and no change in ECG or level of oxygen saturation during the procedure. The procedure was completed in 30 minutes and no supplemental dose of drugs were needed. Postprocedure recovery was uneventful and babies were shifted to day-care.

Discussion a

There is dearth of experience in anesthesiologist practice regarding management of conjoined twins due rare incidence of conjoined of twins with diverse variety.

Most of the experience and medical literature are individual case reports. Most of the investigative procedures for detailed planning for future intervention needs team work, proper planning especially in MRI room makes anesthetist risk very high.

b

Figure 2 a and b. Conjoined twins fixed at lower lumbar and sacral region.

After parental consent for anesthetic procedures, two anesthetic teams and an MRI compatible anesthesia machine was set-up in MRI room, 24 gauge intravenous cannula was fixed in outermost upper limb of both babies.

The drugs, intubation cart, MRI compatible monitors were separately prepared and labeled. After applying the monitors, baseline oxygen saturation, ECG, noninvasive blood pressure (NIBP) temperature was noted. To check for presence of cross-circulation 0.06Â mg atropine was administered intravenously to baby 1 and heart rate was observed in baby 1, which shot up to 140/min but no change in heart rate of baby 2 showing no crosscirculation.

These investigations/diagnostic procedures are usually carried out under inhalational general anesthesia. The largest study on anesthetic management belongs to Red Cross Children Hospital, Cape Town, South Africa by Thomas and Lopez over 15 sets of conjoined twins but it was for separation surgery.

My case is also an individual case report depending upon available infrastructure and institutional preferences to use TIVA as way of management, because my patient was likely to require numerous diagnostic procedures before final separation.

There is no study over success and complication rate by using general anesthetic or isolated reports of use of TIVA as reported by Joy Sanders et al done at Childrenâ&#x20AC;&#x2122;s Hospital, Vancouver, Canada.

Considering constraints in MRI room, this was conducted under TIVA without any complications that can be utilized by anesthesiologist, as frequent use of general anesthesia can be cumbersome for short diagnostic procedures like MRI, hence the case is being reported.

IJCP Sutra 14: Do not give venom immunotherapy (VIT) to patients with reactions to stinging insects limited to cutaneous systemic symptoms and not involving other organ systems. Ann Allergy Asthma Immunol. 2017;118:28. However, VIT is effective in reducing the severity of future reactions and may still be offered in selected situations.

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Indian Journal of Clinical Practice, Vol. 28, No. 9, February 2018

Conclusion TIVA is also a modality other than general anesthesia, which can be practiced for short procedures in conjoined twins with a very safe outcome.

Suggested Reading 1. Stone JL, Goodrich JT. The craniopagus malformation: classification and implications for surgical separation.

Brain. 2006;129(Pt 5):1084-95.

2. Thomas JM, Lopez JT. Conjoined twins - the anaesthetic management of 15 sets from 1991-2002. Paediatr Anaesth.

2004;14(2):117-29.

3. Walker M, Browd SR. Craniopagus twins: embryology, classification, surgical anatomy, and separation. Childs Nerv Syst. 2004;20(8-9):554-66.

4. Wong TG, Ong BC, Ang C, Chee HL. Anesthetic management for a five-day separation of craniopagus twins. Anesth Analg. 2003;97(4):999-1002, table of contents.

5. Paganini E, Naya J. Anesthesia in surgical separation of omphalopagus conjoined twins. Acta Anesthesiol Scand.

2004,48:919-21.

6. Girshin M, Broderick C, Patel D, Chacko S, Reddy S, Staffenberg D, et al. Anesthetic management of staged separation of craniopagus conjoined twins. Paediatr Anaesth. 2006;16(3):347-51.

7. Squair J. Craniopagus: Overview and implication of sharing a brain. BJA. 2010;105:368-70.

8. Spitz L, Kiely EM. Conjoined twins. JAMA. 2003; 289(10):1307-10.

9. Sanders JM, Peiris K, Purdy R, Scheepers L. Craniopagus conjoined twins having functional MRI under TIVA. 1344067.

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Chat with Dr KK

© Dr KK Aggarwal

Never Ignore a Symptom, which is Unusual, Unexplained or Occurs for the First Time in Life

820

IJCP Sutra 15: Tax Rate: Capital gains over Rs. 1 lakh to be taxed at 10% (no indexation benefit).

CRITICAL CARE

Inadvertently Lost Cannula Sheath in External Jugular Vein: A Rare Incident SANJIV K GOYAL*, SANDEEP SINGH MAAVI†, ASHISH GARG‡, VIJAY JAGAD#

Abstract External jugular vein cannulation is frequently used method for IV access and medications in cases where there is difficulty securing IV access in extremity. It is generally a safe procedure with fairly good technical success rate. Here we discuss a case of lost cannula sheath with in the external jugular vein that was recovered successfully surgically.

Keywords: External jugular vein, cannulation, lost cannula sheath

Case Report External jugular vein (EJV) has been used for IV access in many different condition right from trauma, burns involving extremities and in conditions like sepsis. It has been proved to be valuable for providing fluid and medications to the patients in whom cannulation of extremities is found difficult. We have a case in which the patient presented to our emergency department with chief complaints of pain in abdomen and vomiting for past 3 days.

On presentation, patient was dehydrated and was in shock. Multiple attempts were made for securing IV access over the extremities but were all futile. Plan was to insert a wide bore cannula in right EJV for fluid resuscitation and for giving medication. Patient was shifted to intensive treatment unit (ITU).

On further blood investigation and CT scan, it was revealed that patient was suffering from acute necrotizing pancreatitis. Patient was managed with fluid resuscitation, nil per mouth and IV antibiotics.

On third day of admission, on examination of the neck, it was revealed that the cannula inserted in right EJV

*Consultant General Surgeon †Senior Resident in General Surgery ‡Consultant Critical Care Medicine #Consultant Surgical Oncologist Grecian Superspeciality Hospital, Mohali, Punjab Address for correspondence Dr Sanjiv Goyal Flat No. 004, Tower No. 22, Royale Estate, Chandigarh Ambala Highway, Zirakpur - 140 603, Punjab E-mail: sanjivgoyal92@yahoo.in

had fractured at the junction with the port site and complete sheath of the cannula had got lost in EJV. Ultrasound on the local area was done and that revealed a well-defined linear artefact with parallel echogenic lines, of approximate size 3.9 cm, in distal part of right EJV with thrombus in the surrounding region, upper part of the right EJV was normal. This was suggestive of broken catheter with thrombus in EJV. After discussion, it was decided to explore under general anesthesia. Patient was taken to the operation theater and after giving general anesthesia, part was painted and draped, transverse neck skin incision was given, flaps raised and the right EJV located (Fig. 1).

Phlebotomy done and cannula sheath removed safely (Fig. 2). Complete hemostasis was achieved and skin was closed with staplers. Patient was then inserted central venous line in left subclavian vein. She was managed in ITU for another 4 days and after complete resolution of pancreatitis, she was shifted to general ward and discharged form there after 2 days.

Figure 1. Cannula sheath within the right EJV seen at exploration.

IJCP Sutra 16: Any notional gains till Jan 31, 2018 are proposed to be exempted in calculations for long-term capital gains.

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Indian Journal of Clinical Practice, Vol. 28, No. 9, February 2018

Hematoma, infection, air embolism and subcutaneous infiltration of drug are among the top in the list. Here we report a patient who had undergone EJV cannulation for IV access and had cannula fractured with the complete sheath within the right EJV. With ultrasound guidance, the sheath was confirmed within the right EJV. Under general anesthesia, local exploration was done and the sheath was recovered. Patient tolerated the procedure well and after resolving her pancreatitis issue, she was discharged home.

Figure 2. Extracted cannula sheath.

Conclusion

Discussion

EJV has been tried and tested method for IV access.

It is tolerated well in most of the patients with few complications to be kept in mind. Daily vigilance and proper technique helps to reduce the complications rate associated with it.

EJV has long been used as access for fluid resuscitation and drug administration in indoor patients.1 Cannulation of EJV is generally done under conditions where peripheral IV access to the extremities is difficult such as in cases of shock, extremity trauma or burns involving extremity.2 Cannulation of EJV is pretty easy and especially right side is used, usually 16 or 18 gauge canula is inserted for access. The technical success rate has ranged from 70% to 90%.3 There are certain contraindications of EJV cannulation such as agitated and uncooperative patient, patient with short neck or with neck mass, patient having continuous vomiting.

EJV cannulation is not a fully safe procedure, there have been multiple complication associated with it.

References 1. Scales K. Intravenous therapy: a guide to good practice. Br J Nurs. 2008;17(19):S4-S12.

2. Uvelin A, Kolak R, Putnik D. External jugular cannulation is irreplaceable in many situations. Resuscitation.

2010;81(6):773; author reply 774.

3. Chakravarthy M, Krishnamoorthy J, Nallam S, Kolur N, Faris A, Reddy K, et al. External jugular venous route for central venous access: our experience in 563 surgical patients. J Anesth Clin Res. 2011;2:144.

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IJCP Sutra 17: All dividends received after April 1 2018, to be taxed at 10% (payable by the AMC). Not taxed in the hands of recipient.

CLINICAL PHYSIOLOGY

Some Facts About Cellular Oxygenation and Daily Life KK Aggarwal*, S sharma†

Abstract Oxygen is the most vital nutrient for our bodies. The human body can live days without water, weeks without food, but only minutes without oxygen. Without a continuous, proper supply of oxygen our body's internal organs begin to degrade, become diseased and age fast. This review discusses various aspects of cellular oxygenation and daily life. These include various measures of oxygenation like SaO2, SpO2, PaO2 and the 6-minute walk test (6MWT), oxygen requirement during exercise, oxygen requirement in pregnancy, oxygen levels during sleep, role of oxygen therapy in COPD and dangers of oxygen toxicity and hyperoxia, which occur during administration of supplemental oxygen to treat hypoxemia. Also, touched upon are usefulness of oxygen bars and the role of 6MWT in evaluating ambulatory oxygen therapy.

Keywords: Cellular oxygenation, 6-minute walk test, oxygen therapy, oxygen toxicity, hyperoxia

O

xygen is essential for life. One cannot live without air or oxygen for more than 3 minutes.

The air we breathe contains about 21% oxygen.

The other gases in air are 78.09% nitrogen, 0.93% argon, 0.04% carbon dioxide and small amounts of other gases.

The amount of oxygen inhaled during each breath depends on the percentage of oxygen in the inspired air and the ambient pressure.

The partial pressure of inspired oxygen (PiO2) can be calculated as PiO2 = FiO2 × (Patm - pH2O), where ÂÂ

FiO2 is the fraction of inspired oxygen (0.21 in atmospheric air)

ÂÂ

Patm is the atmospheric pressure (760 mmHg at sea level)

ÂÂ

pH2O is the partial pressure of water (47 mmHg at 37°C).

Reduction in the PiO2 will decrease the alveolar partial pressure of oxygen (PaO2). A lower PaO2 impairs oxygen diffusion by decreasing the oxygen gradient from the alveolus to the artery. The net effect is a lower arterial PaO2, which may reach the level of hypoxemia.

*Group Editor-in-Chief, IJCP Group †Editor, IJCP Group

Measures of Oxygenation

SaO2 and SpO2 The amount of oxygen in the blood is the oxygen saturation level. If it is measured by a pulse oximeter, it is termed SpO2. If it is measured directly from an arterial blood sample, it is called SaO2.1 A healthy individual has an arterial oxygen saturation of 95% at rest.

SpO2 value less than 90% at rest or exertional decreases of 5% are abnormal, while in pregnancy, SpO2 value less than 95% is taken as abnormal. A value of SpO2 ≤88% is generally an indication for supplemental oxygen.

PaO2 PaO2 is the partial pressure of oxygen in the blood. It is the amount of oxygen dissolved in the plasma, which is measured by arterial blood gas.

Factors that are needed to continuously supply cells and tissues in body with oxygen are as follows: ÂÂ

Enough oxygen in the air

ÂÂ

Adequate lung capacity to be able to inhale the oxygen-containing air and exhale carbon dioxide

ÂÂ

Normal hemoglobin (Hb) and normal pumping function of the heart to be able to circulate blood to your lungs, take up the oxygen and carry it throughout your body.

Hypoxemia is a condition when the PaO2 is below normal (<80-100 mmHg). Hypoxemia is not the same as hypoxia, which is failure of oxygenation at tissue level.2

IJCP Sutra 18: Set off under 54EC now only available for long-term capital asset being land or building or both.

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Indian Journal of Clinical Practice, Vol. 28, No. 9, February 2018

Six-minute Walk Test The 6-minute walk test (6MWT) measures the distance that a patient can quickly walk in a period of 6 minutes on a hard, flat surface.3 This test is a good index of physical function and therapeutic response in patients with chronic lung disease, such as chronic obstructive pulmonary disease (COPD), pulmonary fibrosis or pulmonary arterial hypertension.4,5 In patients with interstitial lung disease, desaturation during a 6MWT is an important prognostic indicator.6 A healthy person can typically walk 400-700 m in a 6MWT. An improvement of about 30 m in distance walked is the minimally important difference.7,8 The 6MWT is done when the resting oxygen saturation is between 92% and 95% and the person is symptomatic.

Cellular Oxygen Glucose (C6H12O6) combines with 6 molecules of oxygen to form 6 molecules of carbon dioxide, 6 molecules of water and 36 adenosine triphosphate (ATPs) in the mitochondria in a process called cellular respiration.

ATP is the energy used by the cell to perform various functions. Therefore, mitochondria can be called powerhouses of cells. This cellular energy is dependent on oxygen.

Cellular hypoxia will deplete the energy and ATP needed for body functioning. Cellular hypoxia has also been linked with defective apoptosis and autophagy and vulnerability to cancer.

In critically ill patients such as those with acute respiratory distress syndrome (ARDS), sepsis or septic shock, metabolic demand is increased. Hence, oxygen consumption (VO2) increases as more oxygen is required to maintain aerobic cellular metabolism.

The relationship between oxygen delivery (DO2) and VO2 in critically ill patients is similar to that in healthy persons during conditions of increased metabolic demand e.g., exercise, pregnancy.

Oxygen Requirement During Exercise Skeletal muscle metabolism can rise quickly up to 50 times its resting rate during heavy exercise. This is achieved by increases in minute ventilation, cardiac output and systemic oxygen extraction along with microvascular adaptations that increase oxygen delivery to the muscles.

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During exercise, ventilation may increase from 5 to 6 L/min at rest to >100 L/min. In an average young male, resting oxygen consumption is about 250 mL/min and in an endurance athlete, oxygen consumption during very high intensity exercise may be 5,000 mL/min,9 i.e., oxygen consumption increases up to 20 times during high intensity/strenuous exercise in comparison to rest.

In patients with idiopathic pulmonary fibrosis, supplementation of oxygen significantly improved exercise-induced hypoxemia and also reduced exerciserelated dyspnea leading to greater endurance capacity during exercise.10 Oxygen Requirement in Pregnancy Oxygen consumption during pregnancy increases by almost 20%. Beginning in the first trimester, increases in tidal volume and respiratory drive caused by increased progesterone levels cause hyperventilation and a chronic respiratory alkalosis. The partial pressure of oxygen or PaO2 may be slightly increased at 104-108 mmHg as a result of the increase in carbon monoxide and minimization of the ventilation-perfusion mismatch in the lung. The upward displacement of the diaphragm at around 20 weeks of gestation, leads to a 20% decrease in functional residual capacity.

Maternal oxygen saturation during pregnancy should be maintained at a value more than 95%, which is in excess of the oxygen delivery needs of the mother. If arterial oxygen saturation (SaO2) falls below 95%, an arterial blood gas (ABG) is obtained to measure PaO2.

A PaO2 value >70 mmHg is desirable to maintain a favorable oxygen diffusion gradient from the maternal to the fetal side of the placenta.

Oxygen supplementation should be used liberally whenever in doubt because anoxia develops more quickly in pregnant women.

Intrauterine hypoxia becomes important during the second and third trimester of pregnancy when fetal growth occurs.11 Fetal hypoxia causes intrauterine growth restriction (IUGR) and low birth weight, and is associated with prematurity and infant mortality.12 Maternal hypoxia during pregnancy may also cause neurodevelopmental brain damage in the fetus.13 Recently, it has been suggested that hypoxia in early pregnancy may increase the risk for congenital malformations.11 Oxygen Levels During Sleep Blood oxygen levels are lower during sleep in all individuals due to reduced breathing. If the waking

IJCP Sutra 19: Corporate Tax Rates reduced to 25% for corporates with turnover below Rs 250 crores in FY 2016-17.

CLINICAL PHYSIOLOGY oxygen saturation is greater than about 94% on room air, then saturation during sleep is not likely to fall below 88%.14 However, adequate oxygen during sleep has to be ensured in certain conditions as follows: ÂÂ

Supplemental oxygen during sleep, along with positive airway pressure, is indicated in patients with central sleep apnea with Cheyne-Stokes breathing who have hypoxemia during sleep.15

ÂÂ

Supplemental oxygen alone during sleep is indicated in patients who do not tolerate positive airway pressure therapy.

Low flow nocturnal oxygen (2-3 L/min) reduces Cheyne-Stokes breathing and improves left ventricular function, heart failure functional class, quality of sleep and cognitive function.16-24 Relative reduction in apnea-hypopnea index (snoring with apnea) (AHI) is achieved by nocturnal oxygen ranging from 30% to 80% of baseline.18 AHI is used to define the severity of sleep apnea. It is the number of episodes of apnea and hypopnea per hour of sleep. It is generally expressed as the number of events per hour.

In a study of 36 ambulatory male patients with heart failure, the mean AHI decreased significantly from 49 to 29 events per hour with oxygen treatment.25 In two small studies that compared nocturnal oxygen with continuous positive airway pressure (CPAP) (19 total patients), both therapies were effective compared with baseline and the magnitude of the reduction in AHI was similar between groups.26,27

and endothelial dysfunction in these patients32 putting them at higher risk of heart diseases such as systemic hypertension, pulmonary arterial hypertension, coronary artery disease, cardiac arrhythmias, heart failure and stroke.

Sleep apnea is also often associated with neurocognitive impairment manifesting as deficits in reasoning, attention, vigilance, learning and memory.33 Role of Oxygen Therapy in COPD According to the American Lung Association, oxygen therapy is needed in COPD when lung function is reduced to such a degree that it interferes with normal bodily functions and the ability to maintain or increase activity.34 Alveolar hypoxia and the resultant hypoxemia increase as the severity of disease increases. Hypoxemia in COPD reduces quality-of-life, exercise tolerance, skeletal muscle function and increases risk of death.

Complications such as pulmonary hypertension, secondary polycythemia may result.35 The indications of oxygen supplementation differ in COPD patients according to the severity of the disease.

Long-term oxygen therapy is indicated in: ÂÂ

All patients with severe COPD who have chronic hypoxemia, defined as a resting PaO2 ≤55 mmHg (7.33 kPa) or pulse oxygen saturation (SpO2) ≤88%.36

ÂÂ

Patients with moderate COPD who had either a SpO2 89-93% at rest, or oxygen desaturation during a 6MWT to <90% for ≥10 seconds, but not <80% for ≥15 seconds.37

Nocturnal supplemental oxygen is used to temporarily treat patients with severe hypoxemia (low oxygen levels in blood) associated with obstructive sleep apnea (OSA) until definitive therapy can be provided, as well as to support patients with medical complications who are poor candidates for surgical treatment and are unable to tolerate or use positive airway pressure.28,29

In patient with mild COPD, oxygen supplementation is indicated in patients with resting hypoxemia or exercise-induced hypoxemia.38

The typical flow setting of 2 L/min increases FiO2 to about 27-28%. Though this is a small amount of oxygen enrichment, it adequately corrects hypoxemia in most patients during rest, particularly patients with COPD.30 The FiO2 increases by about 4% with each additional L/min.

Oxygen toxicity may occur during administration of supplemental oxygen to treat hypoxemia. Hyperoxia is a condition of excess supply of oxygen in tissues and organs.40 The PaO2 is significantly raised when FiO2 is greater than 21% of atmospheric pressure. The increased oxygen tension in blood, alveoli or at the cellular level may result in adverse events.

Intermittent hypoxia is a major pathophysiological characteristic of OSA.31 Hypoxic stress leads to sympathetic activation, systemic inflammation, impaired glucose and lipid metabolism

IJCP Sutra 20: Education Cess increased from 3% to 4%.

Supplemental oxygen improves exercise tolerance of normoxemic and hypoxemic COPD patients.39 Oxygen Toxicity and Hyperoxia

Hyperoxia may cause cellular injury via increased production of reactive oxygen intermediates (ROIs) - the superoxide anion, the hydroxyl radical and

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Indian Journal of Clinical Practice, Vol. 28, No. 9, February 2018

hydrogen peroxide.41,42 When production of ROIs increases and/or the antioxidant defenses of the cell are depleted, they can react with and impair the function of essential intracellular macromolecules leading to cellular death.43 The FiO2 should be titrated to the lowest concentration required to meet oxygenation goals. One should aim for an arterial oxygen tension (PaO2) between 60 and 70 mmHg and oxygen saturation between 90% and 93%.

Any increase in PaO2 beyond this does not add much to the oxygen content of the blood.

If the patient does not have significant hypoxemia at rest (SpO2 <88%), they may not be suitable candidates for oxygen supplementation.

In hospital settings, 100% oxygen may be delivered, but only for less than 24 hours and preferably less than 12 hours. Breathing pure oxygen for duration longer than this can results in toxicity, including ARDS, also known as shock lung, a life-threatening condition.

Oxygen Bars There is a trend for oxygen bars now, which offer oxygen for recreational use, but not medical use.

Customers pay to inhale oxygen delivered through a mask worn over the face for a fixed period of time. The benefits of recreational oxygen have been described as a decrease in stress and increase in relaxation and energy.44 The concentration of oxygen provided in oxygen bars is less 40%.

Is there any scientific rationale to these oxygen bars?

According to the American Lung Association, inhaling oxygen at oxygen bars is unlikely to have a beneficial physiological effect, but also says “there is no evidence that oxygen at the low flow levels used in bars can be dangerous to a normal person’s health”. Though people with certain medical conditions such as some types of heart disease, asthma, congestive heart failure, pulmonary hypertension, COPD need supplemental oxygen, they should avoid oxygen bars. Use of “flavored” oxygen, especially aroma oils, in oxygen bars is another major concern expressed by the US Food and Drug Administration (FDA).45 Proponents of oxygen “therapy” debate that it boosts cellular oxygen on the lines of Pranayama (deep breathing which increases lung volumes and stimulates cellular oxygen leading to generation of more ATP in the mitochondria), which increases endurance during exercise, facilitates quicker recovery from physical exertion, provides relief from stress and pollution,

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IJCP Sutra 21: No mention of Inheritance Tax or changes to Gift Tax.

increases concentration, helps relaxing and eases headaches and hangovers.

However, in a study, the use of oxygen bars for 10 minutes was not found to have an effect on subject’s energy, relaxation or stress levels. But, no study has been done on its efficacy when used for more than 10 minutes.44 Role of 6MWT in Evaluating Ambulatory Oxygen Therapy The 6MWT is an effective method for detecting desaturation during activities of daily living and for establishing the oxygen flow needed to correct exerciseinduced desaturation.46 Oxygen during exercise is used if the distance walked by COPD patients in 6 minutes increases with oxygen.47,48 Patients with COPD who undergo rapid or early desaturation (<1 minute) during the 6MWT have major clinical repercussions than those with late-onset desaturation.49 Only the early desaturators or patients who exhibit desaturation within the first minute of the walk test, also experience desaturation during their daily activities, while, the late desaturators or patients who desaturate past 3.5 minutes, do not undergo desaturation in their daily life activities.49 Early desaturators will require long-term oxygen therapy sooner than the late-onset group. These patients will benefit from ambulatory oxygen therapy, as they will desaturate during their activities of daily living.

Late-onset desaturators will not experience oxygen desaturation in their daily lives. Hence, they would not benefit from oxygen therapy while walking around.

However, depending on the individual case and their activity, those intermediate desaturators—with an onset between 1 and 3.5 min—may go through desaturation at home.49 Is pollution linked to oxygen levels?

Increase in levels of ambient pollutants is associated with reduced oxygen saturation and increased risk of respiratory and cardiovascular morbidity.50 The reduction in oxygen saturation associated with air pollution may result from subtle particulate-related pulmonary vascular and/or inflammatory changes.51 In pollution, carbon monoxide enters the bloodstream through the lungs and binds to hemoglobin leading to cellular hypoxia. People with cardiovascular symptoms, such as coronary artery disease, are most at risk. They may experience chest pain and other cardiovascular

CLINICAL PHYSIOLOGY symptoms if they are exposed to carbon monoxide, particularly while exercising. People with marginal or compromised cardiovascular and respiratory systems (congestive heart failure, cerebrovascular disease, anemia or COPD and possible young infants and fetuses), also may be at greater risk from carbon monoxide pollution.

Inhalational exposure to particulate air pollutants decreases heart rate variability, causes ST-segment depression and endothelial dysfunction, increases blood pressure and blood coagulability, and accelerates the progression of atherosclerosis.52 ÂÂ

Short-term exposure to high levels of PM10 and PM2.5 was associated with increased risk of CHD outpatient and emergency department visits.

Season, gender and age were effect modifiers of their association.53

Mechanisms of air pollution-induced cardiotoxicity include increased generation of reactive oxygen species followed by activation of proinflammatory and prothrombotic pathways.52 ÂÂ

Increased exposure to air pollution, including the nontraffic sulfate (SO4-2) from industrial sources in elderly patients, decreases oxygen saturation. An increase of 13.4 μg/m in PM2.5 is associated with a decrease of -0.18% and a 5.1 μg/m3 increase in SO4-2 is associated with a decrease of -0.16% in oxygen saturation during the initial 5-minute rest period.50

Mean pollution concentration (PM 2.5) was associated with reduced oxygen saturation during the baseline rest period, post-exercise with a trend toward decrease during post-exercise paced breathing, but not during exercise. Participants taking β-blockers have a greater pollution-related decrease in oxygen saturation at rest.51 Exposure to particulate pollution was not significantly associated with oxygen saturation (SpO2) except in male participants 80 years of age or older. Increased daily pulse rate, as also the odds of having pulse rate 5 or 10 beats/min above normal are significantly associated with exposure to particulate pollution on the previous 1-5 days.54 A 100 µg/m3 increase in PM10 the previous day is associated with an average increase of 0.8 beats/ min and 29 and 95% increased odds of the pulse rate being elevated by 5 or 10 beats/min, respectively.55

BTS guideline for oxygen use in adults in healthcare and emergency settings. Thorax. 2017;72(Suppl 1): ii1-ii90.

2. Samuel J, Franklin C. Hypoxemia and hypoxia. In: Myers JA, Millikan KW, Saclarides TJ (Eds.). Common Surgical Diseases. New York, NY: Springer; 2008. pp. 391-4.

3. ATS Committee on Proficiency Standards for Clinical Pulmonary Function Laboratories. ATS statement: guidelines for the six-minute walk test. Am J Respir Crit Care Med. 2002;166(1):111-7.

4. Pellegrino R, Viegi G, Brusasco V, Crapo RO, Burgos F, Casaburi R, et al. Interpretative strategies for lung function tests. Eur Respir J. 2005;26(5):948-68.

5. Singh SJ, Puhan MA, Andrianopoulos V, Hernandes NA, Mitchell KE, Hill CJ, et al. An official systematic review of the European Respiratory Society/American Thoracic Society: measurement properties of field walking tests in chronic respiratory disease. Eur Respir J. 2014;44(6): 1447-78.

6. Rasekaba T, Lee AL, Naughton MT. The six-minute walk test: a useful metric for the cardiopulmonary patient.

Intern Med J. 2009;39(8):495-501.

7. Swigris JJ, Wamboldt FS, Behr J, du Bois RM, King TE, Raghu G, et al. The 6 minute walk in idiopathic pulmonary fibrosis: longitudinal changes and minimum important difference. Thorax. 2010;65(2):173-7.

8. du Bois RM, Weycker D, Albera C, Bradford WZ, Costabel U, Kartashov A, et al. Six-minute-walk test in idiopathic pulmonary fibrosis: test validation and minimal clinically important difference. Am J Respir Crit Care Med. 2011;183(9):1231-7.

9. Burton DA, Stokes K, Hall GM. Physiological effects of exercise. Continuing Education in Anaesthesia Critical Care & Pain. 2004;4(6):185-8.

10. Dowman LM, McDonald CF, Bozinovski S, Vlahos R, Gillies R, Pouniotis D, et al. Greater endurance capacity and improved dyspnoea with acute oxygen supplementation in idiopathic pulmonary fibrosis patients without resting hypoxaemia. Respirology. 2017;22(5):957-64.

11. Hutter D, Kingdom J, Jaeggi E. Causes and mechanisms of intrauterine hypoxia and its impact on the fetal cardiovascular system: a review. Int J Pediatr.

2010;2010:401323.

12. Ream M, Ray AM, Chandra R, Chikaraishi DM. Early fetal hypoxia leads to growth restriction and myocardial thinning. Am J Physiol Regul Integr Comp Physiol.

2008;295(2):R583-95.

References

13. Golan H, Kashtuzki I, Hallak M, Sorokin Y, Huleihel M. Maternal hypoxia during pregnancy induces fetal neurodevelopmental brain damage: partial protection by magnesium sulfate. J Neurosci Res. 2004;78(3):430-41.

1. O'Driscoll BR, Howard LS, Earis J, Mak V; British Thoracic Society Emergency Oxygen Guideline Group; BTS Emergency Oxygen Guideline Development Group.

14. The need for supplemental oxygen. Available at: https:// www.ucsfhealth.org/education/supplemental_oxygen/ the_need_for_supplemental_oxygen/

IJCP Sutra 22: Salaried taxpayers: Standard deduction up to Rs. 40,000 per annum.

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Indian Journal of Clinical Practice, Vol. 28, No. 9, February 2018 15. Aurora RN, Chowdhuri S, Ramar K, Bista SR, Casey KR, Lamm CI, et al. The treatment of central sleep apnea syndromes in adults: practice parameters with an evidence-based literature review and meta-analyses.

Sleep. 2012;35(1):17-40.

16. Hanly PJ, Millar TW, Steljes DG, Baert R, Frais MA, Kryger MH. The effect of oxygen on respiration and sleep in patients with congestive heart failure. Ann Intern Med. 1989;111(10):777-82.

17. Walsh JT, Andrews R, Starling R, Cowley AJ, Johnston ID, Kinnear WJ. Effects of captopril and oxygen on sleep apnoea in patients with mild to moderate congestive cardiac failure. Br Heart J. 1995;73(3):237-41.

18. Bordier P, Lataste A, Hofmann P, Robert F, Bourenane G. Nocturnal oxygen therapy in patients with chronic heart failure and sleep apnea: a systematic review. Sleep Med. 2016;17:149-57.

19. Andreas S, Clemens C, Sandholzer H, Figulla HR, Kreuzer H. Improvement of exercise capacity with treatment of Cheyne-Stokes respiration in patients with congestive heart failure. J Am Coll Cardiol. 1996;27(6):1486-90.

20. Sasayama S, Izumi T, Seino Y, Ueshima K, Asanoi H; CHFHOT Study Group. Effects of nocturnal oxygen therapy on outcome measures in patients with chronic heart failure and Cheyne-Stokes respiration. Circ J. 2006;70(1):1-7.

21. Krachman SL, Nugent T, Crocetti J, D'Alonzo GE, Chatila W. Effects of oxygen therapy on left ventricular function in patients with Cheyne-Stokes respiration and congestive heart failure. J Clin Sleep Med. 2005;1(3):271-6.

22. Staniforth AD, Kinnear WJ, Starling R. Effect of oxygen on sleep quality, cognitive function and sympathetic activity in patients with chronic heart failure and Cheyne-Stokes respiration. Eur Heart J. 1998;19(6):922-8.

28. Marcus CL, Carroll JL, Bamford O, Pyzik P, Loughlin GM. Supplemental oxygen during sleep in children with sleep-disordered breathing. Am J Respir Crit Care Med. 1995;152(4 Pt 1):1297-301.

29. Aljadeff G, Gozal D, Bailey-Wahl SL, Burrell B, Keens TG, Ward SL. Effects of overnight supplemental oxygen in obstructive sleep apnea in children. Am J Respir Crit Care Med. 1996;153(1):51-5.

30. Mithoefer JC, Keighley JF, Karetzky MS. Response of the arterial PO2 to oxygen administration in chronic pulmonary disease. Interpretation of findings in a study of 46 patients and 14 normal subjects. Ann Intern Med. 1971;74(3):328-35.

31. Badran M, Ayas N, Laher I. Cardiovascular complications of sleep apnea: role of oxidative stress. Oxid Med Cell Longev. 2014;2014:985258.

32. Drager LF, Polotsky VY, O'Donnell CP, Cravo SL, LorenziFilho G, Machado BH. Translational approaches to understanding metabolic dysfunction and cardiovascular consequences of obstructive sleep apnea. Am J Physiol Heart Circ Physiol. 2015;309(7):H1101-11.

33. Lal C, Strange C, Bachman D. Neurocognitive impairment in obstructive sleep apnea. Chest. 2012;141(6):1601-10.

34. Supplemental oxygen: When do you need to start? June 4, 2015. Available at: https://www.inogen.com/blog/copdand-oxygen-therapy-when-do-you-need-to-start/ 35. Kent BD, Mitchell PD, McNicholas WT. Hypoxemia in patients with COPD: cause, effects, and disease progression.

Int J Chron Obstruct Pulmon Dis. 2011;6:199-208.

23. Toyama T, Seki R, Kasama S. Effectiveness of nocturnal home oxygen therapy to improve exercise capacity, cardiac function and cardiac sympathetic nerve activity in patients with chronic heart failure and central sleep apnea.

Circ J. 2009;73(2):299-304.

36. Qaseem A, Wilt TJ, Weinberger SE, Hanania NA, Criner G, van der Molen T, et al; American College of Physicians; American College of Chest Physicians; American Thoracic Society; European Respiratory Society. Diagnosis and management of stable chronic obstructive pulmonary disease: a clinical practice guideline update from the American College of Physicians, American College of Chest Physicians, American Thoracic Society and European Respiratory Society. Ann Intern Med. 2011;155(3):179-91.

24. Sasayama S, Izumi T, Matsuzaki M, Matsumori A, Asanoi H, Momomura S; CHF-HOT Study Group.

Improvement of quality of life with nocturnal oxygen therapy in heart failure patients with central sleep apnea.

Circ J. 2009;73(7):1255-62.

37. Long-Term Oxygen Treatment Trial Research Group, Albert RK, Au DH, Blackford AL, Casaburi R, Cooper JA Jr, Criner GJ, et al. A randomized trial of long-term oxygen for COPD with moderate desaturation. N Engl J Med. 2016;375(17):1617-7.

25. Javaheri S, Ahmed M, Parker TJ, Brown CR. Effects of nasal O2 on sleep-related disordered breathing in ambulatory patients with stable heart failure. Sleep. 1999;22(8):1101-6.

38. Jarosch I, Gloeckl R, Damm E, Schwedhelm AL, Buhrow D, Jerrentrup A, et al. Short-term effects of supplemental oxygen on 6-min walk test outcomes in patients with COPD: a randomized, placebo-controlled, single-blind, crossover trial. Chest. 2017;151(4):795-803.

26. Krachman SL, D'Alonzo GE, Berger TJ, Eisen HJ. Comparison of oxygen therapy with nasal continuous positive airway pressure on Cheyne-Stokes respiration during sleep in congestive heart failure. Chest. 1999;116(6):1550-7.

27. Arzt M, Schulz M, Wensel R, Montalvàn S, Blumberg FC, Riegger GA, et al. Nocturnal continuous positive airway pressure improves ventilatory efficiency during exercise in patients with chronic heart failure. Chest. 2005;127(3): 794-802.

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39. Emtner M, Porszasz J, Burns M, Somfay A, Casaburi R. Benefits of supplemental oxygen in exercise training in nonhypoxemic chronic obstructive pulmonary disease patients. Am J Respir Crit Care Med. 2003;168(9):1034-42.

40. Mach WJ, Thimmesch AR, Pierce JT, Pierce JD. Consequences of hyperoxia and the toxicity of oxygen in the lung. Nurs Res Pract. 2011;2011:260482.

IJCP Sutra 23: To withdraw the exemption under Clause (38) of Section 10 and to introduce a new Section 112A in the Income-Tax Act, 1961 (‘the Act’) vide Clause 31 of the Finance Bill, 2018 so as to provide that long-term capital gains arising from transfer of such long-term capital asset exceeding one lakh rupees will be taxed at a concessional rate of 10%.

CLINICAL PHYSIOLOGY 41. Freeman BA, Crapo JD. Hyperoxia increases oxygen radical production in rat lungs and lung mitochondria.

J Biol Chem. 1981;256(21):10986-92.

42. Winslow RM. Oxygen: the poison is in the dose.

Transfusion. 2013;53(2):424-37.

43. Fridovich I. Oxygen toxicity: a radical explanation. J Exp Biol. 1998;201(Pt 8):1203-9.

44. Walsh C, Thimmesch AR, D'Achiardi A, Pierce JD. Oxygen bar effectiveness: a randomized quantitative study.

J Complement Integr Med. 2011;8.

45. Bren L. Oxygen bars: is a breath of fresh air worth it? FDA Consum. 2002;36(6):9-11.

46. Morante F, Güell R, Mayos M. Efficacy of the 6-minute walk test in evaluating ambulatory oxygen therapy. Arch Bronconeumol. 2005;41(11):596-600.

47. Leggett RJ, Flenley DC. Portable oxygen and exercise tolerance in patients with chronic hypoxic cor pulmonale.

Br Med J. 1977;2(6079):84-6.

48. Calverley PM, Leggett RJ, Flenley DC. Carbon monoxide and exercise tolerance in chronic bronchitis and emphysema. Br Med J (Clin Res Ed). 1981;283(6296):878-80.

49. Talavera IG, Gonçalves JM. Ambulatory oxygen therapy in COPD patients with oxygen desaturation during exercise.

Chron Obstruct Pulmon Dis. 2016;1:5.

50. Luttmann-Gibson H, Sarnat SE, Suh HH, Coull BA, Schwartz J, Zanobetti A, et al. Short-term effects of air pollution on oxygen saturation in a cohort of senior adults in Steubenville, Ohio. J Occup Environ Med. 2014;56(2):149-54.

51. DeMeo DL, Zanobetti A, Litonjua AA, Coull BA, Schwartz J, Gold DR. Ambient air pollution and oxygen saturation.

Am J Respir Crit Care Med. 2004;170(4):383-7.

52. Simkhovich BZ, Kleinman MT, Kloner RA. Particulate air pollution and coronary heart disease. Curr Opin Cardiol.

2009;24(6):604-9.

53. Ye X, Peng L, Kan H, Wang W, Geng F, Mu Z, et al. Acute effects of particulate air pollution on the incidence of coronary heart disease in Shanghai, China. PLoS One. 2016;11(3):e0151119.

54. Dockery DW, Pope CA 3rd, Kanner RE, Martin Villegas G, Schwartz J. Daily changes in oxygen saturation and pulse rate associated with particulate air pollution and barometric pressure. Res Rep Health Eff Inst. 1999;(83): 1-19; discussion 21-8.

55. Pope CA 3rd, Dockery DW, Kanner RE, Villegas GM, Schwartz J. Oxygen saturation, pulse rate, and particulate air pollution: A daily time-series panel study. Am J Respir Crit Care Med. 1999;159(2):365-72.

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IJCP Sutra 24: Long-term capital gains mean gains arising from the transfer of long-term capital asset.

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Drugs

Nitrofurantoin as a First-line Drug in the Treatment of “Escherichia coli Causing Community-acquired Urinary Tract Infection” SHASHI CHOPRA*, GOMTY MAHAJAN†

Abstract Introduction: Urinary tract infections (UTIs) are the most common infections described in outpatients setting. Objectives: A study was conducted to evaluate uropathogenic Escherichia coli and its antimicrobial susceptibility profile among outdoor patients of teaching hospital at Jalandhar, Punjab. Material and methods: A total number of 5,077 urine samples collected from outdoor patients were processed in Microbiology laboratory. Bacterial isolates obtained were identified using biochemical reactions. Antimicrobial susceptibility testing was performed against E. coli isolates by the Kirby-Bauer disc diffusion method.

Results: Out of 5,077 samples, 514 (10.12%) were culture positive. The majority of the positive samples were of female patients (83.26%). Maximum patients (62.65%) with E. coli infection belonged to the age group 45-64 years. Out of 514 (10.12%) pathogens, Gram-negative bacteria were 87.74% and Gram-positive bacteria were 12.26%. E. coli (324) was the most frequently isolated bacteria (63.03%) and high majority of them were sensitive to nitrofurantoin (77.46%). Conclusion: Nitrofurantoin is considered a first-line antimicrobial agent for community-acquired uncomplicated UTI. Knowledge of local susceptibility patterns is important for the selection of appropriate empirical therapy for UTI and will help clinicians to provide safe and effective empirical therapy with minimal therapeutic failures.

Keywords: Urinary tract infection, nirtofurantoin, Escherichia coli, community-acquired infection

B

acteria are the prime perpetrator responsible for conferring the infection among humans but the role of certain fungi and viruses cannot be overlooked. However, the incidence of urinary tract infection (UTI) as a result of viral or fungal infection is considered to be a rare phenomenon. Research studies have defined UTI as the most common form of bacterial infection1,2 especially in outdoor patient clinics and it’s emerging as an important community-acquired and nosocomial bacterial infection. Uncomplicated UTIs were defined as the first episode of UTI in outpatients with no underlying anatomical anomalies and no indwelling devices.

UTIs can occur in both men and women but clinical studies suggest that the overall prevalence of UTI is

*Professor †Associate Professor Dept. of Microbiology, Jalandhar, Punjab Address for correspondence Dr Shashi Chopra EJ 227-228, Chahar Bagh, Jalandhar City, Punjab - 144 001 E-mail: dr.shashichopra@yahoo.com

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higher in women. An estimated 150 million people worldwide are diagnosed with a UTI each year.3 Uncomplicated UTIs in healthy women have an incidence of 50/1,000/year.4 An estimated 50% of women experience at least one episode of UTI at some point in their lifetime and between 20% and 40% of women have recurrent episodes.5,6 Approximately 20% of all UTIs occur in men.7 The introduction of antimicrobial therapy has contributed significantly to the management of UTIs. However, the main problem with current antibiotic therapies is the rapid emergence of antimicrobial resistance in hospitals and the community8 and it continues to be a major health problem in different parts of the world.

This is particularly the case for Gram-negative bacteria (GNB) where antibiotic development faces more substantial challenges than Gram-positive organisms, yet antimicrobial resistance is readily acquired. Most cases of UTI are caused by Gramnegative bacilli, with E. coli accounting for over 90% of uncomplicated UTIs.9

IJCP Sutra 25: Assets means equity Shares in a company listed on a recognized stock exchange; Unit of an equity oriented fund; and Unit of a business trust.

Drugs Aims and Objectives

Results

The aim of this study was to evaluate oral antimicrobial agents, which could be used in outpatient healthcare for the treatment of community-acquired uncomplicated UTIs caused by E. coli. For this purpose, we analyzed susceptibility rates of E. coli isolates from clinically significant UTIs.

Five thousand seventy-seven samples of all ages (15 to >60 years) and both sexes were studied during a period of 2 years. Out of these, 4521 (89.04%) samples were of female and 556 (10.96%) samples were of male patients. Of the total 514 (10.12%) had a positive urine culture.

Material and Methods

The majority of the positive samples 428 (83.26%) were of female patients and 86 (16.74%) were of male patients. Maximum culture isolates were those of E. coli (324). Maximum patients (62.65%) with E. coli infection belonged to 45-64 years age group and minimum from (5.55%) 15-24 years age group.

A prospective study was carried out in Dept. of Microbiology of a teaching hospital for 2 years (October 2014 to September 2016) on 5,077 urine samples collected from outdoor patients (14 to >60 years of age) having history of UTI. All the culture positive urine samples were included and analyzed. Cultures positive for Candida species and cultures with mixed growth were excluded.

Mixed growth was defined as a growth of more than two organisms in a midstream urine sample indicative of contamination. Only E. coli positive growth was further considered for this study.

The antimicrobial susceptibility testing was carried out on Mueller-Hinton agar by using the Kirby-Bauer disc diffusion method and the Clinical and Laboratory Standards Institute (CLSI) criteria.10 The oral antimicrobial discs, nitrofurantoin (300 mg), norfloxacin (10 µg), ciprofloxacin (5 µg), cefuroxime (30 µg), cefixime (5 µg), cefpodoxime (10 µg) and amoxicillin + clavulanic acid (30 µg) were used during sensitivity testing. Statistical analysis was done to study the resistance pattern of E. coli and variables were expressed as percentages.

Among patients aged >65 years, males were more infected than females whereas in all other groups, female were more infected than male. The difference between distribution of male and female patients of UTI was statistically significant (p ≤ 0.001) (Table 1).

Out of 514 (10.12%) pathogens, Gram-negative bacteria were 87.74% (451) and Gram-positive bacteria were 12.26% (63). E. coli (324) was the most frequent isolate (63.03%) of the total isolates.

The next most frequently isolated bacteria were Klebsiella pneumoniae (15%), Staphylococcus aureus (9.33%), Acinetobacter spp. (3.50%), Pseudomonas aeruginosa (3.30%), Enterococcus spp. (2.91%), Proteus spp. (1.75%) and Citrobacter spp. (1.16%).

A high proportion of strains of E. coli were sensitive to nitrofurantoin (77.46%) followed by amoxicillin + clavulanic acid (30.86%) as depicted in Table 2 throughout the 2 years study period.

Table 1. The Distribution of Male and Female Patients of UTI having E. coli Infection During October 2014 to September 2016 Age (years)

Total (%)

Female (%)

Male (%)

15-24

18 (5.55%)

16 (6.22%)

2 (2.98)

25-34

29 (8.95%)

23 (8.94%)

6 (8.95)

35-44

45 (13.90%)

36 (14%)

9 (13.43)

45-54

74 (22.83%)

60 (23.34)

14 (20.89)

55-64

129 (39.82%)

113 (43.96)

16 (23.88)

>65

29 (8.95%)

9 (3.50)

20 (29.85)

Total

324 (100%)

257 (79.32%)

67 (20.68%)

Chi-square (χ2)

P valve

47.7

<0.001

IJCP Sutra 26: The long-term capital gain tax will be levied only upon transfer of the long-term capital asset on or after 1st April, 2018, as defined in Clause (47) of Section 2 of the Act.

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Indian Journal of Clinical Practice, Vol. 28, No. 9, February 2018

Table 2. Antibiotic Sensitivity Pattern of Oral Drugs Used for E. coli (324) Antimicrobial agents

No. of sensitive isolates

Percentage (%)

Nitrofurantoin

251

77.46

Norfloxacin

78

24.07

Ciprofloxacin

89

27.46

Cefuroxime

80

24.69

Cefixime

95

29.32

Cefpodoxime

92

28.39

Amoxicillin + Clavulanic acid

100

30.86

Discussion Our data were restricted to the patients who could afford laboratory analysis; therefore, this study may not reflect the true prevalence of UTI among patients in Punjab as most patients are initially treated empirically for their symptoms of uncomplicated UTI. In this study, the incidence of UTI in outdoor patient was 10.12%. The similar value of 10.86% was obtained by Akarm et al,7 whereas 17.19% and 34.5% were reported by other workers, respectively.11,12 The differences in the type and distribution of uropathogens may result from different environmental conditions and host factors, and practices such as healthcare, socioeconomic standards and hygiene practices in each geographical area.

Our study showed a high prevalence of UTI in females 257 (79.32%) patients than in males 67 (30.68%) patients, similar findings were reported by the other workers (females 69.32%, males 30.68%) also.13 The reason behind this high prevalence of UTI in females is due to close proximity of the urethral meatus to the anus, shorter and wider urethra, sexual intercourse, incontinence and less acidic pH of vaginal surface and poor hygienic conditions.14,15 In our study, E. coli was the predominant uropathogen accounting for 63.03% (324) of the total isolates, which correlate with the study done by other workers (61.84%).11 Among outpatients, E. coli is the primary urinary tract pathogen, accounting for 75-90% of isolates from uncomplicated UTI.5 We documented the pattern of oral antimicrobial sensitivity among 324 E. coli isolates during the study period of 2 years. We observed that isolates showed increased sensitivity to nitrofurantoin (77.46%).

Similar findings (81%) were observed by other

832

workers also;16 however, a similar study conducted by Akram et al reported high level of the resistance to nitrofurantoin (80%).7 Nitrofurantoin is bactericidal in urine at therapeutic doses, and its multiple mechanisms of action appear to have enabled it to retain potent activity against E. coli despite nearly 50 years of use.17 The reason for high sensitivity to nitrofuratoin, may be due to their narrowspectrum of activity, decreased prescription of these drugs and their narrow tissue distribution.18 Though the drug has side effects it is still an important first-line drug against UTI before culture and sensitivity as, it achieves 85% higher cure rates and serum concentrations than either co-trimoxazole or quinolones.19,20 In this study, 24.07% and 27.46% isolates were sensitive to norfloxacin and ciproflaxacin, almost same findings (20.7% and 27.5%) were reported by other workers, respectively.16,21 However, some workers have reported 44% and 46.6% resistance to norfloxacin and ciprofloxacin, respectively.12,22 Norfloxacin and ciprofloxacin being oral drugs with easy dosage schedule are commonly prescribed by the clinicians for the treatment of UTI in outpatients not only in India but in other countries also.23 Fluoroquinolones have a wide variety of indications, permeate most body compartments and are ubiquitously prescribed, accounting for the emergence of their resistance.11 This may be the reason of increasing quinolones resistance in our area and is also revealed by other studies.7,24 In our study, 30.86% of isolates were sensitive to combination of amoxicillin + clavulanic acid whereas 26.4% and 36.3% sensitivity were reported by other workers, respectively.12,21 In the present study, sensitivity to second-generation cephalosporins was 24.69%, whereas other workers reported it to be 36% and 73.1% sensitivity, respectively11,25 and 28.85% isolates in this study were sensitive to third-generation cephalosporin, whereas 34.1% and 41.8% sensitivity were reported by other workers, respectively.12,13 Resistance rate for thirdgeneration cephalosporin (71.15%) is indicative of production of extended-spectrum β-lactamases enzyme by the isolates from community.

Our study revealed that among Gram-negative bacteria, the most common isolate E. coli showed high level of resistance to commonly used empirical antibiotics β-lactams (amoxicillin + clavulanic acid, cefuroxime, cefixime and cefpodoxime) and fluoroquinolones (ciprofloxacin and norfloxacin). This value is similar to

IJCP Sutra 27: The long-term capital gains is computed by deducting the cost of acquisition from the full value of consideration on transfer of the long-term capital asset.

Drugs previous community based studies.11,20,26 It is possible that due to poor access to healthcare services, irrational prescription of antimicrobials which are available overthe-counter in India, has contributed to this alarming situation.27 Conclusion In our study, nitrofurantoin was found to be the most effective drug against E. coli. The consistent and highlevel susceptibility of E. coli to nitrofurantoin may be influenced by nitrofurantoin’s narrow-spectrum of activity, limited indication (treatment of acute cystitis), narrow tissue distribution (low or undetectable serum concentrations), and limited contact with bacteria outside the urinary tract.28 According to our findings we recommend nitrofurantoin as an appropriate agent for first-line treatment of community-acquired UTI and according to recently published international treatment guidelines, nitrofurantoin is considered a first-line antimicrobial agent for uncomplicated cystitis,29 and it is commonly used for the long-term prevention of recurrent UTI.30 Generally drug resistance in E. coli is transmitted via plasmid and bacterium resistant to one antibiotic is often much more likely to be resistant to second choice of antibiotics, thereby increasing the chances of failure of therapy in UTI. Knowledge of local susceptibility patterns is important for the selection of appropriate empirical therapy for UTI. This will help clinicians to provide safe and effective empirical therapies with minimal therapeutic failures.

References 1. Demilie T, Beyene G, Melaku S, Tsegaye W. Urinary bacterial profile and antibiotic susceptibility pattern among pregnant women in North West Ethiopia. Ethiop J Health Sci. 2012;22(2):121-8.

2. Parveen K, Momen A, Begum AA, Begum M. Prevalence of urinary tract infection during pregnancy. J Dhaka National Med Coll Hos. 2011;17(2):8-12.

3. Karlowsky JA, Kelly LJ, Thornsberry C, Jones ME, Sahm DF. Trends in antimicrobial resistance among urinary tract infection isolates of Escherichia coli from female outpatients in the United States. Antimicrob Agents Chemother. 2002;46(8):2540-5.

tract isolates, London 2005-2006. Ann Clin Microbiol Antimicrob. 2008;7:13.

7. Akram M, Shahid M, Khan AU. Etiology and antibiotic resistance patterns of community-acquired urinary tract infections in J N M C Hospital Aligarh, India. Ann Clin Microbiol Antimicrob. 2007;6:4.

8. Habte TM, Dube S, Ismail N, Hoosen AA. Hospital and community isolates of uropathogens at a tertiary hospital in South Africa. S Afr Med J. 2009;99(8):584-7.

9. Talan DA, Stamm WE, Hooton TM, Moran GJ, Burke T, Iravani A, et al. Comparison of ciprofloxacin (7 days) and trimethoprim-sulfamethoxazole (14 days) for acute uncomplicated pyelonephritis in women: a randomized trial. JAMA. 2000;283(12):1583-90.

10. Clinical and Laboratory Standards Institute. Performance standards for antimicrobial susceptibility testing. 18th informational supplement. M100-S18.Wayne, PA: CLSI; 2008.

11. Sood S, Gupta R. Antibiotic resistance pattern of community acquired uropathogens at a tertiary care hospital in Jaipur, Rajasthan. Indian J Community Med. 2012;37(1):39-44.

12. Dash M, Padhi S, Mohanty I, Panda P, Parida B. Antimicrobial resistance in pathogens causing urinary tract infections in a rural community of Odisha, India. J Family Community Med. 2013;20(1):20-6.

13. Khan R, Saif Q, Fatima K, Meher R, Shahzad HF, Anwar KS. Clinical and bacteriological profile of UTI patients attending a north Indian tertiary care center. J Integr Nephrol Androl. 2015;2(1):29-34.

14. Ochei J, Kolhatkar A. Diagnosis of infection by specific anatomic sites/antimicrobial susceptibility tests.

In: Medical Laboratory Science Theory and Practice reprint. 6th Edition, New Delhi, India: McGraw-Hill; 2007. pp. 615-43, 788-98.

15. Aiyegoro OA, Igbinosa OO, Ogunmwonyi IN, Odjadjaro EE, Igbinosa OE, Okoh AI. Incidence of urinary tract infections (UTI) among children and adolescents in Ile-Ife, Nigeria. Afr J Microbiol Res. 2007;1:13-9.

16. Segar L, Srirangaraj S, Kali A, Umadevi S. Hemolysin production and antibiogram pattern of uropathogenic E. coli isolates from South India. RJPBCS. 2014;5(1):225-30.

17. McOsker CC, Fitzpatrick PM. Nitrofurantoin: mechanism of action and implications for resistance development in common uropathogens. J Antimicrob Chemother. 1994;33 Suppl A:23-30.

4. Foxman B. The epidemiology of urinary tract infection.

Nat Rev Urol. 2010;7(12):653-60.

18. Mehta M, Bhardwaj S, Sharma J. Prevalence and antibiotic susceptibility pattern of multi-drug resistant Escherichia coli isolates from urinary tract infection (UTI) patients. Int J Life Pharm Res. 2012;2:6-11.

5. Nicolle LE. Epidemiology of urinary tract infection. Infect Med. 2001;18:153-62.

19. Johnson JR. Virulence factors in Escherichia coli urinary tract infection. Clin Microbiol Rev. 1991;4(1):80-128.

6. Bean DC, Krahe D, Wareham DW. Antimicrobial resistance in community and nosocomial Escherichia coli urinary

20. Kothari A, Sagar V. Antibiotic resistance in pathogens causing community-acquired urinary tract

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Indian Journal of Clinical Practice, Vol. 28, No. 9, February 2018 infections in India: a multicenter study. J Infect Dev Ctries. 2008;2(5):354-8.

26. Sabharwal ER. Antibiotic susceptibility patterns of uropathogens in obstetric patients. N Am J Med Sci. 2012;4(7):316-9.

21. Rani H, Kaistha N, Gupta V, Chander J. Choice of antibiotics in community acquired UTI due to Escherichia coli in adult age group. J Clin Diagn Res. 2011;5(3):483-5.

27. Rao GG. Risk factors for the spread of antibiotic-resistant bacteria. Drugs. 1998;55(3):323-30.

22. Mengistu A, Forster N, Gaeseb J, Habimana G, Kauhondamwa S, Uaaka G, et al. A review of empirical treatment of urinary tract infections based on national antimicrobial sensitivity data. Enliven: Pharmacovigil Drug Saf1. 2014;1:002.

28. Hooper DC. Urinary tract agents: nitrofurantoin and methenamine. In: Mandell GL, Bennett JE, Dolin R (Eds.).

Principles and Practice of Infectious Diseases. 5th Edition, Vol. 1. Philadelphia, Pa.: Churchill Livingstone; 2000. pp. 423-8.

24. Keah Sh, Wee E, Chng K, Keah K. Antimicrobial susceptibility of community-acquired uropathogens in general practice. Malays Fam Physician. 2007; 2(2):64-9.

29. Gupta K, Hooton TM, Naber KG, Wullt B, Colgan R, Miller LG, et al; Infectious Diseases Society of America; European Society for Microbiology and Infectious Diseases. International clinical practice guidelines for the treatment of acute uncomplicated cystitis and pyelonephritis in women: A 2010 update by the Infectious Diseases Society of America and the European Society for Microbiology and Infectious Diseases. Clin Infect Dis. 2011;52(5):e103-20.

25. Debnath J, Das P, Debnath M, Haldar KK. Aetiological profile and antibiotic susceptibility pattern in patients with urinary tract infection in Tripura. J Clin Diagn Res. 2014;8(8):DL01-DL02.

30. Brumfitt W, Hamilton-Miller JM. Efficacy and safety profile of long-term nitrofurantoin in urinary infections: 18 years’ experience. J Antimicrob Chemother. 1998;42(3):363-71.

23. Karlowsky JA, Thornsberry C, Jones ME, Sahm DF. Susceptibility of antimicrobial-resistant urinary Escherichia coli isolates to fluoroquinolones and nitrofurantoin. Clin Infect Dis. 2003;36(2):183-7.

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IJCP Sutra 29: The benefit of inflation indexation of the cost of acquisition would not be available for computing long-term capital gains under the new tax regime.

GASTROENTEROLOGY

Hepatic Granulomas: A Clinician’s Perspective MAYANK JAIN*, JOY VARGHESE†, JAYANTHI VENKATARAMAN

Abstract Hepatic granulomas are focal aggregates of transformed epithelioid histiocytes with or without multinucleated giant cells that are cuffed by lymphocytes and plasma cells. They represent delayed-type specialized cell-mediated immunity to a wide-spectrum of antigenic stimuli. Hepatic granulomas are found in up to 10% of liver biopsies and the causes are usually multifactorial.

Different antigens like infectious agent, medication, foreign body and malignancy can initiate granuloma formation. Hepatic granulomas per se seldom cause architectural changes and often provide a clue to a systemic disease. Most often, to a practicing clinician, it is a combination of clinical presentation, laboratory parameters with information on the typical localization and characterization of the granuloma within the liver by the pathologist that often provides a clue to a definitive diagnosis.

Keywords: Hepatic granulomas, transformed epithelioid histiocytes, multinucleated giant cells, cell-mediated immunity, antigenic stimuli

G

ranulomas are aggregates of modified macrophages (epithelioid cells) and other inflammatory cells that accumulate after chronic exposure to an antigen and are seen in several systemic diseases. The extent of inflammation associated with formation of granuloma is variable. Bland granulomas have little or no associated inflammation. The term granulomatous hepatitis is used when the inflammation is severe, within or around the granuloma and granulomatoid reaction refers to a poorly delineated granuloma.1 The presence of a granuloma may be the first harbinger to an ongoing systemic disease.

groups like patients with fever of unknown origin or those with a human immunodeficiency virus (HIV) infection.11 In India, granulomas are most often reported in tuberculosis (55%) followed by leprosy, sarcoidosis, histoplasmosis, brucellosis, amebic liver abscess, lymphoma and malignant granuloma in that order.12 Etiological Considerations ÂÂ

Autoimmune: Sarcoidosis, primary biliary cirrhosis.

ÂÂ

Infections: zz

Bacterial- tuberculosis, leprosy, brucellosis, Q fever, rickettsia, listeriosis, Bartonella, Tropheryma whipplei

zz

Parasites- schistosoma, leishmania

zz

Viruses- hepatitis C

zz

Fungal- Histoplasma.

Prevalence of Liver Granulomas The prevalence of granulomas in liver biopsy ranges from 2.4% to 15%.2-9 Conn et al10 reported that 66% of their cases of granulomatous reaction were secondary to a systemic disease, 28% to primary liver disorders and 6% were idiopathic. The frequency of granulomas is reportedly high and ranges from 16% to 75% in select

ÂÂ

Drugs and chemicals.

ÂÂ

Malignancy.

Histopathological Characteristics of Granuloma *Consultant Dept. of Gastroenterology Gleneagles Global Health City, Chennai, Tamil Nadu †Senior Consultant Transplant Hepatology (Southern Region) Apollo Hospital, Chennai, Tamil Nadu Address for correspondence Dr Mayank Jain Consultant Dept. of Gastroenterology Gleneagles Global Health City, Chennai - 100, Tamil Nadu E-mail: mayank4670@rediffmail.com

836

A typical granuloma is an inflammatory reaction to a foreign body like microbial organism, drug, etc. It is essentially a compact spherical circumscribed lesion that consists of aggregated epithelioid histiocytes, measuring 50-300 μm. A typical granuloma consists of a central portion of macrophages and is surrounded by lymphocytes and fibroblasts. Differential diagnosis of a granuloma is largely based on its histological characteristics and the location within a hepatic lobule.

IJCP Sutra 30: There will be no deduction of tax at source from the payment of long-term capital gains to a resident tax payer.

GASTROENTEROLOGY The histological variants include:13-15 ÂÂ

Necrotizing (caseating): These are large and destroy the adjacent structures with no respect to the liver architecture. Common example is tuberculosis.

ÂÂ

Noncaseating: These are seen in sarcoidosis

ÂÂ

Granulomatous inflammation: These are poorly formed granulomas with indistinct edges and consist of mixed inflammatory cells. Examples include drug-induced hepatocellular and/or ductular injury.

ÂÂ

Lipogranuloma: This is often seen in steatosis and comprises of aggregates of lipid-containing histiocytes e.g., mineral oil.

ÂÂ

Microgranulomas contain 3-7 cells in cross-section, often admixed with other inflammatory cells and/or apoptotic hepatocytes. This pattern is nonspecific.

ÂÂ

Foreign body granulomas consist of inclusions of particulate material like mineral oil, starch and silicone within cytoplasmic vacuoles.

ÂÂ

Lymphohistiocytic granulomas are similar to epithelioid granulomas, but unlike the latter, these comprise of accumulations of macrophages and lymphocytes with distinct absence of epithelioid cells.

ÂÂ

Fibrin ring or epithelioid granuloma: The fibrin ring or an epithelioid granuloma consists of a central lipid vacuole surrounded by a fibrin ring. The activated macrophages differentiate and aggregate to form giant cells or Langhans cells. These granulomas are seen in infections like cytomegalovirus, hepatitis A, leishmaniasis, toxoplasmosis, Q fever, drugs such as allopurinol and in Hodgkin’s disease.

Per se, granulomas can be located in almost all lobules. However, the distinct forms of necrosis as well as location of a granuloma can provide a clue to its origin and this helps in narrowing the differential diagnosis. For example, caseating necrosis is found in tuberculosis, while noncaseating necrosis is common in sarcoid granulomas.16 The latter are located in the portal and periportal regions. In primary biliary cirrhosis, granulomas are seen near the porta. The druginduced granulomas are poorly defined and are located anywhere within the hepatic lobules.16 Pathogenesis The failure of humoral or cellular immune response to eliminate the offending foreign material leads to granuloma formation.17 Granulomatous reaction is

essentially of 2 types i.e., an immunological reaction to either an inert foreign body or to an active antigen.18 The response to the agent depends on whether it is located within or outside the cell. For intracellular agents, there is a Th1 response while for extracellular, there is a Th2 immunological response. With the former, several cytokines such as interferon-γ, interleukin (IL)-2 and IL-12 are produced soon after phagocytosis of the agent by the macrophages, which reduce them to small peptides. With the Th2 response, there is secretion of IL4, 5, 6 and 10. A vicious cycle ensues wherein by positive feedback mechanism the cytokines constantly stimulate the T cells. Thus, the formation and maintenance of liver granulomas is based on cytokine release.16 With the release of cytokines, clusters of histiocytes and lymphocytes are seen. The histiocytes and macrophages are transformed into epithelioid histiocytes, which conglomerate to a granuloma. The latter have abundant pale cytoplasm. Apart from cytokines, epithelioid cells in particular, within a granuloma secrete proteins like collagenase, lysozyme and angiotensin-converting enzyme (ACE) (e.g., sarcoidosis).18 Elevated ACE levels suggest an active sarcoid.

Typically surrounding the granulomatous reaction is a cuff of lymphocytes, a few plasma cells and eosinophils. Multinucleated giant cells are result of fusion of macrophages. Granulomas when infiltrated by eosinophils are suggestive of either a drug reaction or a parasitic infection. Thus macrophages play a key role in granuloma formation while tissue necrosis (necrotizing granulomas) is largely initiated by epithelioid histiocytes, characteristically seen in infections like tuberculosis.19 Accumulation of these effector cells in the portal tract leads to injury of the septal and interlobular bile ducts that can cause cholestasis.16 Clinical Presentation Majority of the patients are asymptomatic at presentation or have clinical manifestations of underlying systemic disease. Nonspecific symptoms include fever (tuberculosis, sarcoidosis, infectious disease), weight loss, anorexia and night sweats. Lymphadenopathy may be present in systemic diseases.19-23 Two-thirds of patients have a hepatomegaly with an elevated alkaline phosphatase and gammaglutamyl transferase.21 Jaundice is rare unless there is bile duct injury. Portal hypertension is reported in schistosomiasis (noncirrhotic portal hypertension), sarcoidosis and primary biliary cirrhosis.16 Final diagnosis is at histology.

IJCP Sutra 31: An association between exercise-induced albuminuria and an increase in nocturnal BP values in seen in type 2 diabetes. World J Nephrol.

2017;6(4):209-16.

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Indian Journal of Clinical Practice, Vol. 28, No. 9, February 2018

Diagnostic Evaluation A comprehensive medical history and physical examination should be pursued along with an extensive medication and travel history. Symptoms and signs are helpful in developing a differential diagnosis.

Blood investigations, serological tests and biopsy lead to a definitive diagnosis. Ultrasound can detect a hepatomegaly. Granulomas of 0.5 cm in diameter or greater can be identified on magnetic resonance imaging (MRI) as multiple nodular lesions or, less commonly, isolated hepatic granulomas. Caseating granulomas as in tuberculosis have a high or low signal

in T1-weighted MRI, and no enhancement or sometimes peripheral enhancement after gadolinium injection in comparison to noncaseating granulomas in sarcoidosis, which have intermediate signals on T1-weighted images with gadolinium enhancement that may or may not persist on late images.24-26 However, these findings are operator dependent and difficult to interpret.

In a recent study27 on 251 explant livers, we found the prevalence of liver granulomas to be 7.2%. Five patients who had undergone transarterial chemoembolization prior to transplantation, had foreign body granuloma.

Five patients were diagnosed to have caseating

Table 1. Salient Features of Important Causes of Hepatic Granulomas Categories

Causes

Clinical picture

Biochemistry

Granulomas

Autoimmune

Sarcoidosis

Hepatic involvement: 5-15%

Raised SAP, GGT

Noncaseating epithelioid granuloma

Asymptomatic, cholestatic liver disease, cirrhosis, PHT, hepatic vein thrombosis Infections:

Location: Portal tract

PBC

Cholestatic liver disease

AMA +

Simulates sarcoidosis

Tuberculosis

Systemic symptoms:

Abnormal LFT; raised GGT and SAP

Around portal tract, caseating or noncaseating, AFB+ 90%: military TB

Bacterial, viral, fungal, parasitic, rickettsial, spirochaetal

Fever, night sweats, fatigue, anorexia and weight loss Jaundice rare

70%: extrapulmonary TB, 25%: isolated liver

Symptoms of primary HIV related: Associated infections e.g., M. tuberculosis, infection M. avium intracellulare, C. neoformans, CMV, histoplasmosis, toxoplasmosis

Abnormal LFT: Raised SAP, GGT, hepatomegaly

Usually similar to infective granulomas

Cirrhosis

HCV, alcohol, HCC, NASH

Features of cirrhosis

Raised SAP, GGT

Often epithelioid granulomas: treatment related (e.g., Interferon or primary disease)

Malignancy

Hodgkin’s, non-Hodgkin’s lymphoma, renal cell carcinoma

Primary disease

Raised SAP, GGT

Granulomas not considered for staging in lymphomas

HCC

May be related to primary etiology e.g., HCV or may be intratumoral Diffuse, ill-defined

Drugs

Allopurinol, sulfa, chlopropamaide, quinidine

History of drugs

Foreign body

Post-TACE

History

>HCC

Idiopathic

10-36%

Granulomatous hepatitis: Fever, myalgia, arthralgia, hepatoslenomegaly

Raised ESR

Microgranulomas with suppuration

PHT = Portal hypertension; SAP = Serum alkaline phosphatase; GGT = Gamma-glutamyl transferase; PBC = Primary biliary cirrhosis; AMA = Antimitochondrial antibodies; LFT = Liver function tests; AFB = Acid-fast bacilli; TB = Tuberculosis; HIV = Human immunodeficiency virus; CMV = Cytomegalovirus; HCV = Hepatitis C virus; HCC = Hepatocellular carcinoma; NASH = Nonalcoholic steatohepatitis; TACE = Transarterial chemoembolization; ESR = Erythrocyte sedimentation rate.

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IJCP Sutra 32: Monitoring glucose patterns over 24-hour as a therapeutic target is important in patients with type 2 diabetes and CV autonomic neuropathy.

J Diabetes Complications. 2017;31(9):1389-93.

GASTROENTEROLOGY granulomas and were started on four drug regimen for tuberculosis - isoniazid, rifabutin, pyrazinamide and ethambutol. All responded well to treatment.

Three patients with hepatitis C virus infection showed portal microgranulomas/granulomas. These were compact, non-necrotizing, epithelioid granulomas of varying sizes observed within portal tracts and lobules. Five cases, where the diagnosis of granulomas remained elusive, isoniazid prophylaxis was given for 9 months to reduce the risk of reactivation of tuberculosis.

The presence of granulomas suggestive of tuberculosis in the explant liver is associated with the development of tuberculosis in the recipients.28 Granulomas in hepatitis C virus patients could be due to an interferonmediated stimulation of Th1 immune response or intravenous drug use.29 The differential diagnosis (Table 1) for hepatic granulomas can be broadly classified as those associated with:

experience over a 10-year period in the West of Scotland.

Q J Med. 1982;51(202):162-70.

6. Satti MB, al-Freihi H, Ibrahim EM, Abu-Melha A, al-Ghassab G, al-Idrissi HY, et al. Hepatic granuloma in Saudi Arabia: a clinicopathological study of 59 cases. Am J Gastroenterol. 1990;85(6):669-74.

7. Mir-Madjlessi SH, Farmer RG, Hawk WA. Granulomatous hepatitis. A review of 50 cases. Am J Gastroenterol.

1973;60(2):122-34.

8. Neville E, Piyasena KH, James DG. Granulomas of the liver. Postgrad Med J. 1975;51(596):361-5.

9. McCluggage WG, Sloan JM. Hepatic granulomas in Northern Ireland: a thirteen year review. Histopathology.

1994;25(3):219-28.

10. Conn HO, Klatskin G. Histopathology of liver. London: Oxford University Press; 1993. pp. 293-311.

11. Sharma S. Granulomatous diseases of the liver. In: Zakim D, Boyer T (Eds.). Hepatology. 4th Edition, Philadelphia, PA: Saunders Elsevier Science; 2003. pp. 1317-30.

12. Gaya DR, Thorburn D, Oien KA, Morris AJ, Stanley AJ. Hepatic granulomas: a 10 year single centre experience.

J Clin Pathol. 2003;56(11):850-3.

ÂÂ

Infections

ÂÂ

Drugs

ÂÂ

Autoimmune disorders

ÂÂ

Malignancy

ÂÂ

Idiopathic.

14. Flamm S. Hepatic granulomas. In: Chopra S (Ed.).

UpToDate: Hepatology. Waltham, MA: UpToDate; 2008.

Conclusions

15. Maddrey WC. Granulomas of the liver. In: Schiff ER, Sorrell MF, Maddrey WC (Eds.). Schiff's Diseases of the Liver. 8th Edition, Philadelphia: Lippincott-Raven; 1989. p. 1572.

Hepatic granulomas are of multifactorial origin. A definite diagnosis regarding the granulomas can only be made using clinical data and histopathology. In a quarter, the cause for a granuloma remains unknown.

In Indian setting, treatment for tuberculosis should be initiated in presence of caseating granulomas and a high index of disease suspicion.

References

13. Matheus T, Muñoz S. Granulomatous liver disease and cholestasis. Clin Liver Dis. 2004;8(1):229-46, ix.

16. Dourakis SP, Saramadou R, Alexopoulou A, Kafiri G, Deutsch M, Koskinas J, et al. Hepatic granulomas: a 6-year experience in a single center in Greece. Eur J Gastroenterol Hepatol. 2007;19(2):101-4.

17. Sabharwal BD, Malhotra N, Garg R, Malhotra V. Granulomatous hepatitis: a retrospective study. Indian J Pathol Microbiol. 1995;38(4):413-6.

1. Ferrell L. Hepatic granulomas: a morphologic approach to the diagnosis. Surg Pathol. 1990;3:87-106.

18. Ishak KG. Granulomas of the liver. Adv Pathol Lab Med. 1995;8:247.

2. Wagoner GP, Anton AT, Gall EA, Schiff L. Needle biopsy of the liver. VIII. Experiences with hepatic granulomas.

Gastroenterology. 1953;25(4):487-94.

19. Sherlock S, Dooley J. Hepatic granuloma. In: Sherlock S, Dooley J (Eds.). The Liver in Systemic Disease, Hepatic Trauma. 9th Edition, London: Blackwell; 1993. pp. 460-6.

3. Guckian JC, Perry JE. Granulomatous hepatitis. An analysis of 63 cases and review of the literature. Ann Intern Med. 1966;65(5):1081-100.

20. Dincsoy HP, Weesner RE, MacGee J. Lipogranulomas in non-fatty human livers. A mineral oil induced environmental disease. Am J Clin Pathol. 1982; 78(1):35-41.

4. Sartin JS, Walker RC. Granulomatous hepatitis: a retrospective review of 88 cases at the Mayo Clinic. Mayo Clin Proc. 1991;66(9):914-8.

5. Cunnigham D, Mills PR, Quigley EM, Patrick RS, Watkinson G, MacKenzie JF, et al. Hepatic granulomas:

21. Denk H, Scheuer PJ, Baptista A, Bianchi L, Callea F, De Groote J, et al. Guidelines for the diagnosis and interpretation of hepatic granulomas. Histopathology.

1994;25(3):209-18.

IJCP Sutra 33: Risk of overall cancer in patients with type 2 diabetes with T2DM using SGLT2i is not significantly high. Diabetologia. 2017 Jul 19.

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Indian Journal of Clinical Practice, Vol. 28, No. 9, February 2018 22. Wahl SM. Hepatic granuloma as a model of inflammation and repair: an overview. Methods Enzymol. 1988;163:605-22.

23. Heyworth PG, Cross AR, Curnutte JT. Chronic granulomatous disease.

Curr Opin Immunol.

2003;15(5):578-84.

24. Mills PR, Russell RI. Diagnosis of hepatic granulomas: a review. J R Soc Med. 1983;76(5):393-7.

25. Israel HL, Margolis ML, Rose LJ. Hepatic granulomatosis and sarcoidosis. Further observations. Dig Dis Sci. 1984;29(4):353-6.

26. Lefkowitch JH. Hepatic granulomas. J Hepatol. 1999;30 Suppl 1:40-5.

27. Jain M, Venkataraman J, Vij M, Shruthi S, Kedarishetty CK, Varghese J, Harika K, et al. Explant liver opening a Pandora’s box! Indian J Gastroenterol. 2016;35(S1):A8.

28. Olithselvan A, Rajagopala S, Vij M, Shanmugam V, Shanmugam N, Rela M. Tuberculosis in liver transplant recipients: experience of a South Indian liver transplant center. Liver Transpl. 2014;20(8):960-6.

29. Alfageme Michavila I, Merino Sánchez M, Pérez Ronchel J, Lara Lara I, Suárez García E, López Garrido J. Sarcoidosis following combined ribavirin and interferon therapy: a case report and review of the literature. Arch Bronconeumol. 2004;40(1):45-9.

■■■■

Make sure During Medical Practice

Situation:

A severely hypertensive patient on angiotensin-converting enzyme inhibitor (ACEI) was found to have left ventricular hypertrophy (LVH) on electrocardiography (ECG).

© IJCP GROUP

Why did you not stop ACEI and start candesartan?

Lesson:

Make sure to remember that angiotensin receptor blockers (ARBs) are more effective in reducing LVH in hypertensive patients. The SARA study demonstrated that a candesartanbased regimen reduces ECG-LVH in patients with hypertension.

Vasc Health Risk Manag. 2008;4(1):67-73. J Hypertens. 2007;25(9):1967-73.

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IJCP Sutra 34: Refractive error and cataract are the leading but treatable causes of incident visual impairment in patients with type 2 diabetes. Indian J Ophthalmol. 2017;65(7):589-95.

Issue of the Month

IMA Clarifications on FAQs by Ministry of Health, Government of India Regarding National Medical Commission Ravi Wankhedkar*, RN Tandon†, A Marthanda Pillai‡, Vedprakash Mishra¥, KK Aggarwal§

NMC will be a Bureaucratic Body GoI Stand: Not true. At least 16 members and up to 21 out of 25 members would be only senior medical doctors. The chairperson of National Medical Commission (NMC) would have at least 20 years’ medical experience, out of which at least 10 years would be as HoD or Head of Institution. Similarly, Presidents of the 4 autonomous boards would have at least 15 years’ medial experience out of which 7 years would be in a leadership role.

IMA Clarification: The main concern is that the proposed NMC Bill will not be a representative body.

It will neither have a national character in terms of nationwide representation, nor a representative character in terms of being a judicious mix of elected and nominated members. It will be a body comprising of mostly member appointed by the Central Government without there being representations from the States and Universities as well as State Medical Councils and other stakeholders. Under the proposed Bill, the members are mostly ex-officio Government servants whose appointing as well as disciplinary authority is the Central Government.

In other words, NMC completely lacks independence or autonomy which is a must so as to take impartial decisions for the betterment of medical education, academic standards and the medical profession. It is for this very reason, the composition of the NMC is not only bureaucratic but fundamentally flawed, as they will be constrained to obey the Central Govt. (in power) policy/dictates rather than applying their

*National

President, IMA IMA ‡Action Committee Chairman, IMA ¥Hon’ble Chancellor Krishna Institute of Medical Sciences "Deemed to be University", Karad, Maharashtra §Immediate Past National President, IMA †HSG,

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independent mind for the betterment of the medical health of the Country.

The NMC will unfortunately function like a ‘department’ of the Central Government when it will come to decision making in the field of medical education and profession of medicine since all the members are going to be appointed by the Central Government and they will be under an obligation to oblige the Central Govt. The proposed National Medical Commission Bill, 2017 provides for composition of NMC. The Commission shall comprise of mostly members appointed by the Central Government as also Directors of reputed institutions and Heads of various Government authorities/department. The autonomy sought to be given to the Commission will be reflected if it comprises of members elected through different modes such as election, nomination by State Government/Universities/State Medical Council, etc., instead of having only appointees of Central Government heading and running the Commission.

In addition as mentioned in the Bill, all the members, will be the heads of their respective institutions, running the same is itself a herculean task, so they will not be able to devote time and mind required to the functioning NMC independently. Hence, these members will rubber stamp the decisions as proposed at the level of the Central Government.

Medical Practitioners will be Able to Elect Only 5 Members in their Own Body GoI Stand: The Department-related Parliamentary Standing Committee (DRPSC) has recommended that "keeping in mind the disastrous experience with an elected regulated body, the Committee is convinced that regulators of the highest standards of professional integrity and excellence will have to be sought by the Government through a rigorous selection process" (Para 3.16). Although the Committee had recommended a purely selected body, the Government has provided for election of 5 (20%) members.

IJCP Sutra 35: Physical activity of any intensity has a positive impact on glucose regulation and insulin sensitivity in people at high risk of type 2 diabetes in a doseresponse pattern. Med Sci Sports Exerc. 2017 Jul 19.

Issue of the Month IMA Clarification: The representative character of the NMC is warranted for the purposes of ensuring the inclusion of all the representatives from the relevant stakeholders as is the case under Indian Medical Council Act, 1956, the composition prescribed therein recognizes 4 key stakeholders namely the Central Government, the State Governments, the Universities having the Medicine faculty and the Registered medical practitioners enrolled in the State Medical Register of the concerned State. Accordingly, the Government of India was entitled to nominate 8 members, each State was entitled to nominate its representative who ought to be a Registered Medical Practitioner included in the State Medical Register and residing in the same state, each University having their medical faculty elected its representative through their Senate from amongst the members of the said faculty and one elected representative from amongst the Registered Medical Practitioner included in the State Medical Register.

The representative character of any apex body of professionals in the Country is primarily established on the core principles of democratic functioning wherein members are elected/nominated from various sources which are intrinsically involved in the matters of its functioning. The NMC through members appointed by the Central Government as also Directors of reputed institutions and Heads of various Government authorities/department, shall function contrary to the manner in which most apex body of professionals in the Country work.

It is not just a question of representation to the stakeholders through elections, but the core issue is a binding conformity with the constitutional mandate of adherence to the democratic principles incorporated in the preamble of the Constitution itself which reads that “India shall be a Sovereign, Secular, Socialist, (vide 42nd Amendment) Democratic republic”. In any excuse and name doing away with the electoral representation would be an antithesis to the very Constitutional Concept which is not open to any waiver, condonation, marginalization or trampling.

In the absence of the people of the various States, it will be difficult to know and understand the geographical difficulties and the various issues faced by the medical professionals, medical colleges and students all over the Country. In the present regime, the members from the respective states not only keep the Council updated about the regional problems but also suggest the solutions from their wide experience in the respective States.

Further, globally Government Regulatory Body had invariably failed as is brought out by the World Medical Association in a very candid and emphatic manner.

Why can’t Members of NMC be Selected Through UPSC? GoI Stand: The Union Public Service Commission (UPSC) generally selects persons for government jobs at the induction level. Search-cum-Selection Committees are the norm for most high level appointments like members of Telecom Regulatory Authority of India (TRAI), Central Electricity Regulatory Commission (CERC), All India Council for Technical Education (AICTE), University Grant Commission (UGC) and even UPSC itself.

IMA Clarification: The regulatory bodies are constituted in order to independently manage their functioning as per the statutory regime. For this purpose, highly qualified professionals with vast experience are required and such cannot be selected by the usual methods of recruitment as adopted by the UPSC. A highly qualified and reputed professional who in the evening of the profession, will never be subjected to a recruitment process at the top of his career and such persons are always nominated or elected to manage the affairs of the apex bodies. Therefore, the appointment of such persons through UPSC is entirely impractical but also not in the interest of such bodies since highly qualified professionals will never apply for such recruitment

by UPSC.

There was no Discussion with State Governments on NMC Bill GoI Stand: Not True. The Committee under the Chairmanship of Vice Chancellor (VC), National Institution for Transforming India (NITI) solicited the views of the State Governments on the reforms required in MCI in the 1st round in May, 2016. Thereafter, the draft NMC Bill was circulated by NITI Aayog to all State Governments for their views in August 2016.

States were also invited for another round of discussion and to express their views on the draft NMC Bill in September, 2016.

IMA Clarification: Notwithstanding, the discussion with the States as claimed towards crystallization while finalizing the Bill; the material reality is that the representation of the State has been marginalized to a great extent. As a matter of fact the States would be represented in an “ex-officio manner” through the Vice Chancellor of the Health Sciences University and the

IJCP Sutra 36: Progressive deterioration of renal function is influenced by BP control especially nocturnal, drug therapy and highly abnormal glucose control. Vasc Health Risk Manag. 2017;13:231-7.

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Vice Chancellor of the traditional University to which maximum number of the medical colleges are affiliated in the given State where there is no Health Sciences University. As such, the discretion of the State to have its nominee is taken away.

Further, the definition of Health Sciences is very wide and includes under its ambit other forms of medicine, for example Ayurveda, Dental Sciences, Nursing, Unani, Siddha, Naturopathy and Yoga. The Vice Chancellor of the Health Sciences University necessarily need not be from the stream of Modern Medicine. Likewise Vice Chancellor of the traditional University, mostly, is not from the field of modern medicine.

The State/Union Territory is given minor representation on the Medical Advisory Body and at a given point of time only three members from the Medical Advisory Board will be appointed as part time members of the Commission. It is quite strange that the ‘term’ of part time members representing the State in the Commission will be 2 years, whereas the Chairpersons and other part-time members have tenure of 4-year term. It is quite significant to note that a State once represented for a period of 2 years would remain unrepresented till its next term, which would be after 10 years. Such marginalization is in the teeth of the material reality that the Article 1 of the Constitution which defines India as a Union of States. For the very reason, the concept of ‘federalism’ came to be evoked resulting in grouping of the subjects under the Central List, the State List and the Concurrent List, respectively.

Such marginalisation of States with reference to their autonomy of representation on the NMC is definitely a breach of the concept and principles governing federalism as enshrined in the Constitution.

The representation from all States, at all points of time, is extremely essential so as to understand the unique situation of the particular State so as to effectively work in the best interest of the medical education and the profession.

No Experts were Consulted During Drafting of the Bill GoI Stand: NITI Aayog held 9 meetings during which consultations took place with 14 experts out of which 10 were eminent doctors. The Committee under the chairmanship of VC, NITI sought views and suggestions of various experts including eminent physicians and surgeons; former Secretaries to the Government of India, Dept. of Health and Family Welfare; public health experts; President/Vice-President and other Members of the MCI; representatives of the

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State Governments and lawyers. The draft NMC Bill was also placed on NITI’s official website to seek views/ opinion of General Public and Experts. Also, a written request to experts was made to give their views on the draft bill. Around 14,500 mails, were received from public, experts (including those who were invited by the Committee), private medical Universities, advocacy groups, MCI and State. In addition, written submissions were also received from experts.

IMA Clarification: Consultation with the relevant stakeholders has to be honest and bonafide with due credence to the suggestions and observations gained therefrom. It should not be ‘cosmetic and for the namesake’. The Consultation as referred in this case seems to be mere lip-service because not even a ‘comma’ has been altered in the draft bill pursuant to the so called consultations and after examining 14,500 emails as claimed by the Ministry. Hence, there was no role or consultation of the experts, if any, in the drafting of the Bill.

Why has CEO, NITI Aayog been Included in the Search Committee?

GoI Stand: NITI Aayog is the highest body to advise the Government on policy matters including health and medical education and hence inclusion of the Chief Executive Officer (CEO) will add value to the selection procedure.

IMA Clarification: The fact that the NITI Aayog is only an Advisory Body to advise to the Central Government, the CEO of an Advisory Body getting included in the search committee is a definite overstepping of the ‘advisory jurisdiction’ to the ‘executive which per se is impermissible in terms of the set out principles of ‘propriety’ in the arena of demarcated governance.

There is Nobody from Outside the Profession in the Bar Council of India and ISRO GoI Stand: The DRPSC has observed that "a perspective has gained ground that self-regulation alone does not work because medical associations have fiercely protected their turf and any group consisting entirely of members from the same profession is unlikely to promote and protect public interest over and above their own self-interests and therefore check and balance mechanisms are required" (Para 3.20). They have recommended "opening Council membership to diverse stakeholders such as public health experts and social scientists, health economists, health NGOs with an established reputation, legal experts, quality assurance experts, patient advocacy groups, to name

IJCP Sutra 37: Combining omega-3 fatty acids with pioglitazone lowers blood glucose levels and improves lipid profile and insulin resistance. Prostaglandins Leukot Essent Fatty Acids. 2017 Jun 17.

Issue of the Month but a few" (Para 3.21). Prof Ranjit Roy Committee Report also recommended introduction of non-medical members in NMC for increasing transparency especially in terms of ensuring that the rights of patients are heard and protected. Similar councils in developed world such as GMC, UK the counterpart of MCI, also comprises equal number of medical and non­medical members (lay members). In NMC, given the request of medicos at the draft/consultation stage, only three non-medical experts have been added and the NMC would still be a body largely constituted of medical experts.

IMA Clarification: A person unknown to the technical functioning of the medical profession or medical education can never understand the pros and cons faced by the persons of the fraternity nor can such person be competent to give suggestions without understanding the nitty-gritty of the system. An individual cannot become a public health expert or health economist without having a qualification in the field of medicine.

As far as the NGOs are concerned, they only work in providing treatment to the needy patients and do not have any expertise either in the field of medical education or the field of medical profession. The health is a matter under the State List in the control of the State Govts., who are obliged to provide healthcare in the States, whereas the NMC Bill seeks to regulate the medical education and profession in the Country. Thus, the outsiders and NGOs have neither any qualification nor do they have any experience in such fields.

Power would be Centralized in a Few Hands Only GoI Stand: It was felt by the Committee that a large 108 member General Body as in the existing the Medical Council of India (MCI) is too unwieldy and is not conducive to good regulatory organization structure [a1]. Moreover, most regulators like AICTE, UGC, TRAI, CERC, PNGRB, AERA, etc. are small in size. Small body will be able to make decisions at a faster pace.

IMA Clarification: In the name of pruning, the size of the regulatory body, the composition of NMC under Section 4, Medical Advisory Body under Section 11, the 4 Autonomous Boards under Section 16 and other provisions vide which the experts could be co-opted and could be included in the committees in an openended manner brings out the said number to be more un-wielding, hence to say that the proposed bill has pruned the size of the regulatory body is palpably false and operationally erroneous.

However, it is true that the NMC is ‘cosmetic’ with reference to its authority and jurisdiction as it has

only ‘generic powers’ vested with it, Medical Advisory Council which is expected to meet once in year and has only ‘advisory’ jurisdiction in nature. The real power is concentrated in Four Autonomous Boards which have only 3 members including its selected Chairman with no representation through the elected members. As a result the said boards also in terms of their composition breach the vital principles of having representative, democratic and national character as a whole. The Chairman will be appointed by the Central Govt. hence won't function independently.

Three Member Autonomous Boards are Too Small GoI Stand: The three Autonomous Boards would be assisted by experts, Secretariat and Advisory Committee(s) of Experts as may be constituted by the NMC. The size has been kept small to ensure quick functioning.

IMA Clarification: In terms of the composition included at Section 16, the Autonomous Boards have 3 members only, who have all the authority vested in them. To say that the number is kept small for the quick functioning is nothing short of an apology. Other councils like Dental Council of India, Nursing Council of India, Homeopathy Council of India, etc. are all having similar structure like MCI, i.e., the various committees are having members from its general body and also members nominated from the Central Government, thus there is representation as well as rule of majority and less scope of any favoritism or personal approach. The IMA has never come across any decision which on account of a bigger membership of the specific committees, had been delayed beyond the time schedules as laid down by the Hon’ble Supreme Court.

How will the Boards be Autonomous vis-a-vis NMC? GoI Stand: Since the Presidents and members will be appointed directly by the Government, there will be a limit to the influence of NMC on the functioning of the Boards. Moreover, there is a clear segregation of powers of these four Autonomous Boards and it has been ensured that standard setting body will be different from those ensure compliance to the standards set.

NMC has two jurisdictions: (1) laying down regulations and policies guiding the boards in discharge of their duties. The Boards then get to decide autonomously individual cases in the light of the regulations laid down. (2) Exercise Appellate jurisdiction over the order of the Boards.

IJCP Sutra 38: Tobacco control programs to reduce smoking may have a significant impact on burden of type 2 diabetes. J Epidemiol. 2017 Jul 14.

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IMA Clarification: The Boards are just designated as Autonomous, for the sake of it and a bare reading of the Bill demonstrates that the said Boards would be merely seeking ‘directions’ from NMC. As if this was not enough, they would also be required to faithfully carry out the ‘directions’ issued by the Central Government from time to time on account of the membership. Further the Central Government is vested with the authority to issue directions on all matters of ‘public policy’, which would be binding in nature and mandatory in character.

Further as to what would constitute ‘public policy’ would be the sole domain and discretion of the Central Government. As such, an Autonomous Board comprising of a selected chairman with two nominated members and devoid of elected members is bound to be under the ‘directions’ of NMC and the ‘dictates’ of the Central Government looks ‘subservient’ and obediently subordinate than being Autonomous in any sense. Further, it is a fallacy to presume that Central Government Nominees cannot be influenced and elected members are readily influenced.

Full-time Members will Practically Run NMC GOI Stand: All full-time/part-time members will have the same voting rights in NMC. The only real full-time members would be the Chairperson, Presidents of the 4 Boards and Member Secretary.

IMA Clarification: The Composition of the NMC and the Autonomous Boards clearly stipulates that they would be run and managed by the full time members only. The same has been worked out with this very purpose resulting in grossest possible marginalization of part time and elected members.

The Bill is Pro-private Medical Colleges GoI Stand: Section 28(1) of the Bill states that no person shall establish a new medical college without obtaining prior permission of the MAR Board. There is no separate provision for private colleges and all the provisions apply uniformly to Government and Private medical colleges. Procedures have been simplified and outcome-based monitoring has been introduced to reduce the necessity of repeated inspections.

IMA Clarification: The proposed bill indeed is ProPrivate medical colleges because the MAR Board is entitled to look into grant of permission only for the starting of a medical college. It is totally silent in regards to the Jurisdiction of the same board in respect of starting of Postgraduate courses including Super-specialty and also increase in the annual intake of Undergraduate

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as well as Postgraduate and Super-specialty courses ongoing in concerned medical colleges/institutions.

To say that this is simplification of the procedure and reduction in repeated inspections is nothing but giving a free hand and easy access to these entitlements devoid of ‘desired checks and appropriate balances’. This is nothing short of giving an absolute free hand attempt at facilitating the private sector to capture anything and everything handily, easily, liberally and freely.

This has been drafted to favor the private medical colleges instead of medical students whose interest is supreme and is required to be looked after by the apex body in the field of medicine. It will be the Statutory duty of NMC later on, to ensure that a medical student in being provided proper teaching/training in the medical colleges, year after year as the said students will provide medical aid to the citizens of the Country.

The Bill is silent on the aspect of annual renewals required to be obtained by every college for admitting students till the time the course has been recognized by the Central Government.

As stated above, under the new Bill, the college is free to admit students without seeking annual renewals from MAR. It is important to ensure that the students pursuing their medicine courses receive proper teaching and training in their respective institutions. Therefore, it is imperative that colleges should be granted permission to admit students if they fulfil the requirement of enhanced admission capacity for which annual renewal to be obtained by the college is very crucial.

If an institution is given discretion to admit students without obtaining annual renewal then there is an apparent danger that even deficient colleges will admit students. Such students will not receive proper teaching and training in medical colleges. Thus, the career of the students will be in jeopardy as also half-baked doctors who have not received proper teaching and training will pass out from the colleges.

Free Increase in Number of Seats and Introduction of PG Courses will Affect Quality of Education GoI Stand: All increased seats would be inspected before recognition. Adherence to prescribed minimum standards would be maintained on the website of the College concerned with heavy penalties in the event of furnishing false information. Licentiate exam will ensure the quality of graduating students.

IMA Clarification: It is true that free increase in number of seats and introduction of PG courses will compromise with the desired quality of Postgraduate

IJCP Sutra 39: Lower hemoglobin level is associated with increased prevalence of diabetic peripheral neuropathy and higher vibrating perception threshold. J Diabetes Res. 2017;2017:2835981.

Issue of the Month Medical Education and result in generation of halfbaked specialists who, instead of serving the society through healthcare delivery, would pose greatest threat to its efficacy and efficiency as a whole. Further, the Licentiate exam is to ensure standard of competency after MBBS degree and not after PG degree.

In the present regime, surprise inspections are conducted so as to give permissions to start medicine courses as well as for recognition of the same. Licentiate exam is to ensure standard of competency after MBBS degree and not after PG degree. Licentiate exam cannot be used to take away the requirement of checking whether medical colleges have adequate infrastructure, teachers, etc.

Why has a Licentiate Exam been Introduced?

GoI Stand: This has been done on the basis of DRPSC recommendations (Para 6.12).

IMA Clarification: Introduction of a Licentiate Examination is an antithesis to the very objective of the proposed bill of augmenting the availability of trained health manpower for the rural healthcare delivery system. In reality, those well over 50% of the medical graduates in a roundabout manner failing to clear the said licentiate examination would be unavailable for any healthcare delivery and thus would be rendered ineligible to practice medicine. The nature of impact of the said examination could be more significant on the learners and graduates belonging to the marginalized and economically weaker sections as they would be devoid of even their livelihood. This would also undermine the sanctity of certifying standards of the various examinations conducting universities and questioning their certifying standards as a whole.

Can the Licentiate Exam be Merged with Common Final Year Exam?

GoI Stand: No format for the licentiate exam has been prescribed in the Act. As an expert body the NMC will take a call on the format and design of NLE and frame regulations after appropriate consultation. It is possible for NMC to take a decision to merge the licentiate exam with common final year exam.

IMA Clarification: No Comments.

Licentiate Exam should be Replaced by a Common Final Year Exam GoI Stand: The DRPSC had noted the demand for a common final year exam instead of an exit exam (Para 5.32) but had finally recommended a common exit exam (Para 5.34).

IMA Clarification: The final MBBS examination itself being converted into a licentiate examination is a welcome step. The same would be in tune with the objectives of the Bill to augment the availability of the trained manpower for the healthcare delivery system.

What are the Pros and Cons of a Common Final Year Exam?

GoI Stand: The biggest advantage of a common final year exam is that students will have to appear for only one examination. However, there are several issues which will have to be considered by NMC before deciding to go for a common final year exam. These include: ÂÂ

Knowledge of only 4 subjects would be tested to grant licence.

ÂÂ

Universities may not agree since their right to confer degrees would be subordinated to an exam conducted by NMC.

ÂÂ

Those who fail would have to stay behind in the concerned medical college, leading to issues of infrastructure and extra fees payment. They would not even become graduates in order to qualify for various recruitment examinations which are open to graduates.

ÂÂ

Students tend to repeat NEET-PG in order to improve their rank, so that they can get admission to PG courses in good colleges. Rank improvement will not be possible with a common final year exam.

ÂÂ

NMC would become party to all litigation related to local issues in colleges. In the event of a stay order granted due to local reasons such as delayed session in a college, the entire licentiate exam will get affected.

ÂÂ

Foreign medical graduates who wish to practice in India would either have to be asked to rewrite the common final year exam or FMGE will have to be restored.

IMA Clarification: The common final year examination is difficult with respect to its feasibility and also its legal permissibility because, the authority of conducting examination, assessment thereto, declaring results and conferring the academic degree is exclusively within the ambit, authority and jurisdiction of the University which is explicitly covered vide the definition included in Section 2(f) and Section 3 of the UGC Act, 1956.

Further, the University is a ‘State’ by itself within the scope and meaning of Article 12 of the Constitution of India.

IJCP Sutra 40: Poor adherence to diabetes treatment is associated with higher HbA1c levels only when HbA1c ≥8%. Diabetes Metab Syndr. 2017 Jul 3.

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Will Graduates of AIIMS, etc. be Required to Take the Licentiate Exam?

GoI Stand: This would not be required since the Institutes of National Importance have their own Act of Parliament and do not fall within the purview of NMC. However, if they wish to take up post-graduation in any medical college within the purview of NMC, then they would have to take the licentiate exam as it will be utilized for post-graduate admissions also.

IMA Clarification: Primarily, there is no relevance for a licentiate examination and more so keeping students passing out from institutions like AIIMS outside its ambit is discriminatory and a breach of guarantee of equality without any discrimination enshrined in the Constitution.

Can the Licentiate Exam be Repeated for Rank Improvement?

GoI Stand: Yes, the exam can be repeated to improve rank for PG admissions.

IMA Clarification: The concept of licentiate examination itself is unnecessary and uncalled for.

NMC has Very Little Representation of States GoI Stand: Three members on rotational basis and 5 elected members would represent States. Thus, 8 out of 25 members will be representing States.

IMA Clarification: The representation of States genuinely is minuscule and has been made more so by taking away its discretion to nominate its nominee and providing states ‘rotational representation’ for a limited term of 2 years and thereafter the State remaining unrepresented for a period of 10 years, is nothing short of mockery of the State representation on the NMC and is a grossest possible onslaught on the concept of Federalism incorporated in the Constitution of India.

Such marginalization is in the teeth of the material reality that the Article 1 of the Constitution, which defines India as a Union of States. For the very reason, the concept of federalism came to be evoked resulting in grouping of the subjects under the Central List, the State List and the Concurrent List, respectively.

Such marginalization of States with reference to their autonomy of representation on the NMC is definitely a breach of the concept and principals governing federalism.

The representation from all States, at all points of time, is extremely essential so as to understand the unique

848

situation of the particular State so as to effectively work in the best interest of the medical education and the profession.

There should be Representation from AYUSH Streams in NMC GoI Stand: NMC is primarily meant to regulate education and practice of modern medicine.

IMA Clarification: There cannot be a representation from AYUSH streams in NMC because alternative stream of medicine does not have any commonality in the education of the profession.

The Member Secretary should be Appointed by NMC, not the Government GoI Stand: Even if Secretary is appointed by the NMC, prior approval of ACC would be required as per standing DOPT instructions. These instructions are invariably followed even in the appointment of Directors of AIIMS, and other Institutes of National Importance.

It stands to reason that appointment of Member Secretary also should be through the same rigorous selection procedure as is followed for Chairperson NMC and Presidents of Autonomous Boards.

IMA Clarification: In order to ensure that there is greater autonomy the member secretary of the Commission has to be appointed by the Commission and must belong to the stream of modern medicine. This is for the simple reason that the secretary has to deal with not only the ‘administrative matters’, but also the matters pertaining to the ‘Medical Education’.

Apart from broadening the eligibility clause for the post of secretary, the proposed bill contemplates the age of superannuation to be raised to 70 years for the incumbent to the post of secretary which exclusively goes to indicate that the entire scheme is solely aimed at the rehabilitation of retired bureaucrats.

Retrenchment of Existing MCI Staff will Cause Hardship GoI Stand: Adequate compensation will be paid to all such employees as specified in Proviso 2, Section 58(3) of the Act. In view of the past legacy of MCI, it will not be advisable to take these employees into the NMC secretariat.

IMA Clarification: Retrenchment of the existing employees of the MCI from their permanent employment is not only ‘inhuman, barbaric’ but also bad in law. As such, it tramples upon the mandate vested with a citizen of decent and dignified living

IJCP Sutra 41: Laparoscopic sleeve gastrectomy provides good long-term weight loss results along with long-standing resolution or improvement of diabetes. Surg Obes Relat Dis. 2017 Jul 18.

Issue of the Month through sources of livelihood as his fundamental right guaranteed under Article 21 of the Constitution, but also, infringes upon Article 12 of the Constitution whereby this employment is in the ambit of a designated State who is duty bound to be an ‘ideal employer’ in perception and reality. Further, the experience gained by the employees over the years could be utilized in a better and effective way by absorbing them at the equivalent post in the new body.

Why has a Separate Autonomous Board been Constituted as an Accreditation Body Instead of Relying on NAAC? GoI Stand: The National Assessment and Accreditation Council (NAAC) accreditation is not mandatory.

Moreover, accreditation of medical colleges needs to be done on specialized parameters rather than the general parameters used by NAAC. Medical Education (ME) is a specialized area which needs technical expertise for evaluation. AICTE is a separate accreditation body to regulate technical institutions. Similar kind of structure is required to accredit ME institutions.

IMA Clarification: An independent accreditation board autonomous in character exclusively for medical education is desired and warranted. NAAC for that matter is a creation under the UGC Act and by the very nature of operation is for the accreditation of Higher education Institutions and not exclusively for the medical education Institutes. Likewise the National Accreditation Boards under the AICTE Act is for Engineering and Technological Institutions.

There is no Representation of SC/ST/OBC in NMC GoI Stand: There was no representation in MCI also.

Other regulators such as AICTE, UGC CERC, TRAI, AERA, etc. also do not have any such representation.

IMA Clarification: The observation thereat is concurred with.

Medical Research is a function of ICMR, not NMC GoI Stand: Section 10(1)(a) of the NMC Act empowers the NMC to "lay down policies for regulating medical institutions, medical researches and medical professionals and make necessary regulations in this behalf". The reference here is to medical research as is carried out in medical colleges as defined in Section 2(i). There is no intention to assume the role of Indian Council of Medical Research (ICMR).

IMA Clarification: The observation thereat is concurred with.

Developing a roadmap for Human Resources in Health and Healthcare Infrastructure is a Function of the Health Ministry, not NMC GoI Stand: NMC’s stand on utilizing medical professionals under the proviso of Section 33, increasing the number of medical seats in the country and designing courses under Section 49(4) has to be shaped by an assessment of the requirements of human resources for health and healthcare infrastructure. MCI did not take active interest in any such planning for the future. The roadmap referred to in this subsection pertains to the future course of action to be adopted by NMC itself.

IMA Clarification: It is the considered opinion that the development of the road map in human resources in health and healthcare infrastructure is totally the function of the Government of India and does not have any concern with the medical education or its profession.

Will there be any Change in the Role of State Medical Councils?

GoI Stand: Under the MCI Act, State Medical Councils look after registration of medical practitioners and enforcement of professional ethics. They will continue to perform these roles. NMC Bill does not poach upon the role of State Medical Councils. It rather promotes the States to constitute State Medical Councils within 3 years of the commencement of this Act. (Clause 30(1)).

IMA Clarification: The proposed Bill is aimed as destroying the autonomy of the State Medical Councils.

NMC, the MAR Board and the Central Government all have been vested with the statutory authority vide explicit governing provisions to issue ‘directions’ binding in nature and mandatory in character to the State Medicine Councils, inspite of the fact that State Councils are the creation of the respective State legislative enactment on the premise that ‘health is a state subject’ and therefore cannot be trespassed in any mode or manner by the Central Government.

However, it is interesting to note that in case on a same subject, directions issued by the three authorities are different and divergent from each other, which one to be obeyed would be a big exercise in itself. More so, such a draconian position resulting in subservience of the State Medical Councils is a big blow to the concept of Federalism as enshrined in the constitution as one of its special and unique features.

Fine up to 10 times the Annual Fees will Give a Handle for Extortion by Inspectors GoI Stand: At present penalties are not graded. It is binary; either recognition or de-recognition. This gives

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huge leeway to the assessors/inspectors of MCI to extract rent. A graded system of monetary penalties with derecognition after 3 instances of continued violation and increasing fines are exhausted will actually be more corrective and less extractive than the current provisions of MCI Act. It is further specified in Section 26(1)(f) that the imposition of monetary penalty would be accordance with the regulations made for this purpose.

IMA Clarification: The imposition of a penalty in terms of heavy fines is open to the likelihood of it being abused is quote imminent, ultimately opening floodgates for free flowing corruption. In the present MCI Act, penalty provision is graded. Initially, in view of deficiencies permission is not recommended by MCI to admit new batch and after giving number of opportunities to rectify deficiencies, if the institution fails to rectify than only de-recognition is recommended to Central Government.

Thereafter, it is Central Government takes a final call on the recommendation of MCI. In this way, the medical college is given opportunity to bring up the infrastructure and other facilities in their college. In any case, a fine or penalty can never be in the interest of medical education once the students have already completed their course in a half baked medical college and also not in the interest of the medical profession as once these half baked doctors start medical practice the same will be detrimental to the public.

Penalty up to 10 Times of the Annual Fee will be Insignificant for Government Colleges GoI Stand: Any penalty on a Government College has to be paid through the consolidated fund. Irrespective of the total amount involved, such unnecessary penal expenditure would be scrutinized by auditors, finance departments and the legislature. Such inbuilt accountability will ensure that corrective action is taken by the concerned State government.

IMA Clarification: No Comments.

Why has a parallel PG degree in the Form of DNB been retained?

GoI Stand: On account of its design, the DNB course allows post-graduate education in comparatively smaller towns, which may not have medical colleges.

This would help in improving the geographical location of PG seats. Moreover, there is a severe shortage of faculty for medical colleges. To meet the expanded demand for faculty, we need to recognize DNB as equivalent to specialist.

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IMA Clarification: Retention of the parallel PG degree in the form of DNB is questionable because the parity thereto itself is disputable on several academic and administrative considerations. The courses being mostly run in non-teaching hospitals which are devoid of full time faculty, handy clinical material, structured teaching schedule, required academic monitoring and planned skill inculcation. This results in compromised teaching and learning and therefore ending up in generation of compromised specialists and a resultant compulsive compromise with the resultant healthcare delivery system catering to the cause of people in the country.

No Steps have been Proposed to Encourage Setting up of Medical Colleges in Remote Areas GoI Stand: Not true. NMC Bill provides for relaxation of criteria for the medical colleges which are set up in underserved areas which would be specified in the regulations to the Act (Proviso to Clause 29 [d]). Further, to address this issue, Government of India is running a scheme to set up 58 medical colleges in underserved areas. Twenty-four more medical colleges are proposed to be taken up in the second phase. In order to enhance the availability of faculty, DNB qualification has been made completely equivalent to MD/MS in the NMC Act and adequate provisions have also been made to allow foreign faculty. The question of allowing equated designations to consultants has to be dealt in the regulations for qualifications of teachers by NMC. IMA Clarification: In this regard, the suggestion of the MCI is worthwhile, wherein they have proposed a National Perspective Development plan for geographic location of new medical colleges to be established by the Government. The said locations would be on the basis of a socioeconomic backwardness of the reason and therefore the resultant accrual of the priority. The said proposition is in tune with the mandate included under Article 371 (2) of the Constitution of India.

Second Appeal to Government is not Proper Since Government Only would be Deciding Matters GoI Stand: All decisions would be taken by Autonomous Boards and first appeal shall lie with NMC. Government will have no role in decision making and will only serve as an appellate body for individual cases. Judicial remedy would continue to be available after Government decides appeals.

IMA Clarification: The second appeal lying with the government is an antithesis to the so called autonomy accorded to NMC. It has been handily made available

IJCP Sutra 43: Stigmasterol treatment has emerged as a potential strategy to protect β-cell function during the progression of diabetes. Sci Rep. 2017;7(1):9536.

Issue of the Month to the Government to be sitting over the decisions of the NMC and yet calling them autonomous. This proves the point that the Central Government shall take over the NMC as its department/wing and make it function as per its policy.

Why has the Provision for imprisonment of quacks been removed?

GoI Stand: Under the MCI Act, the penalty for unregistered practitioners was imprisonment up to 1 year and/or fine up to Rs. 1,000. This has been replaced by a fine between Rs. 1 lakh and 5 lakhs.

It may be noted that the incidence of imprisonment under the existing provisions is extremely low and monetary penalty should prove to be a more effective enforceable provision. Further, The Indian Penal Code (IPC) provides for imprisonment of up to 2 years for death caused due to negligence. This Section 304A can be applied to medical professionals when there is gross negligence. The following sections of IPC 1860 contain the law for medical malpractice in India: 52, 80, 81, 83, 88, 90, 91, 92 304A, 337 and 338. Hence, the Bill in consideration refrains from creating a new/ additional law to deal with criminal misconduct of doctors. In any case, numerous litigations are pending and thus it has become difficult to enforce provisions.

IMA Clarification: The need of the hour is that the Government of India should come out explicitly with the Anti Quackery Bill which is pending since long and which could prove to be an answer to the substantial ills which are plaguing the healthcare delivery system in the country. Perhaps it is the lack of the political will that is coming in the way and therefore the compulsion of evoking prepositions which are nothing short of lip sympathy than a real answer to the panacea of ills plaguing the scenario.

Why has Prior Approval not been Mandated for regulations to be Made by NMC? GoI Stand: The process of consultations has been made mandatory by specifying in Section 55(1) that regulations would be made only after previous publication. It is also specified that regulations must be consistent with the NMC Act and the rules made thereunder. With these stipulations, full autonomy has been granted to NMC to make regulations.

IMA Clarification: The requirement as stipulated in Section 55(1) of the proposed bill pertaining to the mandatory process of consultation with the Government of India for prescribing regulations is

antithesis to the required autonomy of the regulatory body as the experience says that the same has been time consuming and as a result of which the timely implementations of the proposed regulations does not take place. It has been the consistent experience that Government had taken several years to approve many recommendations of MCI on amendments of regulations for better quality education including those in the academic domain which have resulted in lack of timely implementation and loss of timely relevance.

How will NMC Ensure More Accountability?

GoI Stand: Rigorous and independent selection of members through a transparent process will ensure greater accountability. The DRPSC felt that "keeping in mind the disastrous experience with an elected regulatory body, regulators of the highest standards of professional integrity and excellence have to be sought by the Government through a rigorous selection process" (Para 3.16). Four Autonomous Boards have been suggested which are given autonomy to frame policies, standards, guidelines, etc. These four autonomous Boards will function under the NMC. There is clear segregation of powers of these four Autonomous Boards. Further, Central Government has power to give directions and supersede to Commission as well as Autonomous Boards.

IMA Clarification: As a matter of fact the discretionary powers that have been vested with the Autonomous Boards, the Central Government and NMC all are open for liberal abuse and end up in patronizing corruption in a handy and free-flowing manner. This by itself is an indication of acute paucity of required ‘checks and balances’ which should have been worked out in the proposed bill, but unfortunately have not been provided for in any mode or manner. Resultantly, the concept of accountability has been badly and grossly compromised in its entirety.

Having one representative of Each State in the MAC is unfair to States having a Large Number of doctors GoI Stand: Each State is represented in the MAC so that the benefit of the States’ experiences on policy matters can be obtained and also State specific issues can be raised. The Vice Chancellor of the Health University or university having maximum number of medical colleges would represent the State. The intention is not to have representation of doctors in proportion to their strength in their State.

IJCP Sutra 44: Early glycemic and BP control should be considered, perhaps even in the prediabetic stage for preventing diabetes-related decline in cognitive performance.

Diabetes Care. 2017 Aug 25.

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IMA Clarification: The representation of the State as a whole has been marginalized and they have been reduced down to nonentities which is a big blow to the vital Constitutional concept of Federalism, which is tragic and unfortunate.

Doctors who fail the Licentiate Exam will be allowed to Practice Under the proviso to Section 33 GoI Stand: The proviso to Section 33 is not meant to allow doctors failing the NLE to practice but is intended to allow medical professionals like nurse practitioners, dentists and possibly any shorter duration allopathy courses introduced by NMC in future.

IMA Clarification: This is one more discretionary avenue to be availed for permitting the failed graduates at the national licentiate exam which apart from being discretionary is also discriminating and open for grossest possible abuse. To say that the proviso to Section 33 is meant for allowing nurse practitioners, dentists to practice modern medicine is a figment of imagination for want of explicit provision incorporated in the present Bill and therefore to that extent is misleading in nature and statutorily impermissible in character.

Why have Only 40% Seats been regulated in terms of fees?

GoI Stand: There was no provision of regulation of fees in the Indian Medical Council (IMC) Act. Regulation of 40% seats is a step forward. The proportion of regulated seats has a direct impact on the fees of remaining seats and a reasonable balance has to be struck so that the fees of unregulated seats do not become unviable.

IMA Clarification: The provision for regulation of fees for seats up to 40% means anything from 0% to 40%, whereby at any given point of time 60% of the seats in private medical college would be outside the said ambit of prescription and the largest chunk could be freely available for the private managements to have a free field. As such, the said discretionary provision is pro-rich and anti-poor. Moreover, fees of all 100% seats in a private medical colleges are fixed by the respective State Governments. In the present regime after the introduction of NEET Examination, it is only the Deemed Universities, which are outside the said ambit and jurisdiction, primarily on the count that as they are created under Section 3 of the UGC Act, 1956, which is a Central enactment, and have an All India character, the chargeable fee thereat cannot be regulated by the State Government But then is it not the onus of the Central Government to take them under their fold by explicit provisions to be incorporated,

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which is missing in the proposed Bill and therefore it goes a long way in reflecting the intention of the Central Government on the required count.

Why canâ&#x20AC;&#x2122;t a Cap be proposed on the fees for all seats?

GoI Stand: The cost of setting up medical colleges varies from State to State and according to the quality of infrastructure created. Moreover in the case of PG seats, the fee varies widely between pre- and paraclinical subjects and highly sought after subjects on the other hand. Hence, a uniform cap on the fees that can be charged would be difficult.

IMA Clarification: Fees of all seats in private colleges are fixed by the respective State Governments.

Admissions in Deemed universities are made by the Central Government and no fee is fixed by the Central Government in these colleges, which by itself is a contradiction and perhaps a conscious way availed by the Central Government of providing Deemed Universities a free hand for themselves.

Regulation of fees of 40% seats would lead to regulation of SC/ST/OBC Seats Only GoI Stand: SC/ST/OBC quota in medical education is confined to Government/State quota seats only.

Fees for all State quota seats would be fixed by State Governments, out of which fees of 40% seats could be fixed in accordance with NMC guidelines.

IMA Clarification: It is not correct that SC/ST/OBC reservations are only in government colleges. There are states where reservations of SC/ST/OBC also exist in private colleges, as well.

What is the proportion of seats for which Fees is fixed by State Governments under the Present Dispensation?

GoI Stand: This varies from State to State according to the MoUs signed by private medical colleges.

Generally, 33-50% of seats in private medical colleges are designated as State quota seats. In most States, fees of seats in deemed universities is not regulated by State Governments.

IMA Clarification: Fees of all seats in private colleges are fixed by the respective State Governments.

Admissions in Deemed Universities are made by the Central Government and no fee is fixed by the Central Government of even one seat in these colleges under the ambit of Deemed Universities, which speaks volumes about the intent of the Central Government on letting them a free hand of their own.

IJCP Sutra 45: Increased long-term variability of postprandial glucose significantly enhances the risk of prolonged QTc interval. PLoS One. 2017;12(8):e0183055.

Issue of the Month Why has a provision for Bridge Course for AYUSH been Added in Section 49(4)?

GoI Stand: India has a doctor-population ratio of 1:1655 as compared with the WHO standards of 1:1000. In addition, city doctors are not willing to work in rural areas as can be seen in the Urban Rural ratio of doctor density (3.8:1). There are 7,71,468 AYUSH practitioners in India who can be leveraged to improve the health access situation of the country.

There is already a policy for co-locating AYUSH and allopathy to ensure better utilization of resources.

Further, with the government’s ambitious target to revamp 1,50,000 Sub Health Centers into Health and Wellness Centers, there is a need of large human resource to meet this challenge. AYUSH has an effective role in integrating the preventive and promotive aspect of healthcare. In addition, with growing incidence of non-communicable diseases (NCD), there is a need to provide holistic prevention and treatment of diseases.

In many places around the world doctors are not taking care of the preventive and wellness aspect of healthcare.

Countries such as Thailand, Mozambique, China and New York have regularized community health workers/ non-allopathic health providers into mainstream health services, with improved health outcomes. We also need to take such kind of steps when we have acute shortage of doctors and specialists.

The NMC bill seeks to fill in the gaps of availability of healthcare personnel by facilitating trained AYUSH practitioners to expand their skill sets through a Bridge Course and provide preventive and promotive allopathic care. The bridge course may help address this demand and better utilization of resources, and make the health sector a bigger provider of employment. The NMC Bill also promotes this through raising exposure of such NCD patients to non-allopathic practitioners in addition to allopathic doctors.

Thus, in order to homogenize and regulate the entry of AYUSH professionals towards practicing modern medicine through a strict regime, this bill has provided for the clause. Various States such as Maharashtra, Assam, UK, Haryana, Karnataka and Uttar Pradesh, etc. have already amended their Acts and permitted AYUSH professionals to practice modern systems and prescribe all modern medicines.

Any bridge course will be introduced only by a unanimous vote as provided in Section 49(4) and hence each one of the allopathic doctors in the NMC will have a veto power. Even if the bridge course is introduced, it will only be for prescribing specified

medicines at specified levels. The provision is intended for prescribing a small number of medicines including OTC drugs at the Sub-Center/PHC level.

IMA Clarification: The provision for a ‘Bridge course’ in the proposed bill is nothing short of providing a ‘Backdoor entry’ to AYUSH and Homeopathy practitioners into Medical Profession which apart from generating a ‘mixed pathy’ would also severely endanger the pure practice of Ayurveda and Homeopathy which the Government proclaims of patronizing in a big way.

This by itself is also an antithesis to the entire policy declaration and objectives structured for evoking a separate Department of AYUSH as a whole. It was also be a large public danger since persons without knowledge and experience will start treating patients in another system of medicine.

Instead of a Bridge Course for AYUSH, the focus should have been on Nurse Practitioners and dentists GoI Stand: Nurse practitioners and dentists can be allowed under the proviso to Section 33, which is applicable to ‘medical professionals’. It needs to be clarified that all professionals associated with modern medicine systems fall in this category and not only MBBS doctors.

IMA Clarification: Any backdoor entry through a ‘Bridge course’, be it AYUSH doctors or Dentists or Nurse Practitioners is palpably bad, uncalled for, legally impermissible, morally wrong, ethically bad and undesirable as well. It cannot be allowed as the same relates to risking a human life.

What was the need to include a clause for prescription of Allopathic Medicine by Suitably Educated AYUSH doctors?

GoI Stand: As per Supreme Court rulings, AYUSH doctors cannot prescribe any allopathic medicine until there is a provision in the Act. In view of this, an enabling provision is required in the Act. IMA Clarification: The ‘enabling’ provision in the proposed bill providing AYUSH and Homeopathy practitioners into medical profession is inconsistent with the definition of the word ‘medicine’ included in section 2 of the proposed bill. In legislative parlance there is no place for any enabling provision which is not in tandem with the definition statutorily incorporated.

To that extent the said enabling provision turns out to be inconsistent with the required legislative parlance.

Bridge course would be unscientific and dangerous GoI Stand: NMC will be dominated by allopathic doctors. If all of them unanimously approve a bridge

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course after due consideration, then there is no reason to assume that it will be unscientific and dangerous.

The course would be designed in such a manner that it would enable the participants to prescribe a limited set of medicines in a responsible manner.

IMA Clarification: The concept of the bridge course itself being unacceptable, its standardization in any form, rhyme, reason and for that matter any purpose is superfluous, unwarranted, undesired and uncalled for. Apart from the intrinsic vulnerabilities of the said course not only being unscientific it will also end up in posing avoidable dangers. It will completely dilute the standards of medical education which is imperative for producing well equipped doctors and will lead to risking the human lives.

Would AYUSH Doctors Doing the Bridge Course be Under Dual Control?

GoI Stand: Yes, control over their professional conduct would be exercised by the respective Councils/Commission depending on the medicine prescribed by them.

IMA Clarification: Dual control in respect of AYUSH practitioners including that of parent registering council and the NMC respectively is legally impermissible.

The provision for disciplinary jurisdiction on them is not explicitly provided. To that extent the lacuna is substantial and cannot be allowed, as it entails conferment of practicing privileges without any ethical, moral and value based embargo which is tragic and unfortunate as it amounts to a total compromise with ethical and moral practice of the profession.

Enabling AYUSH practitioners to prescribe medicines in Rural Areas would Relegate Rural Citizens to being Second Rate Citizens GoI Stand: Healthcare delivery works on a referral system so that it does not put an extra load to the

secondary and tertiary care facilities. Many SCs and PHCs i.e., point of contact in rural areas are functioning without doctors. AYUSH practitioner may, if posted, can provide better care. It is expected that the quality of primary and preventive healthcare available to rural citizens would improve as a result of giving proper training to AYUSH doctors. This also needs to be viewed in the light of certain states having already permitted them to practice modern medicine.

IMA Clarification: Any compromised, half-baked, ill prepared health practitioner through an impermissible modality in the name of providing manpower to the rural healthcare delivery would amount to generating compromised health personnel for the rural healthcare and thereby treating them as ‘second grade citizens’ and putting them to blatant discrimination and differentiation, which is constitutionally impermissible.

It is very strange that instead of giving incentive to the medical professionals to serve in the rural areas, the bill proposes to allowing unqualified persons to treat patients and risk their lives.

The provision of introducing a Bridge Course Only on Completely Unanimous Approval is Too restrictive and will be Difficult to Operationalize GoI Stand: Such a stringent condition has been incorporated in order to ensure that there is absolutely no doubt or misgiving about the course of action to be adopted.

IMA Clarification: Providing for a provision and then saying it will be difficult to operationlize in itself is a questionable legislative operation which ‘validates’ the intent and then explicitly goes to ‘dispute’ the content. Such a legislative exercise and interpretation thereto by the proposing Govt. itself is unheard of and prima facie appears to be too naive to fetch any credibility or credence of even the slightest magnitude.

■■■■

Formula of 5 to Prevent Diabetes Diabetes can be prevented by controlling five lifestyle factors: ÂÂ

Follow a healthy diet

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Maintain an optimal body weight (less than 23 × height in meters × height in meters)

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Quit smoking.

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IJCP Sutra 47: Moderate increases in physical activity reduces fasting glucose as well as HbA1c levels significantly. Acta Diabetol. 2017 Aug 24.

SANGHI MEDICALCENTRE (P) Ltd. World Class DiagnosticCenter Center World Class Diagnostic

Patient Services Offered

Fully Computerized Automated Laboratory

Radiology & Imaging Facilities

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Corporate Office ADDRESS Sanghi Medical Centre Pvt. Ltd. S-51, Greater Kailash – I, New Delhi – 110048 Tel.: +91 11 29232010, +91 11 29234400

Audiometry

Cardiology Facilities Laboratory

Every citizen of India should have the right to accessible, affordable, quality and safe heart care irrespective of his/her economical background

Sameer Malik Heart Care Foundation Fund An Initiative of Heart Care Foundation of India

E-219, Greater Kailash, Part I, New Delhi - 110048 E-mail: heartcarefoundationfund@gmail.com Helpline Number: +91 - 9958771177

“No one should die of heart disease just because he/she cannot afford it” About Sameer Malik Heart Care Foundation Fund

Who is Eligible?

“Sameer Malik Heart Care Foundation Fund” it is an initiative of the Heart Care Foundation of India created with an objective to cater to the heart care needs of people.

Objectives Assist heart patients belonging to economically weaker sections of the society in getting affordable and quality treatment.

Raise awareness about the fundamental right of individuals to medical treatment irrespective of their religion or economical background.

Sensitize the central and state government about the need for a National Cardiovascular Disease Control Program.

Encourage and involve key stakeholders such as other NGOs, private institutions and individual to help reduce the number of deaths due to heart disease in the country.

To promote heart care research in India.

All heart patients who need pacemakers, valve replacement, bypass surgery, surgery for congenital heart diseases, etc. are eligible to apply for assistance from the Fund. The Application form can be downloaded from the website of the Fund. http://heartcarefoundationfund.heartcarefoundation. org and submitted in the HCFI Fund office.

Important Notes The patient must be a citizen of India with valid Voter ID Card/ Aadhaar Card/Driving License.

The patient must be needy and underprivileged, to be assessed

by Fund Committee.

The HCFI Fund reserves the right to accept/reject any application for financial assistance without assigning any reasons thereof.

The review of applications may take 4-6 weeks.

All applications are judged on merit by a Medical Advisory Board who meet every Tuesday and decide on the acceptance/rejection of applications.

The HCFI Fund is not responsible for failure of treatment/death of patient during or after the treatment has been rendered to the patient at designated hospitals.

To promote and train hands-only CPR.

Activities of the Fund Financial Assistance

The HCFI Fund reserves the right to advise/direct the beneficiary to the designated hospital for the treatment.

Financial assistance is given to eligible non emergent heart patients.

Apart from its own resources, the fund raises money through donations, aid from individuals, organizations, professional bodies, associations and other philanthropic organizations, etc.

The financial assistance granted will be given directly to the treating hospital/medical center.

After the sanction of grant, the fund members facilitate the patient in getting his/her heart intervention done at state of art heart hospitals in Delhi NCR like Medanta – The Medicity, National Heart Institute, All India Institute of Medical Sciences (AIIMS), RML Hospital, GB Pant Hospital, Jaipur Golden Hospital, etc. The money is transferred directly to the concerned hospital where surgery is to be done.

Drug Subsidy

The HCFI Fund has the right to print/publish/webcast/web post details of the patient including photos, and other details. (Under taking needs to be given to the HCFI Fund to publish the medical details so that more people can be benefitted).

The HCFI Fund does not provide assistance for any emergent heart interventions.

Check List of Documents to be Submitted with Application Form Passport size photo of the patient and the family A copy of medical records Identity proof with proof of residence Income proof (preferably given by SDM)

The HCFI Fund has tied up with Helpline Pharmacy in Delhi to facilitate

BPL Card (If Card holder)

patients with medicines at highly discounted rates (up to 50%) post surgery.

Details of financial assistance taken/applied from other sources (Prime Minister’s Relief Fund, National Illness Assistance Fund Ministry of Health Govt of India, Rotary Relief Fund, Delhi Arogya Kosh, Delhi Arogya Nidhi), etc., if anyone.

The HCFI Fund has also tied up for providing up to 50% discount on imaging (CT, MR, CT angiography, etc.)

Free Diagnostic Facility

Free Education and Employment Facility

The Fund has installed the latest State-of-the-Art 3 D Color Doppler EPIQ 7C Philips at E – 219, Greater Kailash, Part 1, New Delhi.

HCFI has tied up with a leading educational institution and an export house in Delhi NCR to adopt and to provide free education and employment opportunities to needy heart patients post surgery. Girls and women will be preferred.

This machine is used to screen children and adult patients for any heart disease.

Laboratory Subsidy HCFI has also tied up with leading laboratories in Delhi to give up to 50% discounts on all pathological lab tests.

About Heart Care Foundation of India

Help Us to Save Lives The Foundation seeks support, donations and contributions from individuals, organizations and establishments both private and governmental in its endeavor to reduce the number of deaths due to heart disease in the country. All donations made towards the Heart Care Foundation Fund are exempted from tax under Section 80 G of the IT Act (1961) within India. The Fund is also eligible for overseas donations under FCRA Registration (Reg. No 231650979). The objectives and activities of the trust are charitable within the meaning of 2 (15) of the IT Act 1961.

Heart Care Foundation of India was founded in 1986 as a National Charitable Trust with the basic objective of creating awareness about all aspects of health for people from all walks of life incorporating all pathies using low-cost infotainment modules under one roof.

HCFI is the only NGO in the country on whose community-based health awareness events, the Government of India has released two commemorative national stamps (Rs 1 in 1991 on Run For The Heart and Rs 6.50 in 1993 on Heart Care Festival- First Perfect Health Mela). In February 2012, Government of Rajasthan also released one Cancellation stamp for organizing the first mega health camp at Ajmer.

Objectives Preventive Health Care Education Perfect Health Mela Providing Financial Support for Heart Care Interventions Reversal of Sudden Cardiac Death Through CPR-10 Training Workshops Research in Heart Care

Donate Now...

Heart Care Foundation Blood Donation Camps The Heart Care Foundation organizes regular blood donation camps. The blood collected is used for patients undergoing heart surgeries in various institutions across Delhi.

Committee Members

Chief Patron

President

Raghu Kataria

Dr KK Aggarwal

Entrepreneur

Padma Shri, Dr BC Roy National & DST National Science Communication Awardee

Governing Council Members Sumi Malik Vivek Kumar Karna Chopra Dr Veena Aggarwal Veena Jaju Naina Aggarwal Nilesh Aggarwal H M Bangur

Advisors Mukul Rohtagi Ashok Chakradhar

Executive Council Members Deep Malik Geeta Anand Dr Uday Kakroo Harish Malik Aarti Upadhyay Raj Kumar Daga Shalin Kataria Anisha Kataria Vishnu Sureka

This Fund is dedicated to the memory of Sameer Malik who was an unfortunate victim of sudden cardiac death at a young age.

Rishab Soni

HCFI has associated with Shree Cement Ltd. for newspaper and outdoor publicity campaign HCFI also provides Free ambulance services for adopted heart patients HCFI has also tied up with Manav Ashray to provide free/highly subsidized accommodation to heart patients & their families visiting Delhi for treatment.

http://heartcarefoundationfund.heartcarefoundation.org

NEUROLOGY

Dyke-Davidoff-Masson Syndrome SASI SEKHAR TVD*, A GOPALA KRISHNA RAO†, SATISH P‡, SASHIDHAR REDDY G#, SARAT M#

Abstract Dyke-Davidoff-Masson syndrome (DDMS) is characterized by seizures, facial asymmetry, contralateral hemiplegia and mental retardation. Characteristic radiological features are cerebral hemiatrophy with homolateral hypertrophy of skull and sinuses.

We report a case of DDMS in a 21-year-old male who presented with generalized tonic-clonic seizures, hemiparesis of the left hand and leg with deformity of the left upper limb and left lower limb and also deviation of the mouth to left.

Keywords: Hemiatrophy, hemiparesis, seizures

F

irst description of Dyke-Davidoff-Masson syndrome (DDMS) dates back to 1933, when Dyke, Davidoff and Masson described the plain skull radiographic and pneumatoencephalographic changes in a series of 9 patients.1 Since, then only few pediatric cases of DDMS have been reported.

Neurological examination: There was asymmetry of face (Fig. 1) and body and no neurocutaneous marker was seen. Cranial nerves: Right UMN facial palsy was present left-sided spastic hemiparesis, brisk tendon reflexes (Fig. 2), hematological profile and cerebrospinal fluid (CSF) were normal.

Figure 1. Facial deviation to left.

Case Report A 21-year-old male, born full-term through normal vaginal delivery presented with recurrent generalized tonic-clonic seizures since 5 years, there was no history of significant antenatal or perinatal complication. The present complaint started at the age of 3 years when the boy suddenly had vomiting and loose stools following which he developed weakness of left upper and lower limb.

*Associate Professor †Professor Dept. of Medicine ‡Assistant Professor Dept. of Radiology #Postgraduate Dept. of Medicine Dr Pinnamaneni Siddhartha Institute of Medical Sciences and Research Foundation, Chinoutpalli, Andhra Pradesh Address for correspondence Dr Sasi Sekhar TVD Dr Pinnamaneni Siddhartha Institute of Medical Sciences and Research Foundation, Panchayat Road, Chinna Avutapalli, Krishna, Gannavaram, Andhra Pradesh - 521 286

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Figure 2. Left hemiparesis with wasting.

CT scan of brain: Diffuse atrophy of right cerebral parenchyma was noted with dilatation of right lateral ventricle and right cerebral sulcal spaces (Fig. 3). Mild thickening of skull vault bones on right side noted.

IJCP Sutra 48: Increase in hepatic lipid content and impaired proinsulin conversion are novel factors that prognosticate nonresponse to lifestyle intervention, independent of change in body weight. Diabetologia. 2017 Aug 24.

NEUROLOGY due to brain damage (usually traumatic) occurring in first 3 years of life.2 Hemiatrophy of one cerebral hemisphere is not frequently encountered in clinical practice. When this develops early in life (during the first 2 years) certain cranial changes like homolateral hypertrophy of the skull and sinuses occur. The compensatory cranial changes occur to take up the relative vacuum created by the hypoplastic cerebrum.

Figure 3. CT scan of the brain: Dilatation of right lateral ventricle and right cerebral sulcus spaces.

The classical clinical presentation includes seizures, facial asymmetry, contralateral hemiplegia or hemiparesis and mental retardation. However, mental retardation was not always present and seizures may appear months or years after the onset of hemiparesis.3 The clinical findings may be of variable degree according to the extent of the brain injury. Imaging studies show unilateral loss of volume of brain and calvarial changes, finding of cerebral atrophy, ventricular dilatation and enlargement of sulci.4 In congenital hemiatrophy, when the insult occurs in utero, there is shift of midline structures towards the side of the disease and the sulcal prominence replacing the gliotic tissue is absent.5 This feature differentiates it from cerebral hemiatrophy, which occurs in early life.

The etiological factor for DDMS has been postulated as trauma, inflammation or vascular malformations and occlusions. When the insult occurs in utero, it could be due to gestational vascular occlusion, primarily involving the middle cerebral vascular territory. A possible etiological relation of cerebral hemiatrophy and seizures has been reported by different studies in India.6,7

Figure 4. Excessive pneumatization of right sphenoid and right ethmoid sinuses and right mastoid air cells.

Excessive pneumatization of right sphenoid and right ethmoid sinuses and right mastoid air cells (Fig. 4).

Discussion In 1933, Dyke, Davidoff and Masson described the plain skull radiographic and pneumatoencephalographic changes in their series of 9 patients whose clinical characteristics included hemiparesis, seizures facialasymmetry and mental retardation.1 It has been reported that DDMS occurs in intrauterine life when the maturation of calvarium has not been completed, or

DDMS should be differentiated from basal cell germinoma, Sturge-Weber syndrome, linear nevus syndrome, Fishman syndrome, Silver-Russell syndrome and Rasmussen encephalitis.8 A proper clinical history and CT/MRI findings provide the correct diagnosis.

The treatment is symptomatic, and should target convulsions, hemiplegia, hemiparesis and learning difficulties. Prognosis is better if hemiparesis occurs after the age of 2 years and in absence of prolonged or recurrent seizures. Children with intractable disabling and hemiplegia are the potential candidates for hemispherectomy with a success rate of 85% in carefully selected cases.9 References 1. Dyke CG, Davidoff LM, Masson CB. Cerebral hemiatrophy and homolateral hypertrophy of the skull and sinuses.

Surg Gynecol Obstet. 1933;57:588-600.

IJCP Sutra 49: A marked increase in circulating IL-8 levels in patients with T2DM is associated with worse inflammatory, glycometabolic and lipid profile and lower vitamin D levels. Acta Diabetol. 2017 Aug 23.

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Indian Journal of Clinical Practice, Vol. 28, No. 9, February 2018 2. Solomon GE, Hilal SK, Gold AP, Carter S. Natural history of acute hemiplegia of childhood. Brain. 1970;93(1): 107-20.

3. Zilkha A. CT of cerebral hemiatrophy. AJR Am J Roentgenol. 1980;135(2):259-62.

4. Sharma S, Goyal D, Negi A, Sood RG, Jhobta A, Surya M. Dyke-Davidoff-Masson syndrome. Ind J Radiol Imag. 2006;16:165-6.

5. Sener RN, Jinkins JR. MR of craniocerebral hemiatrophy.

Clin Imaging. 1992;16(2):93-7.

6. Nair KP, Jayakumar PN, Taly AB, Arunodya GR, Swamy HS, Shanmugam V. CT in simple partial seizures

in children: a clinical and computed tomography study.

Acta Neurol Scand. 1997;95(4):197-200.

7. Garg RK, Karak B. Cerebral hemiatrophy: a possible etiological relation with febrile seizures. Indian Pediatr. 1998;35(1):79-81.

8. Rao KC. Degenerative diseases and hydrocephalus. In: Lee SH, Rao KC, Zimmerman RA (Eds.). Cranial MRI and CT. 4th Edition, New York: McGraw-Hill; 1999. pp. 212-4.

9. Narain NP, Kumar R, Narain B. Dyke-DavidoffMasson syndrome. Indian Pediatr. 2008;45(11): 927-8.

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IJCP Sutra 50: Short-term glycemic control does not influence arterial stiffness, pulse wave velocity, aortic augmentation index, inflammatory markers and oxidative stress in patients with T2DM and hypertension. J Int Med Res. 2017 Jan 1:300060517722697.

OBSTETRICS AND GYNECOLOGY

Heterologous Malignant Mixed Mullerian Tumor of Uterus: An Uncommon Tumor with Uncommon Presentation BHAVANA S

Abstract A malignant mixed mullerian tumor (MMMT) is an extremely rare and aggressive neoplasm with biphasic pattern, consisting of both mesenchymal and epithelial components. The tumor presents in MMMT with heterologous elements women, in 5-7th decade of life accounting for 2-5% of all malignant neoplasm of the uterine corpus. We report the case of a 65-year-old, elderly woman who presented to Gynecology OPD, with complaints of difficulty in passing urine for the past 1 month and acute retention of urine for the past 2 days. The ultrasound revealed markedly enlarged uterus due to large mass filling the uterus 10.9 × 11.4 × 9.6 cm3 with multiple cystic areas within the lesion. The patient was posted for laparotomy and subjected to total abdominal hysterectomy with bilateral salpingo-oophorectomy was done. The histopathology of the tumor confirmed the diagnosis of MMMT with heterologous elements.

Keywords: Malignant mixed mullerian tumor, uterine corpus, menopausal, total abdominal hysterectomy with bilateral salpingo-oophorectomy

T

he uterine malignant mixed mullerian tumor (MMMT) is an uncommon neoplasm with biphasic pattern, consisting of both mesenchymal and epithelial components. They are very aggressive tumors with extremely poor prognosis, presenting in elderly menopausal women.

Case Report A 65-year-old, elderly woman presented to Gynecology OPD, with complaints of difficulty in passing urine for the past 1 month and acute retention of urine for the past 2 days. She had 8 children. She attained menopause 15 years back.

On examination, patient was moderately built and poorly nourished. Weight 35 kg, height 136 cm. Body mass index (BMI) - 18.9 kg/m2. After catheterization; on per abdomen examination, a suprapubic mass was felt, corresponding to uterus of 16-18 weeks, with irregular borders, firm in consistency, dullness on percussion,

Assistant Professor Dept. of Obstetrics and Gynecology Sree Mookambika Institute of Medical Sciences, Kulasekharam, Kanyakumari, Tamil Nadu Address for correspondence Dr Bhavana S W/o: Dr Rakesh Kumar Gupta No. 27, Karthik Nilaya, C-Layout, 2nd Cross, Hanumanthanagar, Bannimantap, Mysore - 570 015, Karnataka E-mail: bhavana_yajat@yahoo.com

with grossly reduced mobility, with no free fluid in the abdomen. On per speculum examination, cervix appeared healthy. On per vaginum examination, uterine mass of 16-18 weeks felt, firm in consistency, impacted in pelvis, with gross reduction in mobility.

The ultrasound revealed markedly enlarged uterus due to large mass filling the uterus 10.9 × 11.4 × 9.6 cm3 with multiple cystic areas within the lesion. No breech of surface, no ascites, no definite adjacent organ infiltration, with mechanical bladder outlet obstruction with left-sided hydronephrosis.

The patient was diabetic on routine investigation and insulin therapy was started. The patient was posted for laparotomy. Intraoperatively, uterus was 18 weeks size, ovaries, parametrium, peritoneum, omentum were normal, with no ascites/adhesions. Total abdominal hysterectomy with bilateral salpingo-oophorectomy was done. The cut section of the uterus showed a large 12 × 12 × 8 cm3 broad based pedunculated polyp arising from the fundus, distending the entire cavity of the uterus (Fig. 1). Cross-section of the tumor showed pinkish, white, solid tumor with areas of extensive necrosis. The histopathology of the tumor showed carcinomatous component composed of adenocarcinomatous, clear cell and undifferentiated areas. Sarcomatous areas with elongated spindle cells. Focal areas with malignant cartilaginous differentiation with extensive areas of tumor necrosis - MMMT with heterologous elements (Figs. 2-4).

IJCP Sutra 51: Chronic insomnia is an important risk factor for T2DM. Diabetes Metab Res Rev. 2017 Aug 18.

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Figure 1. Cut section of uterus with the large pedunculated tumor arising from the fundus.

Figure 4. Heterologous component showing cartilaginous areas of MMMT (H&E stain high power).

But patient refused further treatment, was discharged on the 10th day and follow-up was advised.

Discussion

Figure 2. Carcinomatous component with necrotic areas of MMMT (H&E stain high power).

The MMMT’s account for 2-5% of all malignant neoplasm of the uterine corpus. The tumor presents in postmenopausal women, in 5-7th decade of life.

The reported median interval from menopause to presentation is 15-17 years.1,2 Nulliparity, obesity, diabetes and hypertension are recognized predisposing factors for MMMT’s. The neoplasm has been associated with previous pelvic radiation therapy.1,2 Some patients have developed MMMT while taking tamoxifen and raloxifene.1 In our case, there was no predisposing factors except that she was diagnosed to be diabetic after routine investigation.

The MMMT’s contain admixture of carcinomatous and sarcomatous elements. The epithelial component may be any type of mullerian carcinoma: mucinous, squamous, endometroid, high grade papillary, clear cell or undifferentiated. On the basis of the appearance of sarcomatous component, the neoplasm is classified into homologous (leiomyosarcoma, stromal sarcoma, fibrosarcoma) or heterologous (chondrosarcoma, rhabdomyosarcoma, osteosarcoma, liposarcoma).1

Figure 3. Sarcomatous component of MMMT (H&E stain high power).

The commonest symptoms are postmenopausal bleeding, lower abdominal pain, loss of weight and abdominal mass.1,3,4

The clinical and pathological staging was Stage 1B MMMT of uterus. The patient and the family were counseled and prognosis was explained and the option of adjuvant radiotherapy/chemotherapy was advised.

The MMMT’s are highly aggressive neoplasms. Staging is the most important predictive factor in prognosis.1-3 The International Federation of Gynecology and Obstetrics (FIGO) staging of MMMT’s of the uterus

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IJCP Sutra 52: Improving triglycerides and waist circumference can reduce the risk for type 2 diabetes. Sci Rep. 2017;7(1):9072.

OBSTETRICS AND GYNECOLOGY is the same as for endometrial carcinoma. Five-year survival rate are about 30-40% in Stage I disease (confined to uterine corpus) and considerably less in Stage II and III (when disease extended to cervix, vagina or parametrium) and there were no survivors in those with disease outside the pelvis (Stage IV).1

References

Due to aggressive nature of MMMT’s and its poor prognosis, various modalities of treatment have been employed. Surgery in the form of abdominal hysterectomy and bilateral salpingo-oophorectomy remains the principle treatment.1,4 Adjuvant radiotherapy and chemotherapy (cisplatin and ifosfamide) has been shown to be beneficial.4

3. Rosai J. Uterus - Corpus. In: Rosai J (Ed.). Rosai and Ackerman’s Surgical Pathology. Philadelphia: Mosby; 2004. pp. 1599-602.

1. Ho SP, Ho TH. Malignant mixed mullerian tumours of the uterus - a ten-year experience. Singapore Med J. 2002;43(9):452-6.

2. Moghaddam NA, Pooralborzi F, Aram S, Moghaddas D. Heterologous malignant mixed mullerian tumor in a diabetic patient. JRMS. 2008;13(6):349-53.

4. Wong L, See HT, Khoo-Tan HS, Low JS, Ng WT, Low JJ. Combined adjuvant cisplatin and ifosfamide chemotherapy and radiotherapy for malignant mixed müllerian tumors of the uterus. Int J Gynecol Cancer.

2006;16(3):1364-9.

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IJCP Sutra 53: Improvement in glycemic control attained by aerobic exercise has an association with both the initial and the increase in peak during aerobic exercise.

Diabetol Metab Syndr. 2017;9:63.

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OBSTETRICS AND GYNECOLOGY

Subseptate Uterus Presenting as Unstable Lie at Term SHIKHA SINGH*, SAROJ SINGH†, ANKITA KUMARI‡, RUCHITA SINHA#

Abstract Subseptate uterus presenting as unstable lie at term is uncommon. In this article, we report two rare cases, first where presentation of baby changed four times and in the other lie of the fetus changed twice in a short period of time. On exploration of uterus at the time of cesarean section, it was found to be subseptate.

Keywords: Subseptate uterus, unstable lie, mullerian abnormalities

I

n the past, anomalies of genital tract have aroused interest as anatomical curiosity because of the relative infrequency with which they are thought to occur. In recent years, several investigators have focused attention upon these abnormalities because of their important bearing upon the frequency of abortion, premature labor, abnormal presentation of the fetus and complications of labor and of the immediate postpartum period. Among the mullerian anomalies subseptate uterus is the most common congenital uterine anomaly with an incidence of 33.6%.1

Case History

Case 1 A 22-year-old multiparous woman (G3P1L0A1) presented on 3/3/2010 with amenorrhea of 8 months at 36 weeks of gestational age (according to her ultrasonography [USG] report done 4 days back, exact last menstrual period [LMP] was not known) for routine antenatal check-up.

Her obstetric history had unsuccessful outcome with history of emergency lower-segment cesarean section (LSCS) done for cord prolapse done 2.5 years back, which resulted in intrauterine death of the and one

*Assistant Professor †Professor and Head ‡Senior Resident #PG Student Dept. of Obstetrics and Gynecology SN Medical College, Agra, Uttar Pradesh Address for correspondence Dr Shikha Singh Assistant Professor Dept. of Obstetrics and Gynecology SN Medical College, Agra, Uttar Pradesh E-mail: drshikhasingh.shikha@gmail.com

spontaneous abortion at 3 months of gestational age, 1.5 years back. Her medical history was unremarkable.

She had an USG done 4 days back, which showed a single live intrauterine fetus with mean gestational age of 35 weeks 4 days with breech presentation.

Abdominal examination, at the time of presentation revealed a fundal height of 34 weeks with cephalic presentation. She was advised a repeat USG which revealed a single live intrauterine fetus of gestational age 35 weeks 4 days with cephalic presentation and scar thickness of 2.2 mm and placenta of Grade III maturity.

In view of thin scar and persistent mild but infrequent uterine contractions and Grade III placenta, she was admitted and kept under observation. During observation her lie kept on changing from breech to transverse or cephalic. Because of thin uterine scar an elective cesarean section was decided at 37 weeks.

On the day of elective cesarean, the presentation of baby was found to be transverse with head on right side and back posterior. This was confirmed on USG. She was taken up for cesarean section and on exploration of uterus, a septa measuring 3 inch was found arising from fundus i.e., subseptate uterus was discovered.

Her postoperative period was uneventful. Patient was discharged after 9 days in a satisfactory condition. She has not reached for follow-up yet.

Case 2 In the second case, a 23-year-old, primigravida presented on 3/10/2010 with amenorrhea for 9 months at 39 weeks of gestational age (according to her LMP and 37 weeks 6 days according to USG done at the time of admission), pain in abdomen for 6 hours and leaking per vaginum for 1 hour.

IJCP Sutra 54: Processed food addiction is significantly related to depression, anxiety and stress among people with T2DM. Diabetes Res Clin Pract. 2017;132:95-101.

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On examination, lie of the baby was found to be transverse, cervix was 2 cm dilated and 80% effaced and membranes were absent, which was confirmed on USG. Patient was taken for cesarean section in view of transverse lie and at the time of operation lie was found to be longitudinal with breech presentation. On exploration, a septa of about 2 inches was found arising from the fundus and incompletely dividing the uterine cavity. Her postoperative period was uneventful. She was discharged after 8 days in a satisfactory condition.

She was advised for follow-up at 6 weeks.

Discussion

so the patient should be examined before this juncture with a conventional transabdominal or transvaginal approach. Using 3D studies with power Doppler in first trimester scar (4-9 weeks) may be best performed for diagnosis.3 Patient usually gives history of dysmenorrhea, menorrhagia in the interval period. They may be pregnant despite presence of an intrauterine contraceptive device (IUCD) because of incomplete occupancy of IUCD of whole of the uterus. Various diagnostic modalities like hysterosalpingogram, hysteroscopy and laparoscopy are helpful to detect the anomaly before the patient conceives.

Incidence of uterine malformation in population is 0.5%. Subseptate uterus belong to Class III B according to American Fertility Society (AFS) classification of mullerian anomalies. Apoptosis has been proposed as a mechanism by which the septum regresses. Bcl-2, a protein involved in regulating apoptosis was found absent in septa of subseptate uterus. Absence of this protein plays a pivot role in persistence of septum.2 Patients with this anomaly often have recurrent abortions which is due to abundant muscle tissue in the septum, abnormal endometrium overlying the septum leading to abnormal implantation. Only about 40% of pregnancies reach term with a constantly changing fetal presentation even beyond 36 weeks of pregnancy when it should have been stabilized. This was the presentation in our case in which the lady within 1 week of our observation had breech, cephalic and transverse lie on different occasions which were confirmed by USG also.

The recommended therapy for subseptate uterus in the past was abdominal metroplasty. During the past several years, hysteroscopic resection of uterine septum with intrauterine resectoscope, hysteroscopic resection of uterine septum using flexible or rigid scissors or neodymium-doped yttrium aluminum garnet (Nd-YAG) laser or transcervical septum resection using Metzenbaum scissors under fluoroscopic guidance has replaced the transabdominal approach.4 Unstable lie at term or in labor should arouse suspicion for the obstetricians to be aware of any mullerian anomaly, most common culprit of which may be subseptate uterus.

In the other case, lie of the fetus changed at term in a short period of time in labor within few hours. After 22 weeks of gestation, enlargement of uterus obliterates some subtle findings suggestive of anatomic variablity,

3. Ian Donald’s Practical Obstetrics Problems. 6th Edition, pg. 73.

References 1. Williams Obstetrics. 23rd Edition, pg. 968-9, 893.

2. Te Lende’s Operative Gynaecology. 10th Edition, pg. 567, 565.

4. Berman MC, Cohen HL. Obstetrics and Gynecology. pg. 60.

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Formula of 80 to Treat Diabetes ÂÂ

If fasting sugar is between 80-160: Give one drug (Metformin).

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If blood sugar is more than 80 x 2: Give 2 drugs.

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If blood sugar is more than 80 x 3: Give 3 drugs.

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If blood sugar is more than 80 x 4: Give 4 drugs or add insulin.

Formula of 3 for Diabetes ÂÂ

Start insulin at 0.3 units/kg body weight (double the dose in moderate cases and triple the dose in obese cases).

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Increase by 3 units every 3 days.

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Monitor A1c every 3 months.

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Start insulin, if 3 drugs fail.

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IJCP Sutra 55: The effects of pioglitazone on insulin responsiveness and fuel utilization are considered to be independent of mitochondrial function.

Metabolism. 2017;69:24-32.

IMAGING AND INVESTIGATIONs

Mid-cavity Obstruction of Right Ventricle Without Any Other Congenital Anomaly SR MITTAL

A

7-day-old female infant born of full-term normal delivery was referred for evaluation of a systolic murmur in left lower parasternal region.

Electrocardiogram (ECG) revealed P-pulmonale with right axis deviation and prominent RS configuration in lead V1 (Fig. 1). Echocardiography revealed hypertrophy of right ventricle with a systolic turbulent jet between apex and main cavity of right ventricle (Fig. 2).

Continuous wave Doppler evaluation of the jet revealed a systolic gradient of 65.4 mmHg (Fig. 3). Pulmonary valve was normal. Pulsed wave Doppler evaluation of pulmonary flow was normal with a peak velocity of 0.87 m/sec and peak gradient of 3 mmHg (Fig. 4). Tricuspid leaflets were normal with mild tricuspid regurgitation.

Left ventricle, mitral valve flow, left ventricular outflow tract and aortic flow were normal. There was no other congenital anomaly.

Echocardiography findings of this case resemble left ventricular mid-cavity obstruction seen in some cases of hypertrophic cardiomyopathy. Isolated right ventricular hypertrophy with hypertrophied muscle bundles created gradient between apex and cavity of right ventricle. Such hypertrophied obstructive muscle bundles in the cavity of right ventricle are invariably associated with other congenital anomalies like ventricular septal defect, pulmonary valve stenosis, discrete subaortic stenosis, Ebstein malformation or tetralogy of Fallot. Our case could be a variant of hypertrophic cardiomyopathy. Parents did not agree for any other investigation, chromosome analysis or evaluation of other family members. Patient was first issue and parents denied any history of cardiac disease or sudden death in close relation.

Dept. of Cardiology Mittal Hospital and Research Centre, Pushkar Road, Ajmer, Rajasthan Address for correspondence Dr SR Mittal XI/101, Brahampuri, Ajmer, Rajasthan

Figure 1. ECG showing right axis deviation, P-pulmonale and R/S configuration in lead V1.

Figure 2. Color Doppler echocardiograph in apical fourchamber view showing turbulent jet coming from RV apex to RV cavity.

Figure 3. Continuous wave Doppler showing gradient across the turbulent flow.

Figure 4. Pulsed Doppler evaluation of pulmonary artery flow.

IJCP Sutra 56: An association is seen between the cluster of conditions seen in metabolic syndrome and higher prevalence of albuminuria, reduced kidney function and changes in urinary ACR and estimated GFR in patients with T2DM. J Clin Med Res. 2017;9(9):759-64.

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Case Study on Whether a Doctor can Suffix His Name Other Qualifications Undertaken by Him Which are not Recognised by MCI or Not KK Aggarwal*, Ira Gupta

Case BM Birla Heart Research Centre (BMBHRC) has been directed by West Bengal Clinical Establishment Regulatory Commission to pay Rs. 20 Lakhs compensation to the family of a patient who died during treatment after concluding that two employees including one doctor at BM Birla Heart Research Centre in Alipore were not qualified to conduct and report echocardiography.

The case pertains to a female patient, known hypertensive with chest pain and shortness of breath.

After 4 days of treatment, she was shifted to Calcutta Medical Research Institute where she died. Following her death, her family filed a complaint of negligence against the hospital with the commission.

After going through all the submissions made by the complainant and the hospitals as well as the case files of the patient, the commission observed a number of discrepancies in the submissions made by the hospital to the commission and the case file and discharge summary of the patient.

Besides this, the complainant had alleged that no echo screening report was given to them whereas the hospital submitted an echo report dated 3rd May, 2017 whereby an echo was done by one Dr Giri who noted his findings and recorded his opinion and impression thereon. His authentication stated him as the “Head of Non-invasive department”. Another echo screening report dated 7th May 2017 was given, where the commission found that the screening was done on a portable machine and the findings were recorded and interpreted with impression by one Ms Chaitali who was the Echocardiography Technician at the hospital.

On going through their degree, the commission found

*Group Editor-in-Chief, IJCP Group

that Dr Giri had done his MD from Russia, which is equivalent to MBBS and recognised in India.

He received his registration from the Medical Council of India (MCI) after clearing the Foreign Medical Graduates Examination (FMGE) exam. Post this he was awarded a Post Graduate Degree in Clinical Cardiology (PGDCC) from IGNOU, New Delhi. The commission sought clarification from the Medical Council of India as well as the West Bengal Medical Council.

MCI clauses “that post graduate Medical qualifications (India/foreign) which are included in the Schedules to the IMC Act, can only be considered deemed to be recognised medical qualification(s) for the purposes of registration of additional qualification and entitlement of its holder(s) to practice in the speciality concerned.

Further as per clause 7(2) of the Indian Medical Council (Professional Conduct, Etiquette and Ethics) Regulations, 2002, a physician shall not claim to be specialist unless he/she has special qualifications in that branch.

As per the available records, the post graduate diploma in Clinical Cardiology awarded by Indira Gandhi National Open University is not included in the Schedules to the IMC Act.” The response from the West Bengal Medical Council stated that “With reference to this mail, I am to inform you that the medical qualifications, which are included in the Schedule of the Medical Council of India are only the recognised qualifications for grant of registration by any State Medical Council. The qualifications awarded by the Indira Gandhi National Open University do not appear in the Schedule of Medical Council of India. Hence, registration to such qualification holders cannot be granted for practicing modern scientific medicine (allopathic).”

The commission then opined that: “In view of the above communications, the employment of the doctor as consultant in charge, NI department and engaging him for conducting

IJCP Sutra 57: Development of albuminuria could be majorly attributed to angiotensin II, especially in individuals with impaired glucose metabolism. J Diabetes Complications. 2017 Jul 6.

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noninvasive procedure and echocardiogram and to give study report interpreting the data available from such a procedure and on the basis decide the course of the treatment is not only detrimental to patient care service but also completely unauthorised and illegal. The practice on the part of the Clinical establishment, BM Birla comes with the ambit of deficiency in patient care within the ambit deficiency in patient care service and amounts to irrational and unethical trade practice.”

the states are authorised to start that independent of MCI. Many training certificates are organised by IMA, Universities, Private Bodies, International bodies, etc. cannot be called illegal. If MCI does not approve such diploma or certificate, then MCI should take appropriate action against the universities which are undertaking such courses but the same has never, rightly so, been challenged by the MCI.

Holding deficiency on the part of the establishment, the commission awarded a compensation of Rs. 20 lakhs in favour of the complainant to be paid by the hospital.

Also, as per the provisions of Clause 1.2.3 of Indian Medical Council (Professional Conduct, Etiquette and Ethics) Regulations, 2002 “a Physician should participate in professional meetings as part of Continuing Medical Education programmes, for at least 30 hours every five years, organised by reputed professional academic bodies or any other authorized organisations.

The compliance of this requirement shall be informed regularly to MCI or the State Medical Councils as the case may be”. It is important to note herein that the said Clause 1.2.3 does not talk about MCI recognised updating knowledge.

IJCP OPINION In the above-mentioned case, it is an admitted fact that the doctor had done his MD from Russia, which is equivalent to MBBS in India. He had received his registration from MCI after clearing the FMGE exam.

Thus, the doctor had a recognised medical qualification MBBS, which is recognised by MCI. Post this he was awarded a Post Graduate Degree in Clinical Cardiology (PGDCC).

Further, it is mentioned herein that this is not a qualification/course of echocardiology recognised by MCI. Thus, to do echocardiography any MBBS will have to undertake some diploma/certificate course recognised by MCI/ some university/some association/ some hospital/some individuals. It is important to note the provisions of Clause 1.4.2 of Indian Medical Council (Professional Conduct, Etiquette and Ethics) Regulations, 2002, which is reproduced hereunder: “Clause 1.4.2 Physicians shall display as suffix to their names only recognised medical degrees or such certificates/ diplomas and memberships/honours which confer professional knowledge or recognises any exemplary qualification/ achievements.”

The clause talks about recognised medical degree (MCI recognised) OR such certificates/diplomas and memberships/honours which confer professional knowledge (may not be MCI recognised). The very fact that IGNOU has started such a diploma means they and

Also, as per the provisions of Clause 7.10 of Indian Medical Council (Professional Conduct, Etiquette and Ethics) Regulations, 2002, a registered medical practitioner shall not issue certificates of efficiency in modern medicine to unqualified or non-medical person.

(Note: The foregoing does not restrict the proper training and instruction of bonafide students, midwives, dispensers, surgical attendants or skilled mechanical and technical assistants and therapy assistants under the personal supervision of physicians.). Doctors are also allowed to train technicians independent of MCI permissions. When technicians can be trained doctors can also be.

Thus, in view of the above provision, it is stated that the doctor was correct on his part if he had displayed and mentioned about his qualifications i.e., MBBS and PGDCC. Source: (i) Medical dialogues: MBBS with IGNOU PGDCC performing Echo: Hospital fined Rs. 20 Lakhs. (ii) Indian Medical Council (Professional Conduct, Etiquette and Ethics) Regulations, 2002.

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Rule of 1500 for Diabetes Divide 1500 with the total daily insulin dose and you will get the change in blood sugar levels with 1 unit of insulin for that patient.

Rule of 500 for Diabetes

Divide 500 with total daily dose of insulin and you will get the gms of carbohydrates required to neutralize one unit of insulin for that patient.

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IJCP Sutra 58: Glycemic response to an OGTT is likely to prognosticate the risk of development of diabetes in first-degree relatives of diabetes mellitus patients.

Clin Endocrinol (Oxf). 2017 Aug 9.

Medifinance

Medifinance KK Aggarwal, Arun Kishore

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Property registrars, financial institutions, banks, insurer, mutual fund company and credit card company feed the tax department with information regarding big transactions.

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The bank informs the tax department if you have deposited cash, made a demand draft or fixed deposits aggregating up to Rs. 10 lakhs or more in a financial year under different accounts.

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The property registrar reports purchase or sale of immovable property exceeding Rs. 30 lakhs.

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1% TCS (tax collected at source) is deducted and deposited by the buyer in case of purchase of property over Rs. 50 lakhs.

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If you have made a cash payment of Rs. 1 lakh towards your credit card or Rs. 10 lakhs or more through any other mode during the financial year, your credit card company will report the transactions to the tax authorities.

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Purchase of shares, debentures and mutual funds of Rs. 10 lakhs or more will have to be reported by the companies to the tax authorities.

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If you are earning more than Rs. 50 lakhs a year, you have to report your assets and liabilities in a new ITR (income tax return) form this year.

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Now reporting of PAN is mandatory for making any purchase of goods and services of more than Rs. 2 lakhs.

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Also, a TCS is introduced from June 1 in case of purchase or sale of any goods and services for Rs. 2 lakhs and more in cash.

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TDS is another way of tracking income of tax payers. Banks deduct TDS if interest income on fixed deposits is more than Rs. 10,000 in a year.

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An 1% luxury tax is levied on purchase of car priced over Rs. 10 lakhs.

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PAN number is must for sale or purchase of vehicles other than two-wheelers; opening a bank or a demat account; applying for credit card; opening a fixed deposit of more than Rs. 50,000; payment of more than Rs. 50,000 towards insurance premium; paying more than Rs. 50,000 in cash towards restaurant or hotel or foreign trip bills; purchase of mutual funds, debenture, bonds worth more than Rs. 50,000 and depositing cash or more than Rs. 50,000 in bank.

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Formula of 5 to Managing Lipids Blood lipid levels exhibit mild seasonal variation with a peak in total cholesterol level in the winter. ÂÂ

Amplitude of seasonal variation of total cholesterol concentration is 5 mg/dL.

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The total cholesterol can vary by 5% (up to 5 × 2) within an individual due to multiple factors including stress, minor illness and posture.

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Values may also vary between different laboratories. A single measurement of serum cholesterol can vary as much as 15 (5 x 3) %.

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The serum cholesterol may be 5% lower than the plasma value.

Formula of 55 for Premature CAD ÂÂ

Premature coronary artery disease (CAD) is CAD occurring before 55 years in men (65 years in females).

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Prevalence of dyslipidemia in premature CAD is >55%.

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55% of all patients with premature CAD (and 65% of those with a lipid abnormality) have a familial disorder.

IJCP Sutra 59: The burden of oxidative stress is greater in hypertriglyceridemia of T2DM. Int J Endocrinol Metab. 2017;15(2):e44805.

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69th Annual Conference of Cardiological Society of India (CSI 2017) Role of IV Iron Beyond Anemia and Hemoglobin in Heart Failure Dr Prasant Kr Sahoo, Bhubaneswar Iron plays an important role in cell metabolism throughout the body. Iron is a metabolically active micronutrient with a multitude of effects on the body’s metabolism. It can act as a cofactor for enzymes and a catalyst for biochemical reactions, and is essential for blood cell production.

While the treatment of anemia with erythropoiesisstimulating agents in patients with HF has failed to show a benefit in terms of morbidity and mortality, treatment with IV iron in patients with HF and reduced ejection fraction and iron deficiency is associated with clinical improvement.

Thus, iron therapy can also improve physical functioning in HF patients with iron deficiency. Iron therapy has been found to improve kidney function in patients with HF and iron deficiency.

EFFECT-HF demonstrated that treatment with IV ferric carboxymaltose provided a significantly beneficial effect on peak VO2 compared with the control group. The EFFECT-HF study results confirm and extend upon the findings of the FAIR-HF and CONFIRM-HF studies, which also demonstrated that treatment with IV ferric carboxymaltose was associated with improvements in functional capacity and symptoms, in patients with CHF and iron deficiency.

Ferric carboxymaltose is likely to be the preferred option for most patients requiring parenteral iron supplementation as it can provide a higher dose of non-dextran iron that can be administered in a shorter timeframe.

Percutaneous Mitral Valve in Valve Procedure for Failing Mitral Bioprosthetic Valve

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Percutaneous transferral trans-septal mitral valve in valve procedure using an Edward sepiEn 3 valve is a viable option in such patients.

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Two successful procedures have been done to date with good procedural end result.

Ablative Therapy in ARVD and Brugada Syndrome: Is There a role?

Dr Daljeet Kaur Saggu, Hyderabad ÂÂ

Catheter ablation is feasible in patients with both ARVD and Brugada syndrome, who have recurrent ICD shocks secondary to refractory VT.

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Substrate-based ablation can be performed in both ARVD and Brugada syndrome, without the need to induce unstable VT in the EP lab.

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Epicardial ablation, along with endocardial ablation, is frequently required in both these entities.

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In Brugada syndrome, sodium channel blocker (procainamide/flecainide) can be used to unmask abnormal areas in some patients.

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Triggering PVCs, if present in the EP lab, can be targeted for ablation.

Managing Resistant HT: What Options Do I have When Drugs Fail?

Dr Keshavamurthy V, Mysore ÂÂ

Resistant HT is a common problem in a subset of patients.

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Pseudoresistance needs to be ruled out.

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ABPM is a very helpful tool.

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Secondary causes must be ruled out and treated appropriately.

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Judicious uptitration of single or appropriate combination of drugs overcomes this problem.

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Diuretics are the cornerstone of therapy of resistant HT.

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Stenting renal artery in RAS does not help much.

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Newer drugs and interventions hold promise for the future.

Dr Nagendra S Chouhan, Gurugram ÂÂ

Bioprostetic valve failure rates are significantly high, after 10 years of implant and reoperations.

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It has poor outcome in high risk elderly patients.

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IJCP Sutra 60: Factors such as age, disease duration, psychological distress and high cholesterol have an independent association with poor sleep quality among T2DM population. World J Diabetes. 2017;8(7):358-64.

CONFERENCE Proceedings Visceral Fat Estimation for CAD Risk Dr AK Chauhan, Bareilly, UP CVD is a leading cause of mortality globally. The prevalence of obesity and diabetes is on the rise.

Visceral fat enhancement is more prevalent and is associated with insulin resistance, HT, classical dyslipidemia with abundant inflammatory markers, which eventually is responsible for CV events. Visceral fat is tagged with metabolic inflammation and white adipose tissue mediates systemic inflammation.

The inflammatory markers are increased many folds to produce catastrophic complications. Estimation of visceral fat is easy and precise with USG/CT scan, which is a gold standard to quantify it. Anthropometery is also a simple method.

Endovascular Management of Abdominal A o r t i c A n e u ry s m s : Re ce n t T r i u m p h & Unconquered Territories

and mortality and reduced hospitalization stay. EVAR is also an option in ruptured AA. Limitations of EVAR include: Anatomy of vessels and access vessel morphology being nonconducive, high cost of treatment and deployment accuracy. Endoleaks need to be carefully monitored and managed.

Fenestrated endografts, chimney grafts, Nellix endovascular aneurysm sealing system and Cardiatis Multilayer flow modulator are the recent advances in EVAR. Recent triumphs of EVAR - short neck, angulated neck.

Unconquered territories - juxta renal, suprarenal and juxta mesenteric aneurysm, exact place of lamination of blood flow and multilayered flow modulator and epigenetics in treating complex abdominal AA. Robotic EVAR would reduce operator, staff and patient radiation and also reduce procedure time with increased success and accuracy.

Does Device-detected AF Cause Strokes?

Dr NN Khanna, New Delhi More than 35,000 deaths per year are directly attributed to aortic aneurysm (AA), which is the 9th leading cause of death. The risk of rupture in AA increases with increase in AA diameter; 40-50% of these patients die before receiving any treatment. Risk factor modification and surveillance are important in identifying and stratification of disease progression. If the aneurysm is expanding >1 cm in a year or >0.5 cm in 6 months, it needs urgent attention. Endovascular aortic aneurysm repair (EVAR) is the most common method for the elective management of AAA. Three large RCTs - EVAR1, DREAM and OVER, comparing EVAR with open surgery for AAA - showed significant reductions in perioperative morbidity and mortality with EVAR. Steps for successful EVAR include: Proper case selection, appropriate imaging, planning of procedure, measurement techniques, vascular access, device deployment and endograft surveillance.

Anatomic suitability is important for EVAR. Tortuosity, calcification, stenosis, occlusion or aneurysmal enlargement of iliac arteries can limit device delivery and distal sealing. Vessel length measurement is an essential step and stent-grafts are planned to be of adequate length whilst allowing sufficient overlap of the modular components. IVUS may be a helpful tool for graft selection, deployment and further interrogation during EVAR. EVAR has the advantages of being a minimally invasive technique, reduced major morbidity

Dr Alan Cheng, USA ÂÂ

The epidemiology of AF is different in India compared to the rest of the world.

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AF is strongly associated with an increased risk for stroke but whether AF causes stroke is unclear.

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There is data supporting and refuting the causal link between AF and stroke.

Paroxysmal AF Ablation: My Targets and Endpoints Dr Samuel J Asirvatham, USA ÂÂ

Atrial fibrillation ablation remains an excellent palliative therapy for symptomatic patients with this rhythm disorder. Yet, severe complications may result.

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The key element in understanding how to maximize efficacy and simultaneously improve safety is to have a clear understanding of what the targets for ablation are and what exceptable endpoints are as well.

Clinical Dilemmas in Lipid Management Dr Pamela Morris, USA Case: A 62-year-old diabetic, underwent CABG-6 weeks back, has LDL 124 mg/dl, TG 178 mg/dl; develops significant myalgia with even 20 mg/dL atorvastatin. ÂÂ

Statins are safe and generally well-tolerated.

IJCP Sutra 61: Women with T2DM are comparatively more susceptible to short- and long-term CV complications post-PCI than males with the same chronic disease. BMC Cardiovasc Disord. 2017;17(1):207.

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True statin intolerance is relatively uncommon. It is critical to rigorously and systematically approach the evaluation and management of myalgia.

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Statin discontinuation in high-risk patients is associated with an increased risk of CV events.

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Other management strategies include using lower intensity/dose of statin, alternative dosing strategies, combination with nonstatin agents, nonstatin monotherapy.

of these advanced circulatory pumps have created a complex weave of hemocompatibility. (Mehra MR Eur Heart J. 2017) An alteration in hemocompatibility and a change in clinical management results in an interwoven clinical cascade: during hemolysis the risk for stroke rises; therapy for pump thrombosis impacts stroke rates; gastrointestinal bleeding forces anticoagulant changes; strokes force a change in anticoagulant therapy and BP; BP changes impact pump flow.

PISA for Evaluation of Regurgitant Lesions Dr Vivek Tandon, New Delhi Proximal isovelocity surface area (PISA) has become one of the most useful tools for quantitative and qualitative assessment of regurgitant valvular lesions, especially MR and TR. Great care must be taken while recording and measuring various parameters to ensure accurate calculation of effective regurgitant orifice area (EROA) and regurgitant volume, which are the two most important predictors of outcomes.

Hospitalizations

Life years gained 1.78-3.64 QALY gained 1.5-2.83 ICER $200,000/QALY

CRT has been shown to improve survival in patients with LV dysfunction, LBBB and in ischemic cardiomyopathy.

However, benefit of defibrillator in DCM is less clear.

DANISH trial showed that absolute benefit of ICDs in typical and well-treated HF patients without NIDCM might be small. Younger patients might receive most benefit.

ICDs are not required for every patient with NIDCM. ICD should only be targeted for patients who are at SCA risk despite optimal medical treatment and CRT. CRT-D is useful in patients with ICM with/without VA and in DCM with h/o VA/SCA. CRT-P alone may be adequate in DCM without history of VA and at time of PG replacement in super responders.

Dr Paolo Verdecchia, Italy ÂÂ

Studies suggest that a more intensive BP control (systolic BP target <130 or <120 mmHg) in hypertensive patients who are in sinus rhythm could prevent new-onset AF. Such evidence is suggestive, but not yet conclusive.

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In hypertensive patients with paroxysmal/ persistent AF, RAAS inhibition with ACEIs/ARBs could prevent AF recurrence, but evidence is not yet conclusive.

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It is unclear whether achievement of more intensive BP control in anticoagulated patients with AF reduces the risk of thromboembolic stroke and serious bleeding.

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In the four pivotal trials of NOACs vs. warfarin in patients with nonvalvular AF, HT did not interfere with the effects of these drugs vs. warfarin.

RV Septal Pacing: Should We Go for It? Dr John Roshan Jacob, Vellore ÂÂ

RV apical pacing is definitely substandard. It is associated with electromechanical dyssynchrony which, over time, can cause ventricular dysfunction.

It is also associated with increased incidence of atrial fibrillation (AF) and hospitalization with admissions for heart failure (HF).

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Pacing from RV septum is associated with a narrower QRS duration and the ventricular activation is closer to the normal physiology when compared to RV apical pacing.

Advanced Therapy in Advanced Heart Failure Dr Mandeep R Mehra, USA “Success is not final, failure is not fatal; it is the courage to continue that counts”.—Winston Churchill There has been a paradigm change in LVADs, from the old (HeartMate XVE) pulsatile flow to the new (HeartMate II) devices (Wilson et al. J Am Coll Cardiol. 2009;54:164759). The low pulsatile characteristics of blood flow

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4-7 3-5 $100,000/QALY

AF in a Patient with HT: Clinical Dilemmas and Evidence-based Management

Do All Patients Needing CRT-P Require CRT-D? Dr Nitish Naik, New Delhi

Lifelong support Current state: Still a “3-5” My target: Getting to “5-7” 1.6-2.2/year 1/year

IJCP Sutra 62: Insufficient glycemic control, particularly along with low HRQoL is often associated with a worse biopsychosocial profile. PLoS One. 2017;12(7):e0182053.

CONFERENCE Proceedings ÂÂ

There are studies that show RV septal pacing to be superior to RV apical pacing in causing less BP variation and less LV dysfunction.

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However, there are also studies, like the PROTECT PACE that show that it is not superior to RV apical pacing. Besides, RV septal pacing is associated with longer procedure and fluoroscopy time. It is still unclear if RV septal pacing is superior to RV apical pacing and long-term studies with larger patient numbers are required.

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RV septal pacing currently has a role in patients who have a peripheral atrioventricular block; for whom His bundle or para-hisian pacing will not result in a narrow QRS.

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Selecting Antidiabetic Drugs in a Patient with CAD Dr Shashank R Joshi, Mumbai ÂÂ

Indians have low metabolic tolerance, known as ‘thin-fat’ Indian phenotype. Hence, weight loss is of importance in Indian patients with type 2 diabetes.

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Intensive glycemia control has not demonstrated consistent improvements in macrovascular complications of diabetes, particularly death.

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Metformin has demonstrated some CV protection in obese patients with diabetes, and remains the first-line agent of choice, unless contraindicated.

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The CV safety of sulfonylurea agents has demonstrated mixed results, and needs more evidence. There may be differences in the CV safety profiles of different sulfonylurea agents.

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Thiazolidinediones have demonstrated an increased risk of heart failure.

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The regulatory authorities (US-FDA and EMA) have mandated demonstration of CV safety of newer agents for type 2 diabetes.

Live-in-box Cases: LMCA Dr Seung-Woon Rha, Korea ÂÂ

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How to overcome very angulated lesion? Single wire with Sion blue/Sion black, Reverse wire technique and Double lumen microcatheter.

How to deliver the stent in complex anatomy?

Buddy wire, daughter catheter, anchor balloon technique.

Yoga: A Promising Technique to Control CVD Dr SC Manchanda, New Delhi

Yoga works through two interconnected pathways in reducing the risk of cardiovascular diseases: by decreasing reactivity of the sympathoadrenal system and hypothalamic pituitary adrenal together with increased parasympathetic activity through vagus.

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Cardiovascular diseases attribute to almost 31% of global deaths.

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There are strong evidences to show the role of yoga in reducing stress with improvement in both CV response and recovery from stress.

The newer agents, including DPP4-i, SGLT2-i and GLP1-RA have been evaluated/are under evaluation for CV safety, apart from the newer insulins.

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Empagliflozin, Canagliflozin, Liraglutide and Semaglutide have demonstrated evidence of CV protection beyond glycemia control.

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Empagliflozin reduced 3P-MACE, CV death, all-cause death and hospitalizations for HF. Canagliflozin reduced 3P-MACE and hospitalizations for HF.

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Liraglutide reduced 3P-MACE, CV death and allcause death. Semaglutide reduced 3P-MACE and nonfatal stroke.

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Empagliflozin is the only oral antidiabetic agent, approved by the regulatory authorities including the Indian regulators, for reduction in the risk of CV death in type 2 diabetes patients with established CVD.

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The CV benefit of empagliflozin, as observed in EMPA-REG OUTCOME study, applies to patients with known history of CV events, as well as

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Yoga + conventional treatment in metabolic syndrome patients significantly reduced early atherosclerosis as assessed by CIMT (J Yoga Phys Ther. 2013;3:132).

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Yoga is ideally suitable as a cheap and simple method for cardiac rehabilitation.

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A few control trials also suggest that 12 weeks practice of yoga improves LVEF, peak oxygen consumption and QoL in HF patients (Integrative Medicine Insights. 2014;9:1-6; J Card Failure.

2008;14:407-13).

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A yoga-based post-CABG cardiac rehabilitation program led to significantly better improvement in LVEF, blood glucose and lipids vs. controls.

Yoga also reduced perceived stress, depression and negative effects (Indian Heart J. 2014;66(5): 490-502).

IJCP Sutra 63: It is important to control CV risk factors in order to reduce morbidity and mortality in patients with T2DM. Postgrad Med. 2017 Jul 27:1-11.

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asymptomatic patients of type 2 diabetes with CV disease (>50% blockade in coronary arteries). ÂÂ

Amongst the SGLT2-i agents, the adverse events of lower limb amputations and bone fractures have been observed only with canagliflozin.

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CVD REAL is an observational study with inherent channeling bias. Only with the results of the DECLARE-TIMI 58 study, due in 2019, will we have definitive evidence for the cardiovascular benefit and safety of dapagliflozin.

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Wherever possible, achievable, affordable and necessary, one should attempt to achieve HbA1c goal, without increasing risk of hypoglycemia or weight-gain. SGLT2-i agents and incretin-based therapies may benefit in this regard.

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In patients with type 2 diabetes and established ASCVD, empagliflozin or liraglutide may be considered. Evidence of similar benefit with other SGLT2-i or GLP1-RAs is uncertain.

Quality and Safety of Acute Cardiovascular Care in India

PCI and pharmacoinvasive treatment to build a hub and spoke model. ÂÂ

It has shown a significant reduction in mortality and MACE in the implementation phase vs. the preimplementation phase in the Tamil Nadu (TN) STEMI program.

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Cost-effectiveness analysis as per WHO methods indicates that STEMI India Model is efficacious, effective and cost-effective vs. the “no intervention” case.

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TN STEMI program was conducted in 4 clusters (a set of spokes connected to a hub via data linkages and an ambulance network is dubbed a “cluster”) in Tamil Nadu. The integrated, regional quality improvement program that was developed linked the 35 spoke healthcare centers to the 4 large PCI hub hospitals and leveraged recent developments in public health insurance schemes, emergency medical services and health information technology.

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The STEMI Kit - a multifunctional 12-lead ECG integrated multi-parameter monitoring unit with data entry capability – which was used in the TN STEMI program, significantly helped to improve diagnostic accuracy of STEMI and quality of data capture. Many of these data entry in real-time helped in quality improvement. The role of a statewide ambulance service was critical in the success of the TN STEMI program.

Dr PP Mohanan, Thrissur ÂÂ

As per the National Academy of Medicine (US), quality is defined as the “degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge.”

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The quality/safety challenges in India are the lack of national coordination for improving quality and safety (who will lead?), out of pocket health expenditures (who will pay) and underdeveloped healthcare infrastructure, systems and personnel in many parts of the country (who will build or train).

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ACS patients from the lower socio-economic strata have a higher percentage of STEMI. They use less evidence-based treatment and have a higher mortality. STEMI care can be delivered to this class of STEMI patients through a government insurance scheme.

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Insights from the Indian registries have shown that: Higher mortality is likely to be attributed to wide variability of optimal medical care. Quality improvement programs showed improvements in hospital and discharge medications but not in the rate of 30-day MACE after accounting for temporal trends. The intervention may have been effective in settings where the baseline quality of care is not as high.

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STEMI India has developed the model, run the TN STEMI program, designed the STEMI Kit with its partners and has developed the software to run the program.

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It has acquired unique competencies to run similar programs in other states and countries and is in the process of doing so.

LDL is Only Half Truth; Non-HDL-C is the Real Thing

Developing an Appropriate STEMI System of Care in India: The STEMI India Model Dr Thomas Alexander, Coimbatore ÂÂ

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The STEMI India model for STEMI management combines the two reperfusion strategies of primary

Dr SN Narasingan, Chennai ÂÂ

Despite marked ASCVD risk reduction, residual risk of ASCVD in statin-treated patients remains as high as 55-70%. Hence, we need to concentrate on all atherogenic lipoproteins and not just LDL alone.

IJCP Sutra 64: Compared to traditional risk factors in the QRISK2 score, high hs-cTnT seems to be the most promising biomarker in improving prediction of vascular risk in people with T2DM. Atherosclerosis. 2017;264:67-73.

CONFERENCE Proceedings ÂÂ

Non-HDL-C is a more accurate predictor of ASCVD risk than LDL-C as it effectively measures all atherogenic lipoprotein in blood, including LDL, VLDL, IDL, Lp(a) and chylomicron remnants.

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Non-HDL-C is particularly informative in patients with diabetes who have high TGs and so have a greater difference between LDL-C and non-HDL-C.

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Non-HDL-C is an accurate predictor of residual ASCVD risk in patients already on statin therapy.

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No additional testing or fasting blood sample required to estimate non-HDL-C.

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Non-HDL-C includes both LDL-C and the TG rich non-LDL lipoproteins. It also covers, to some extent, the excess ASCVD risk imparted by the small dense form of LDL, which is significantly more atherogenic than the normal large buoyant particles.

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An elevated non-HDL-C, being a surrogate for elevated TG, indirectly suggests greater proportion of the small dense variety of LDL particles.

SAVR vs. TAVR Dr OP Yadava, New Delhi ÂÂ

TAVR is a welcome development, and is a big boon for a large number of patients with clinically significant aortic valve pathologies, which are deemed prohibitive risk for SAVR.

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However, it is a technology in continuous evolution and has not yet matured enough to be applied to low surgical risk cases. Issues concerning paravalvular leak, conduction abnormalities, need for permanent pacemaker and stroke or cognitive dysfunction continue to be its bug bear.

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Experience of surgical bioprosthesis show that inflection point for degeneration with second and third generation valves is around 10-12 years, and 12-15 years respectively. Till TAVR reaches this point, one must reserve the jury in matters of durability.

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New issues like HALT and HAM need further enquiries including the role of anticoagulant therapy and their duration of use.

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Universal applicability due to costs and in pathologies like AR, bicuspid aortic valve is sub judice.

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Further advances in SAVR like sutureless valves and minimally invasive techniques have reduced the level of invasiveness to seriously challenge TAVR.

Preoperative Rosuvastatin Protects Patients with Coronary Artery Disease Undergoing Noncardiac Surgery Dr Dilip Kumar, Kolkata The prevalence of cardiovascular disease (CVD) increases with age, as does the need for emergency surgical intervention in a variety of other health conditions.

Since the number of people aged >65 years will increase 25-35% over the next 30 years, the number of people with CVD undergoing emergency surgical procedures will increase as well.

Perioperative major adverse cardiovascular and cerebrovascular events (MACCE) continue to be important clinical problems.

Several studies suggest that statins can prevent adverse CV events at both the primary and secondary levels.

In recent years, perioperative CV evaluations and CV protection strategies for noncardiac surgery have reduced the incidence of this condition. Strategies include the use of dual antiplatelets, β blockers, ACE inhibitors and statins.

The cholesterol-independent effects of statins can occur immediately after a single dose of these drugs.

They lead to an improvement in microvessel coronary circulation and endothelial function, a reduction of thromboembolic events and myocardial protection that translate into early and long-term positive clinical outcomes.

A variety of physiologic perturbations induced by the perioperative status, such as increased sympathetic tone, anemia, pain and abrupt changes in metabolic, hemodynamic and electrolytic parameters may precipitate plaque instability and thrombosis, especially during emergency surgical procedures.

Because the response of plaques to surgery is not predictable, systemic medical therapy with a statin that can stabilize plaques is an attractive option.

Preoperative rosuvastatin reload therapy decreases the incidence of myocardial necrosis and MACCE after noncardiac emergency surgery in patients with stable coronary artery disease on long-term statin therapy.

Coronary Myocardial Bridge: A Long-term Follow-up Study Dr Chandan Kumar Das, Bilaspur ÂÂ

CAD has taken the shape of epidemic in India, particularly in the young population today.

IJCP Sutra 65: Incidence of thyroid cancer is presumed to be low in early T2DM up to 6 years after the diagnosis. J Diabetes Res. 2017;2017:5850879.

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Many of them do not have conventional risk factors, but their symptoms should not be ignored.

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Screen them to rule out a coronary myocardial bridge, which may be a significant risk factor itself for a fatal outcome.

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Treat them with dual antiplatelets, metoprolol and nicorandil, if found suitable.

Treating HFpEF: “Huff-Puff” without a Solution?

emergency medical services. In addition, delays since chest pain till first medical contact are high.

Though revascularization rates are high, primary PCI still has a significant shortfall as compared to fibrinolytic therapy. ÂÂ

Myocardial Reperfusion Injury Dr Ramesh Daggubati, USA

Dr PB Jayagopal, Palakkad ÂÂ

HFpEF is prevalent mostly in elderly with multiple comorbid conditions.

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Other treatable causes for heart failure like HT, CAD, AF have to be identified and treated.

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Medications like ACEIs, ARBs, β blockers, MRA, which are useful in the treatment of HFrEF do not improve outcomes in HFpEF.

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However careful assessment of volume overload, treatment with diuretics, small dose β-blocker and ARB are useful in reducing hospitalization in a minority of patients.

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PARAGON-HF trial may give insight in the use of ARNI in the management of the same.

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Myocardial reperfusion injury can present in patients as stunning, no-reflow, arrhythmias or lethal reperfusion injury after opening an occluded artery during STEMI.

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Several mechanisms and mediators have been proposed including mitochondrial membrane permeability transition as the reason for apoptosis.

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Animal studies have shown promise in reducing reperfusion injury with few agents such as cyclosporine and Bendavia. However, translation of these agents into humans have not been possible so far.

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Hence prevention is better than cure for myocardial reperfusion injury and one should make every attempt in opening up the occluded artery as soon as possible.

Scar VT Ablation: Substrate-based Ablation or Entrainment Mapping of VTs?

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Dr Samuel J Asirvatham, USA

Renal Dysfunction in HF: A Catch 22 Situation

Although ICDs have clearly been documented to improve lifespan in patients with structural heart disease and ventricular tachycardia (VT), frequent shocks remain a major disadvantage.

Dr I Sathyamurthy, Chennai

Ablation for VT was developed primarily to manage single morphology VT that is hemodynamically stable.

Present day patients with frequent shocks have multiple VTs that are typically not hemodynamically stable.

STEMI Care for All in UAE

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HF patients are prone to renal dysfunction due to interplay between heart and kidney. Type I and II CRS are secondary to HF. The incidence varies from 20% to 30%.

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Renal involvement is not only due to low CI, but also increased venous pressures.

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Neutrophil gelatinase-associated lipocalin (NGAL): Blood/urine biomarker for early recognition. Lowdose frusemide infusion preferable.

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In resistant cases, ultrafiltration may be helpful for symptom relief.

Dr Brajesh Mittal, UAE ÂÂ

Death rates from cardiovascular diseases is more than double of that in the western countries.

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As per UAE data, at least 30% deaths are caused by diseases of heart and circulatory system,

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ACS registries and studies in the region have demonstrated that there is underutilization of

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Education of public and healthcare professionals besides the integrated approach of all stakeholders to develop a system would address the ideal STEMI care.

A Novel Risk Factor for Heart Failure Prof UC Samal, Patna ÂÂ

Dietary-associated and intestinal microbiotadependent metabolite TMAO has emerged as an independent CV risk factor. TMAO is a toxic end product in our food consumed daily but remains

IJCP Sutra 66: Extensive care and effective strategies are required to control glucose metabolism among patients with physical disability. Diabetol Metab Syndr.

2017;9:58.

CONFERENCE Proceedings generation OCT machines use only FD-OCT. As blood is opaque to light, it has to be replaced with a transparent medium like the contrast medium during image acquisition.

in permissive limits. When in excess of 3.5 µM/L, it is observed to be baneful and act as independent risk factor for CAD, HF, CRS, CKD, CVA and premature death. ÂÂ

Our gut flora/microbiome is a key regulator of TMAO production, though as commensals enormously beneficial in providing nutrition and other essential nutrients and offer immunity.

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Carnivorous diet is principal source of TMAO, particularly, Egg yolk and red meat and some sea food like cod, salmon, tuna, shark, scallop, etc. and even in ‘wheat germ’.

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Mediterranean diet being rich in complex carbs and fibers (vegetables, fruits, nuts and also olive oil) very low in TMAO yield are already recommended in global guidelines (UNESCO:2013:Baku). Vegetarian diet, more so vegan diets are safer proposition against TMAO, but the food in moderation always.

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DMB (Dimethyl-1-butanol), a choline analog, is a small molecule being used in trial models which inhibits TMA production (TMA-FMO3-TMAO), and safe for human use is the future hope for the risk intervention. TMAO is a novel risk factor, modifiable and measurable, but needs further validation by larger multicentric RCTs.

OCT: Technique and Image Interpretation Dr G Sengottuvelu, Chennai ÂÂ

OCT started as a research tool, but now is graduating to become an important clinical tool particularly to view the endoluminal structure of the blood vessels. The basic principles of OCT consist of a single mode optic fiber that transmits and receives infrared light waves at a bandwidth of 1250-1350 nm, which is the ideal spectral range for imaging biological tissue.

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The received signals, depending on the tissue characters (that determines the back scatter and attenuation) are reconstructed and displayed in cross section. The back scattered optical echoes are processed based on the frequency change (frequency domain) or time change (time domain).

As the speed of light is extremely high, a reference mirror is used in the time domain OCT to calculate the relative rather than the absolute change.

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Processing of frequency domain OCT signals has better spatial and temporal resolution. The present

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The learning curve for OCT image interpretation is much shorter than IVUS and because of its high resolution, the type of plaque can be recognized well and appropriate strategy planned.

Acute Myocarditis with HF: Role of Pharmacotherapy Prof Dr Amal Kumar Choudhury, Bangladesh ÂÂ

Myocarditis is a ‘gray zone’.

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Knowledge is still evolving.

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Diagnosis is often late.

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Treatment is mainly supportive.

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Drug treatment has limited auxiliary role.

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Newer upcoming treatment modalities are a ray of hope.

Improving Survival Rates Among Heart Failure Patients with the Use of Novel Drugs Dr PK Hazra, Kolkata Heart failure is an important global health problem, affecting about 26 million people worldwide.1 In India, cardiovascular diseases like heart failure and cardiac arrhythmias contribute to a major component of the non-communicable disease burden.2 Approximately 40,000-50,000 CA/HF patients receive international device therapies like pacemakers, ICD, CRT and/or RFA.2 In Asia Pacific region, patients receive lower-thanrecommended levels of pharmacological treatment.3 The cornerstone of contemporary pharmacological therapy targets the over activated renin-angiotensin-aldosterone and sympathetic autonomous systems.4 In 2016, the focused pharmacologic update on the current Heart Failure Guidelines introduced the use of two newly approved drug regimens: Valsartan/ sacubitril and ivabradine. These novel compounds were reported to exert additional mortality and morbidity benefits in heart failure subpopulations with reduced ejection fraction.4 References: 1Dokainish H, et al. Lancet Glob Health. 2017;5(7):e665-e672.

2Vora A, et al. Indian Heart J. 2017;69(2):229-39. 3Rajadurai J, et al. J Card Fail. 2017;23(4):327-39. 4Papadimitriou L, et al. Trends Cardiovasc Med. 2017;27(5):316-23.

IJCP Sutra 67: Standard antiplatelet therapy, considered the cornerstone for primary and secondary prevention of CVD may fail in many patients with diabetes.

Diabetes. 2017;66(1):7-13.

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CONFERENCE Proceedings

58th Annual Conference of the Indian Society of Gastroenterology (ISGCON 2017) Noninvasive Biomarkers for Diagnosis and Monitoring of CD Dr Govind K Makharia, New Delhi

There is no single gold standard test for the diagnosis of CD.

Risks of stopping or continuing antithrombotics for endoscopy: Bleed after endoscopy - usually treatable; thromboembolic event - potentially devastating.

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ESPGHAN criteria: 1990 - Presence of symptoms; presence of villous atrophy; unequivocal response to gluten-free diet (GFD).

Antithrombotic medications: Antiplatelet agents aspirin; thienopyridines. Anti-coagulant medications warfarin; direct oral anticoagulants (DOACs).

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Risk factors for GI bleeding - Age >65 years, especially >75 years; hepatorenal dysfunction; low body weight; concomitant antiplatelet agents or NSAIDs; drugs that affect cytochrome P450; rivaroxaban > dabigatran > apixaban.

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Antithrombotic management depending on GI bleeding severity: Mild GI bleeding - No change in antithrombotic medications; no reason to reverse. Moderate GI bleeding - Hold antithrombotic medications if possible; reverse medications if ongoing bleeding; restart after endoscopy in 1-7 days. Severe GI bleeding - Hold antithrombotic medications; reverse medications; restart when clinically stable (within 7 days).

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For patients taking ASA for secondary prophylaxis, restart when bleeding is controlled (within 1-7 days). For patients on thienopyridines, hold if possible but continue ASA.

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For patients on warfarin: For life-threatening GI bleeding, give 4-factor PCC and vitamin K or FFP; perform endoscopy when INR ≤2.5; for patients at high risk for thromboembolism, restart when bleeding is controlled (within 1-7 days).

Celiac disease (CD) is a life-long disease and hence there is a need that we make confirmed diagnosis.

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Presence of villous abnormality is the hallmark of diagnosis.

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Advent of serological tests - IgA anti-gliadin ab, IgG anti-gliadin ab, anti-endomysial ab, IgA antitissue transglutaminase ab, IgA anti-deamidated peptide ab and IgG anti-deamidated peptide ab.

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Evolution of diagnosis - ESPGHAN 2012: Presence of gluten-dependent symptoms; CD-specific antibody levels; characteristic histological changes.

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Serology is great but may have fallacies, especially at low titer. If there is demonstration of villous atrophy along with positive serology, the diagnosis is good.

Obtaining biopsies is invasive and expensive.

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Potential molecules as noninvasive markers of villous atrophy: Citrulline; I-FABP; Reg1a; CYP3A4.

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Citrulline is an excellent biomarker for assessment of enteropathy.

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FABP - No standard test kit is available; does not show a time trend on a model of cyclical enterocyte injury and recovery; need more studies.

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Reg1a is not useful.

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Other potential biomarkers - Elafin; high mobility group Box 1; glutathione S-transferase; polyethylene glycol and plasma D lactate.

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Dr John R Saltzman, Boston ÂÂ

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GI Bleeding in Anticoagulated Patients

Citrulline is the most reliable marker for demonstrating villous abnormalities and has potential for avoiding biopsies in 78% subjects with 95% specificity.

If citrulline is ≤30 µM/L and/or I-FABP is >1,100 pg/ml - No biopsy.

Endotherapy for GERD: Present and Future Dr DN Reddy, Hyderabad ÂÂ

Unmet needs in GERD management: Refractory GERD; long-term PPI use and volume reflux.

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Endoscopic management of GERD - Radiofrequency ablation; transoral fundoplication and mucosal resection.

IJCP Sutra 68: High blood glucose, oxidative stress and elevated vascular shear forces contribute to platelet hyperreactivity increasing risk of CV events in diabetes.

Diabetes. 2017;66(1):7-13.

CONFERENCE Proceedings ÂÂ

Stretta for GERD - Low power RF energy delivered to tissue; multi-level treatment remodels lower esophageal sphincter (LES) and gastric cardia; function is improved.

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Stretta procedure significantly improves subjective and objective clinical endpoints except LES basal pressure, and therefore, should considered as a viable alternative in managing GERD.

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In patients with GERD, electrical stimulation therapy (EST) significantly and consistently increases LES pressure.

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Patients diagnosed with acute-on-chronic liver failure (ACLF) as per the Asian Pacific Association for the Study of the Liver (APASL) definition were enrolled.

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Follow-up data was available for 1,021 patients.

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At presentation, age, total bilirubin, creatinine, INR, hepatic encephalopathy (HE) grade, lactate were independent predictors of 28 days mortality.

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Following conditions need emergent LT: MELD score >30; MELD score 25-30 with single organ failure; HE Grade III-IV at any time; new onset HE anytime within first week; progressive liver failure as defined by bilirubin >12 mg/dl and PTINR >2.5.

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Emergent live donor LT or special allocation policy for deceased donor liver transplantation (DDLT) should be explored in the first week.

Management of Acute Severe Colitis in 2017 Dr Vineet Ahuja, New Delhi ÂÂ

10% of ulcerative colitis (UC) experience acute severe colitis (ASC).

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11% undergo colectomy at index hospitalization.

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A recent study revealed that clinical features, especially response at Day 7 hospitalization for index ASC, can predict both colectomy and steroid dependence with reasonable accuracy.

Incidence, Predictors and Outcomes of Transition of AKI to CKD in Cirrhosis: A Prospective Cohort Study

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Markers of steroid failure: On admission: UC Endoscopic Index of Severity (UCEIS) >6. Day 3: fecal calprotectin (FCP) >1,000.

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The study aimed to investigate the impact of acute kidney injury (AKI) in causing structural kidney damage (CKD). It also studied cystatin C as a biomarker for prediction of structural kidney damage (CKD). Another objective was to develop predictive scores for structural AKI.

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This was a prospective cohort study from August 2013 to February 2016. Consecutive cirrhotics with or without AKI were followed for a year or until death or liver transplant. Patients with cirrhosis seen as outpatients or inpatients at the Institute of Liver and Biliary Sciences were enrolled.

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Cystatin C predicts AKI and mortality in cirrhotics.

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In all, 950 episodes in 501 patients yielding a mean of 1.89 episodes of AKI per patient were noted.

Median time to AKI was 85 days.

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This is the first study in cirrhotics identifying structural AKI.

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Decline in eGFR was significantly increased after an AKI episode.

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Stratification by structural AKI score - preventive strategies for AKI risk of structural kidney damage.

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All efforts should be made to prevent AKI in cirrhotics.

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FCP has a reasonable diagnostic accuracy to diagnose ASC, but requires validation before clinical use. Left colitis and extensive colitis have similar colectomy rates after index episode of ASC. Early surgery yields best results.

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Infliximab is the biologic agent of choice in ASC; accelerated infliximab regimen: 0, 1 and 2/3 weeks in select cases.

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Truelove and Witt’s criteria can be used to define ASC in developing countries despite lower mean hemoglobin in the native population.

The Decision for Liver Transplant in ACLF First Week is the Crucial Period: Analysis of the APASL-ACLF Research Consortium (AARC) Prospective Data of 1,021 Patients Dr Ashok Choudhury, New Delhi ÂÂ

A study was conducted with the primary aim to identify the predictors of outcome and their dynamic change for 28 days survival. Secondary aims were survival at 7 days, ideal timing for liver transplant, causes of ineligibility for transplant, comparison for existing prognostic models, transplant-free survival or spontaneous recovery at 90 days.

Dr Rakhi Maiwall, New Delhi

IJCP Sutra 69: Hyperfiltration is a risk factor for accelerated GFR reduction and nephropathy in people with T2DM with abdominal obesity. Diabetes.

2017;66(1):75-86.

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practice is poor. Targeted biopsy - White light high definition colonoscopy with targeted biopsy of abnormal areas; chromoendoscopy with biopsy of abnormal areas; NBI with biopsy of abnormal areas.

Urinary Potassium is a Potential Biomarker of Disease Activity in Ulcerative Colitis and Displays in vitro Immunotolerant Role Dr Sandeep Goyal ÂÂ

Available biomarkers in IBD: Serum - CRP; trefoil factor. Stool - FCP; fecal lactoferrin; fecal neopterin; labeled leukocyte scintigraphy.

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CRP is nonspecific, while FCP has issues with cost and availability. Search for a better biomarker continues.

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A study was conducted to compare 24 hours urinary potassium levels in UC and healthy controls. It also compared urinary potassium levels in patients with UC with active disease and in clinical remission/response following 3-6 months of therapy. It evaluated in vitro effect of potassium on effector CD4+ T cells in the presence of Th17 inducing inflammatory environment.

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This was a prospective observational cohort study from September 2015 to May 2016. It enrolled 30 UC patients and 18 healthy volunteers.

Conclusion: Urinary potassium level is inversely associated with disease activity in UC. In vitro data - It suppresses inflammation by reducing IL-17 and IFN-γ and inducing Foxp3 expression on Th17 cells. It has the potential to be a biomarker.

Endoscopic Surveillance for Cancer in Patients with IBD Dr Sawan Bopanna, New Delhi ÂÂ

1% of all colorectal cancer (CRC) are IBD-associated.

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CRC is a significant contributor to long-term morbidity in IBD. Pathogenesis involves chronic mucosal inflammation and repair.

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Random biopsies are futile and greater adaptation of chromoendoscopy is required. Chromoendoscopy guided targeted biopsies are better than random biopsies for detection of dysplasia.

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Role of NBI is fast evolving, but further studies are required.

Impaired Circulating GM-CSF Secreting IRA-B Cells and Humoral Immunity in MTCT of HBV Dr Ashish Kumar Vyas, New Delhi ÂÂ

Prevalence of hepatitis B virus (HBV) infection among pregnant females varies from 1.2% to 1.6% in India.

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HBV chronicity is inversely proportional to age.

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A study was designed with the aim to understand the role of maternal B cells and cellular immunity in HBV vertical transmission.

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Hypothesis - Dendritic, Tfh and B cells crosstalk underlies prevention of HBV vertical transmission in HBsAg positive pregnant females.

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There were 125 HBsAg+ mothers in the study.

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Conclusion - Impaired immunity in HBV-infected pregnant females enhances the chances of HBV vertical transmission to their newborns.

Biologics in IBD: Which, When and How? Dr Rupa Banerjee, Hyderabad ÂÂ

The targets of IBD treatment have changed.

Therapeutic goals include induction of clinical remission; maintenance of clinical remission; improvement of quality-of-life.

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Number of patients with IBD is increasing in Asia and India. Risk of CRC in Indian patients with UC is high.

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Better immunosuppression may lead to longer colectomy free survival.

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Biologic therapy should be initiated with moderateto-severe unresponsive or complicated disease.

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Whom to screen - Risk factors: Extent of disease; duration of disease; associated PSC; family history of CRC; age of onset; severity of inflammation; backwash ileitis.

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Choices of biologics: Anti-TNFs - Infliximab, adalimumab, golimumab, certolizumab; Antiintegrins - natalizumab, vedolizumab.

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Screening and surveillance colonoscopy is important in high-risk patients.

All available biologics have comparable efficacy for the induction of remission. Only infliximab is recommended for ASC.

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Techniques for surveillance: Random biopsy - White light high definition colonoscopy with 4 quadrant biopsy from every 10 cm. This is labor- and resourceintensive. Patient and physician adherence to this

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Consider the following while choosing a first-line biologic agent: Efficacy and safety profile; route of administration; specific country availability and labeling; patient preferences and cost-effectiveness.

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IJCP Sutra 70: Metformin is a commonly prescribed hypoglycemic drug that exhibits CV protective actions in patients with diabetes. Diabetes. 2017;66(1):193-205.

CONFERENCE Proceedings ÂÂ

Vedolizumab is a lucrative first-line option due to the low-risk of infective and other complications so far.

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Approximately 30-40% patients in anti-TNF trials are primary nonresponders. Assess for response at 8-12 weeks.

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Factors that influence the efficacy of antiTNFs: Presence of ADAs; concomitant use of immunosuppressives; low serum albumin; high baseline CRP concentration; high baseline TNF concentration; sex (males have higher clearance).

Therapeutic drug monitoring can help decide when to switch to another agent.

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Latent TB poses a challenge for biologic therapy.

Chemoprophylaxis is preferred when in doubt. The right drug at the right time can achieve optimal disease control, prevent complications and ensure long-term safety.

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A study determined serum and tissue levels of retinoic acid (RA) and their correlation with Th1, Th17 and T regulatory cells in steroid naive UC and Crohn’s disease (CD) during relapse as well as remission of disease activity. Secondary objective was to determine the role of RA primed dendritic cells in influencing inflammatory and tolerogenic T cells.

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This was a prospective cohort study done from August 2013 to July 2017. Adult patients with suggestive history and characteristic endoscopic and histologic findings were included. Controls patients with suspected hemorrhoidal bleed in absence of any other major disorder or intestinal disease - were included.

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A sensitive LC-MS assay was developed for the quantitative determination of RA. RA levels in tissue and serum are significantly increased in patients with UC and CD. RA level is significantly increased in inflamed region of UC and CD patients as compared to serum levels.

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Patients with active disease have an increased tissue RA level as compared to controls and patients in remission.

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Tissue RA positively correlates with IL-17and IFN-γ and negatively correlates with IL-10 in UC patients.

Acute on Chronic Liver Failure Dr Kaushal Madan, New Delhi ÂÂ

ACLF is a distinct syndrome characterized by: Acute insult/injury; on patients with bad underlying liver; leading to worsening-decompensation and extrahepatic organ failures; high short-term mortality (almost 50%).

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Meticulous intensive care is needed: Nutrition; empirical antibiotics; organ supports - inotropes, RRT, ventilatory support.

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The best outcomes can be achieved by targeting specific treatable etiological agents - HBV; AIH.

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Liver transplantation seems to be the only modality which offers the best long-term outcomes; but it has to be instituted early: 7-10 days (Golden window).

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Results of liver transplantation are similar to nonACLF patients.

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Even patients with high grade ACLF (2 and 3) can be transplanted with satisfactory result; but the post transplantation course is stormy.

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Downgrading MELD to <30 prior to transplantation may improve outcomes.

Vitamin A Promotes Mucosal Inflammation

by Augmenting Th1/Th17 Differentiation in Inflammatory Bowel Disease Dr Ritika Rampal ÂÂ

Vitamin A (retinoic acid) is a crucial immune modulator. High dietary vitamin A levels trigger relapse in patients with UC in remission.

Current Spectrum of ACLF in India Dr Vivek Saraswat, Lucknow ÂÂ

There are over 47 definitions of ACLF in literature.

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Prevalence of ALD, NAFLD is increasing.

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Entire spectrum of WGO ACLF types A to C seen in India: Alcoholic hepatitis as an acute insult and underlying ALD as the cause of cirrhosis form the largest subset of ACLF in India; viral hepatitis as an acute insult and cause of underlying LC is 2nd to 3rd commonest cause.

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Severity of acute insult plays a major role in outcome: Severity of liver injury is the single most important factor; role of AKI, other OF is secondary to LF.

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Severity scores are evolving and need to be applied to cohorts of ACLF patients from different parts of India to validate which is better: CLIF OF score or Simple OF count (SOFC); CLIF C ACLF score; AARC score and grade; AARC ACLF score.

IJCP Sutra 71: Adults with sleep-disordered breathing are 26% more likely to develop clinically relevant cognitive decline or dementia. JAMA Neurol.

2017;74(10):1237-45.

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AROUND THE GLOBE

News and Views Supreme Court for Larger Warnings on Cigarette Packs Recently, the Supreme Court stayed an order of the Karnataka High Court reducing the size of pictorial warnings on packages of tobacco products to 40% of the package space. The court foregrounded the health of citizens over the concerns of the tobacco industry and favored a government regulation requiring packets of tobacco products to sport pictorial warnings covering 85% of their packaging space. A Bench led by Chief Justice Dipak Misra said it is mild to say that tobacco consumption and use causes “deterioration of health”.

The apex court said “destruction of health” is a more appropriate phrase to explain the harm caused by tobacco… (The Hindu, Krishnadas Rajagopal, New Delhi, January 9, 2018)

World could See 1.8 Billion Tourists by 2030 By 2030, there could be 1.8 billion tourists - just over one in five persons in the world - traveling around the globe, the United Nations World Tourism Organization (UNWTO) has said. Speaking with UN News, Taleb Rifai, the Secretary-General of UNWTO, highlighted the role of travel and tourism in impacting global developments and making the world a better place. “It is bringing the world together in an incredibly impressive way: it is making the world smaller, more connected, more informed and therefore… a more caring world,” he said.

At the same time, the global phenomenon has also brought about serious challenges, including pollution, waste, labor exploitation, prostitution and abuse of children and looting of natural resources. Given that all human activity has both advantages and disadvantages, it is up to people to ensure that the impacts from tourism are positive and contribute to sustainable development, Mr Rifai noted. “1.8 billion travelers by 2030 could be 1.8 billion opportunities or 1.8 billion disasters and it is all up to us [to choose].” (UN, December 27, 2017)

Insufficient Evidence to Screen Kids for Scoliosis, Says USPSTF In an update to its 2004 recommendation, the US Preventive Services Task Force (USPSTF) has concluded that presently there is insufficient evidence to assess the balance of benefits and harms of screening children and adolescents aged 10-18 years for idiopathic scoliosis.

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The final recommendation statement is published on the USPSTF website and also January 9, 2018 in JAMA.

Metformin Associated with Lower Risk of TB in Type 2 Diabetes Patients Results of a retrospective cohort study show that predominantly metformin-users in the initial 2 years had a significantly lower risk for tuberculosis (TB).

Compared to sulfonylurea-users, non-CKD type 2 diabetes patients on metformin had a significantly lower TB risk.

Multicomponent Approach Works Best for Control of Hypertension Multilevel, multicomponent strategies that include physician- and nonphysician-led interventions were found to be the most effective for control of high blood pressure (BP) control in patients with hypertension in a study published online December 26, 2017, in Annals of Internal Medicine.

Adjuvanted Herpes Zoster Subunit Vaccine is Costeffective At the proposed price of $280 per 2-dose course, the adjuvanted herpes zoster subunit vaccine was more effective and less expensive than the live attenuated herpes zoster vaccine at all ages in as study published online January 2, 2018 in JAMA Internal Medicine. The vaccine also had an incremental cost-effectiveness ratio from $20 038 to $30 084 per quality-adjusted life-year vs. no vaccination.

Neighborhood Factors may Predict Heart Failure Neighborhood-level socioeconomic factors in lowincome areas may significantly predict heart failure risk beyond individual health factors and socioeconomic status, according to new research published in the journal Circulation: Cardiovascular Quality and Outcomes.

Improvements in community resources such as exercise facilities, healthy food outlets and medical facilities could benefit residents.

Predictors of Invasive Mechanical Ventilation in patients with AECOPD A study published December 31 in Croatian Medical Journal has identified anemia, hypoalbuminemia and

IJCP Sutra 72: Self-reported sleep duration <6 h/day is associated with multiple cardiometabolic risk factors - central obesity, elevated fasting glucose, hypertension, low HDL cholesterol, hypertriglyceridemia, and metabolic syndrome. Sleep. 2017;40(10).

AROUND THE GLOBE high levels of troponin as predictors for the need of invasive mechanical ventilation in patients with acute exacerbations of chronic obstructive pulmonary disease (AECOPD).

UN Environment and WHO Collaboration on Environmental Health Risks UN Environment and WHO have agreed a new, wideranging collaboration to accelerate action to curb environmental health risks that cause an estimated 12.6 million deaths a year. Mr Erik Solheim, head of UN Environment, and Dr Tedros Adhanom Ghebreyesus, Director-General of WHO, have signed an agreement in Nairobi to step up joint actions to combat air pollution, climate change and antimicrobial resistance, as well as improve coordination on waste and chemicals management, water quality and food and nutrition issues. The collaboration also includes joint management of the BreatheLife advocacy campaign to reduce air pollution for multiple climate, environment and health benefits. This represents the most significant formal agreement on joint action across the spectrum of environment and health issues in over 15 years.

Priority areas of cooperation between WHO and UN Environment include: ÂÂ

Air quality: More effective air quality monitoring including guidance to countries on standard operating procedures; more accurate environment and health assessments, including economic assessment; and advocacy, including the BreatheLife campaign promoting air pollution reductions for climate and health benefits.

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Climate: Tackling vector-borne disease and other climate-related health risks, including through improved assessment of health benefits from climate mitigation and adaptation strategies.

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Water: Ensuring effective monitoring of data on water quality, including through data sharing and collaborative analysis of pollution risks to health.

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Waste and chemicals: Promotion of more sustainable waste and chemicals management, particularly in the area of pesticides, fertilizers, use of antimicrobials. The collaboration aims to advance the goal of sound lifecycle chemicals management by 2020, a target set out at the 2012 United Nations Conference on Sustainable Development.

(WHO, January 10, 2018)

Older Adults with Metabolic Syndrome do not Respond Well to Antidepressant Treatment In a study published January 10, 2018 in the Journal of the American Geriatrics Society, metabolic syndrome in older adults aged 60 years and above with depression was associated with more severe symptoms and chronicity of depression. Also, the depression did not respond well to antidepressant treatments.

New Guidelines do not Recommend Disulfiram as First-line Treatment for Alcohol Use Disorder The American Psychiatric Association practice guideline for the pharmacological treatment of patients with alcohol use disorder has recommended naltrexone and acamprosate as first-line for patients with moderateto-severe disease. The guidelines do not recommend disulfiram as first-line treatment.

The guidelines are published online January 5, 2018 in the American Journal of Psychiatry.

Aerobic Exercise Reduces Risk of Heart Failure Associated with Sedentary Behaviors A new study in the journal Circulation, published online January 8, 2018 says that 2 years of exercise training during middle age may reduce or reverse the cardiac consequences of a sedentary lifestyle and reduce the risk of heart failure associated with sedentary behaviors such as sitting or reclining for long periods of time. Exercise also decreased cardiac stiffness.

Study shows Signs of CTE in Brain in Younger Adults with Difficult-to-treat Epilepsy Younger adults with difficult-to-treat epilepsy may have early signs of chronic traumatic encephalopathy (CTE) in their brain tissue, according to a small, preliminary study of 10 people living with epilepsy for an average of 24 years, and who had undergone respective surgery to control seizures at an average age of 33.

The study is published in the January 10, 2018 online issue of the journal Neurology.

Obesity Increases risk of Disability Post-joint Surgery According to a study published online December 13, 2018 in the British Journal of Anaesthesia, 22% of people who underwent joint surgery became dependent 2 years post-surgery. Being obese was associated with 35% higher risk of dependence after surgery than not being obese.

IJCP Sutra 73: The ACP and CDC advise HBV testing in patients with high aminotransferases and in asymptomatic individuals at high risk for exposure or severe adverse outcomes with a missed diagnosis. Ann Intern Med. 2017;167(11):794-804.

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Complex Perianal Fistulas in Crohn’s Disease may Resolve with Stem Cell Therapy Results from the ADMIRE CD trial published online December 22, 2017 in the journal Gastroenterology have shown resolution of treatment-refractory complex perianal fistulas at 1 year with local stem cell therapy with allogeneic expanded adiposederived stem cells (Cx601) in patients with Crohn’s disease.

Kerala Govt. Permits Prisoners in State Jails to Donate Their Organs to Close Relatives Kerala Government has decided to permit prisoners in State Jails to donate their organs to close relatives, but with certain conditions. Decision was taken at Cabinet meeting chaired by CM Pinarayi Vijayan.

Govt. in its Press Release stated that, “Prisoners can henceforth donate their organs to close relatives only and Government has decided to make necessary amendments in Kerala Prisons and Correctional Services (Management) Act 2014”. Also, they have to take sanction from concerned Court, the same which convicted them, besides permission of Medical Board for any such organ donation.

Government further added that, “It was also resolved that period the Prisoner is hospitalized post donation, will be considered as parole and hospital expenses will be met by Jail Department”.

Government took the decision on hearing about experience of P Sukumaran, a convict serving life sentence in Kannur Central Jail, who had sought permission to donate one of his kidneys. However, before a decision could have been taken, patient in question had passed away. Government has made it clear that there will be ‘no relaxation in prison term’ for the prisoner following the organ donation.

Another issue that may come up is can a mentally challenged person who is represented by natural guardians - the father and mother donate his organs or tissues within the meaning of Section 2(f) of the Transplantation of Human Organs and Tissues Act, 1994? And, can such a person be permitted to donate human organ for transplantation in favor of his real brother in spite of bar provided under Section 9(1-C) of the same Act? These issues were dealt with by the Hon’ble High Court of Bombay Bench at Aurangabad in the matter of “Ganpatrao & Others versus State of Maharashtra & Others, Writ Petition No. 13918 of 2017.

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The provisions of Section 9(1C) of the Transplantation of Human Organs and Tissues Act, 1994 are reproduced hereunder: “9. Restrictions on removal and transplantation of [human organs or tissues or both] (1C) No human organs or tissues or both shall be removed from the body of mentally challenged person before his death for the purpose of transplantation.

Explanation for the purpose of this subsection,

i. the expression “mentally challenged person” includes a person with mental illness or mental retardation, as the case may be;

ii. the expression “mental illness” includes dementia, schizophrenia and such other mental condition that makes a person intellectually disabled;

iii. the expression “mental retardation” shall have the same meaning as assigned to it in clause(r) of section 2 of the Persons with Disabilities (Equal Opportunities, Protection of Rights and Full Participation) Act, 1995 (1 of 1996)]”

Taking into considerations, the provisions of Section 2(f) and Section 9(1C) of the Act, the Bench ruled that a mentally challenged person who is represented by natural guardians - father and mother cannot be a donor for removal of his organs or tissues within the meaning of Section 2(f) of the Transplantation of Human Organs and Tissues Act, 1994. Also, he cannot be permitted to donate human organ for transplantation in favour of his real brother in view of the bar provided under Section 9(1-C) of the Transplantation of Human Organs and Tissues Act, 1994. ÂÂ

“15. As has been recorded above, the principles in Common Law jurisdiction based upon “best interest test” cannot be made applicable in view of specific provisions in Transplantation of Human Organs and Tissues Act, 1994. Section 2(f) of the Act defines donor as the person not less than 18 years of age, who voluntarily authorises removal of his organ or tissues. In the instant matter, petitioner no. 3 is not an individual who is in a position to voluntarily authorise removal of his organ or tissues. Apart from this, section 9(1C) puts bar on removal of human organ or tissues or both from body of a mentally challenged person. In the instant matter, petitioner no. 3 is adjudged as suffering from mental retardation and he is reported to be a person not capable of making decision for himself. We, with a view to find out whether petitioner no. 3 has a minimum level of understanding, interviewed him by calling him in chamber in presence of the counsel of both the sides.

We have noticed that petitioner no. 3 even was not in a

IJCP Sutra 74: The Canadian Task Force on Preventive Health Care (CTFPHC) recommends one-time screening for AAA with ultrasonography in men aged 65-80 years. CMAJ. 2017;189:E1137-45.

AROUND THE GLOBE position to understand the questions put to him and is incapable of understanding the consequences of his act.

His decision making power is severely impaired and we do not doubt the opinion of the Consultant Psychiatrist. ÂÂ

16. The restriction on removal and transplantation of human organs or tissues or both contained in subsection (1C) of section 9 of the Act in respect of mentally challenged person is an absolute prohibition. The Statutory provision is couched in negative language and as such shall have to be construed mandatory.”

Govt. to Launch a Clean Air Campaign for 2 Weeks in Delhi Next Month Union Minister for Environment, Forest and Climate Change, Dr Harsh Vardhan has said that starting from February 10, the Union Government will launch a joint campaign for 2 weeks, with Delhi Government, New Delhi Municipal Council (NDMC), Central Pollution Control Board (CPCB) and other municipal agencies, for clean air in Delhi. “The campaign seeks to sensitize ground-level functionaries and general public to enforce the habit of environmental protection”, the Minister pointed out. Chairing a meeting on mitigation of air pollution, Dr Harsh Vardhan emphasized that there will be a team of 70 officers, led jointly by one officer each from the Ministry of Environment, Forest and Climate Change and one officer from the State Government of Delhi. These officers will be assisted by officers from CPCB, Delhi Pollution Control Committee (DPCC) and respective municipal corporations.

Children Aged 6 months can Now also be Given the Fluarix Quadrivalent Flu Vaccine The US Food and Drug Administration (FDA) has expanded the indication for the four-strain influenza vaccine Fluarix Quadrivalent (GlaxoSmithKline) to children as young as 6 months. The vaccine is approved for use in adults and children aged 3 years and older to prevent disease due to seasonal influenza virus subtypes A and B

Static Perimetry Feasible in Children with Glaucoma Static perimetry appeared to be effective and appropriate in children with glaucoma younger than 10 years and for detecting mild field restriction, and far-peripheral kinetic perimetry was feasible and added value to assessment of older children, especially with severe visual field restriction in the Optimal Perimetric Testing in Children (OPTIC) published online December 28, 2017 in JAMA Ophthalmology.

Short-term Discontinuation of ART does not Expand HIV Reservoir A short-term analytical treatment interruption (ATI) and subsequent reinitiation of antiretroviral therapy (ART) does not lead to lasting expansion of the HIV reservoir nor cause irreversible damage to the immune system, according to a new study from the NIH published January 11, 2018 in the journal PLos Pathogens.

The Minister emphasized that Resident Welfare Associations (RWAs), Shopkeeper Associations and the Civil Society will be encouraged to become a part of these teams and participate in the campaign for mitigation of pollution. The teams will be provided with check lists so that there is focused activity on mitigation of pollution, including effective measures for dust mitigation, solid waste management and prevention of garbage burning… (PIB, Ministry of Environment, Forest and Climate Change, January 12, 2018).

Obese Children with Psoriasis Prone to Comorbidities

First Treatment for Breast Cancer with a Certain Inherited Genetic Mutation

Impact of Radiation Treatment for Breast Cancer in Women with Scleroderma

The US Food and Drug Administration (FDA) has expanded the approved use of the PARP inhibitor Lynparza, (olaparib tablets) to include the treatment of patients with certain types of breast cancer that have spread (metastasized) and whose tumors have a “BRCA” gene mutation. Patients are selected for treatment with Lynparza based on an FDA-approved genetic test, called the BRAC Analysis CDx.

Researchers from Johns Hopkins University School of Medicine in Baltimore have shown that few women with scleroderma who received radiation for breast cancer had acute skin toxicity such as blistering or ulceration, but about half of them experienced long-term radiationinduced skin fibrosis or thickening that was localized to the field of radiation. The study is reported online in Arthritis Care & Research.

A new retrospective cohort study published online January 10, 2018 in JAMA Dermatology has shown that children with psoriasis are at greater risk of developing obesity, hyperlipidemia, hypertension, diabetes, metabolic syndrome, polycystic ovarian syndrome, nonalcoholic liver disease, and elevated liver function enzyme levels than children without psoriasis. Obese children were especially at higher risk.

IJCP Sutra 75: Patients who had surgery for hip fracture <24 hours of admission had lower 30-day mortality vs patients who had surgery >24 hours after admission. JAMA. 2017;318(20):1994-2003.

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South Africa Responding to Largest-ever Listeria Outbreak

were seven pediatric flu deaths last week, bringing the total to 20 for the flu season that started October 1.

What is believed to be the largest-ever outbreak of the bacterial disease Listeriosis - or Listeria - has left more than 60 people dead across South Africa, with nearly 750 confirmed cases. Listeriosis is a serious, but preventable and treatable disease caused by the bacterium, Listeria monocytogenes, which is found in soil, water, vegetation and some animal feces. Animal products, including meat and dairy; seafood and fresh produce, such as fruits and vegetables, can all be contaminated.

High flu activity has been reported in New York City as well as Alabama, Arizona, Arkansas, California, Colorado, Georgia, Illinois, Indiana, Kansas, Kentucky, Louisiana, Mississippi, Missouri, Nebraska, Nevada, New Jersey, New Mexico, Ohio, Oklahoma, Oregon, South Carolina, Texas, Virginia, Washington, West Virginia and Wyoming. Outbreaks of the flu have closed some schools in states including Alabama, Idaho, North Carolina, Tennessee and Texas.

“Infants are often a high target of this bacteria,” said Christian Lindmeier, spokesperson for the World Health Organization (WHO), adding that “newborns are about 40% of the infected people.”

Having a 3-week incubation period makes it difficult to establish the source and thus, tough to prevent. “You wouldn’t know what you ate 3 weeks ago - may be the one particular food that made you sick 3 or 4 weeks later - this is the big challenge we face in this situation,” the spokesperson elaborated.

South Africans are called upon to practice WHO’s ‘Five Keys to Safer Food’ programme that include washing hands before and often during food preparation; separating raw meat, poultry and seafood from other foods and cooking foods thoroughly, especially meat, poultry, eggs and seafood.

Mr Lindmeier underscored the importance for those with weakened immune systems - including the elderly and people living with HIV and cancer - and pregnant women, “who are 20 times more likely to get Listeriosis than other healthy adults,” to exercise care. Nearly two-thirds of the reported cases have been from the Gauteng province, where Johannesburg and Pretoria are located… (UN, January 12, 2018).

H3N2 Epidemic in USA The Centers for Disease Control and Prevention (CDC) has declared H3N2 flu as an epidemic in US. The rate of hospitalizations for pneumonia and the flu is continuing to climb amid a CDC warning of several more weeks of significant flu activity.

This year the influenza season started earlier and is peaking at present. That’s about a month earlier than it normally would be peaking. Lots of cases [are] happening, in lots of states, all at the same time. There

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Antiviral drugs are also approved and recommended for treatment if taken within 48 hours of the beginning of symptoms. They can prevent serious complications particularly for people in the highest risk groups: children younger than 5 and adults older than 65.

Influenza H3N2 has been the most common strain in this cycle, which is usually more severe. H3N2 causes lots of disease, lots of hospitalizations, lots of cases and lots of deaths,” Jernigan said.

Influenza vaccine is the best way to prevent, but in this season it is not as effective as it is for the other viruses that circulate. A recent Australian study raised the idea that the vaccine might be only 10% effective against this year’s flu.

The flu vaccine is still recommended. It’s never too late to get the vaccine because the flu season can go on for months. It takes the vaccine about a week to really kick in.

Stay out of work or school if you’re sick, to try to keep everyone else around you healthy and wash your hands… (ABC News)

Cerebrovascular Events are Common in SLE Patients In a study published January 8, 2018 in Arthritis Care & Research, cerebrovascular events were identified as the fourth most frequent neuropsychiatric event in patients with systemic lupus erythematosus (SLE) and were attributed to the disease activity itself. Stroke (55.0%) and transient ischemia (25.7%) were the most common cerebrovascular events seen.

Sapacitabine + Decitabine does not Improve Overall Survival vs. Decitabine Monotherapy in AML Results of a phase III study of elderly patients with newly diagnosed acute myeloid leukemia (AML) show that the regimen of sapacitabine administered in

IJCP Sutra 76: Hypertension is now defined as BP ≥130 mmHg systolic or ≥80 mmHg diastolic in 2017 ACC/AHA guidelines. Hypertension. 2017 Nov 13.

AROUND THE GLOBE alternating cycles with decitabine was active and welltolerated but it did not significantly improve overall survival as compared to decitabine monotherapy; 5.9 months vs. 5.7 months, respectively.

Adherence to Healthy Diet Prevents Weight Gain in Genetically Predisposed Individuals A study published online January 10, 2017 in the BMJ says that individuals who are genetically at high risk for obesity are more susceptible to the beneficial effect of improving diet quality on weight loss. These results further underline the importance of adhering to healthy dietary patterns to prevent weight gain.

Incomplete Revascularization in PCI Increases Mortality Risk Patients with percutaneous coronary interventions (PCI) with incomplete revascularization are at higher risk of mortality if they have incomplete revascularization with at least 90% stenosis, incomplete revascularization in 2 or more vessels, or proximal left anterior descending artery incomplete revascularization, according to a study published online December 27, 2017 in JAMA Cardiology.

Anxiety may be an Early Sign of Alzheimer’s Disease Findings of a study published January 12, 2018 in the American Journal of Psychiatry show higher levels of amyloid beta to be associated with increasing symptoms of anxiety in cognitively normal older adults suggesting neuropsychiatric symptoms could be an early sign of preclinical Alzheimer’s disease.

Study Shows Effectiveness of MR-guided Focused Ultrasound Thalamotomy for Essential Tremor Magnetic resonance-guided focused ultrasound can stably suppress essential tremor. This effect was stable and maintained at 2 years. Also, no new delayed complications were observed at 2 years in the study reported online December 9, 2017 in the Annals of Neurology.

WHO and UNEP Team up to Tackle Environmental Health Risks Two United Nations agencies are teaming up in a major new initiative taking on the herculean task of combating environmental health risks, which claim an estimated 12.6 million lives a year. The partnership, announced Wednesday, between the UN Environment Program (UNEP) and the World Health Organization (WHO), includes specific action to address air pollution, climate

change and antimicrobial resistance as well as improve coordination on waste and chemicals management, water quality, and food and nutrition issues. The new collaboration has a particular focus on the developing world as the worst impacts of environmental pollution and the related deaths occur in developing countries in Asia, Africa and Latin America. The initiative also includes joint management of the BreatheLife advocacy campaign to reduce air pollution for multiple climate, environment and health benefits “Our health is directly related to the health of the environment we live in. Together, air, water and chemical hazards kill some 12.6 million people a year.

This cannot and must not continue,” said Tedros Ghebreyesus, the Director-General of WHO. “There is an urgent need for [us] to work more closely together to address the critical threats to environmental sustainability and climate – which are the foundations for life on this planet. This new agreement recognizes that sober reality,” added Erik Solheim, the Executive Director of UNEP… (UN, January 10, 2018)

Maharashtra Govt. Makes it Mandatory for MBBS Pass Outs Availing Govt. Fund to Serve 1 Year Rural Posting To overcome the shortage of doctors in rural and remote areas of the state and remove dichotomy in rural posting, the Maharashtra government has made it mandatory for MBBS pass outs from private aided and unaided medical colleges availing government scholarships to serve 1 year rural posting, reported Laxmi Yadav in Pharmabiz. Those who are reluctant to serve the rural posting are required to return the government scholarships with interest. As per the notification issued by the state government on January 5, 2018, the students falling under reserved categories including SC, ST, OBC and economic weaker section availing government scholarships for pursuing MBBS in private medical colleges are required to serve in government health facilities in rural areas for a year.

At present, this rule is applicable to all students doing their MBBS from government colleges. We have decided to introduce a similar bond for reserved category students from private medical colleges whose fees are partially or fully borne by the government depending on the categories they belong to. Over the last few years, students have started opting for private colleges over the government colleges despite securing good marks to avoid the rural posting. This has forced us to make the rural posting mandatory for them, said Dr Pravin Shingare, state director of medical education

IJCP Sutra 77: The US FDA has approved single dose secnidazole for the treatment of bacterial vaginosis. US FDA approved product information. Revised September 2017.

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and research… (Laxmi Yadav, Mumbai, January 16, 2018, Pharmabiz.com).

Most Doctors in US Feel Depressed or Burned Out, Says Medscape Report The 2018 Medscape National Report on Physician Burnout and Depression involving more than 15,000 practicing physicians responding across 29 specialties has found that almost two-thirds of physicians in the US are either depressed (severe or feeling down) (15%), feel burned out (42%) or both (14%). Burnout was defined as experiencing feelings of physical, emotional or mental exhaustion, frustration or cynicism about work, and doubts about one’s experience and the value of one’s work. Work was attributed as the main cause of depression. Depression also had an impact on their interaction with doctors and patients as reported by one in three physicians.

The highest rates of burnout were found among family physicians, intensivists, internists, neurologists and ob-gyns, while plastic surgeons, dermatologists, pathologists and ophthalmologists had the lowest rates.

More women physicians reported burnout than male physicians; 48% vs. 38% respectively. Burnout rates in physicians in the age group 45-50 years was 50% vs.

35% for younger physicians… (Medscape)

Glanders Spread to New Areas; Delhi Govt. Issues Advisory New Delhi, Jan 17 (PTI) Delhi has been notified as a “controlled area” in the wake of spread of glanders, an infectious disease primarily affecting horses, to new areas of the national capital, and an advisory has been issued to owners of equines. The notification declaring the entire Delhi as a “controlled area” was issued on Monday, said divisional commissioner Manisha Saxena.

“Earlier, eight cases were reported from Raja Garden in west Delhi. Cases from new areas have also been reported,” she said. The new cases have been reported from areas in Northwest and Southwest districts, said a government official.

“The notification of controlled area means that there will be no entry or exit of equines from Delhi from and to neighboring states. This will remain in force for three months from the last quelling of an affected animal,” the official said.

The government today advised handlers and owners of equines to isolate animals suspected for glanders and urged them not to throw in open the fodder left by the sick animals, after 40 horses were diagnosed with the

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disease recently. It advised the veterinary officers and personnel involved in the animal handling for sample collection or animal burying to use personal protective equipments and disinfecting sheds with disinfectants such as benzalkonium chloride and iodine.

Glanders is an infectious zoonotic disease primarily affecting horses, donkeys and mules. It is caused by Gram- negative bacterium, Burkholderia mallei. It is a rare disease in humans with cases having occurred in veterinarians, other people working closely with horses, and laboratory workers handling the organism.

According to the advisory, despite many reported cases of the disease in equines, no human case of glanders has been reported in India till date.

Occupation exposure is the main risk factor to veterinarians, farmers, horse traders, laboratory workers and other persons who are closely associated with equines or handling the organism.

Pemafibrate Improves Dyslipidemia in Patients with Type 2 Diabetes Pemafibrate, a novel selective PPAR-α modulator, significantly improved insulin resistance and lipid abnormalities in patients with type 2 diabetes with high triglyceride levels and was well-tolerated, according to a study published January 3, 2018 in Diabetes Care.

Patients with Monoclonal Gammopathy Need Follow-up to Detect Multiple Myeloma Patients with monoclonal gammopathy of undetermined significance are at risk of progressing to multiple myeloma or a related cancer even after three decades of stable disease, says a study published January 17, 2017 in the New England Journal of Medicine.

Slower Walking Speed in the Elderly may be Explained by Loss of Muscle Strength and Mass A new research published January 17, 2018 in The Journal of Physiology has shown that elderly people walk at a slower speed and tire more quickly because of loss of strength and mass in leg muscles.

WHO Position Statement on Use of Delamanid for MDR-TB The WHO Global Tuberculosis Program has released a Position Statement on the use of delamanid in treatment of multidrug-resistant tuberculosis (MDR-TB). WHO is advising national TB programs and other stakeholders to only add delamanid to a longer MDR-TB regimen when the regimen cannot be composed according to

IJCP Sutra 78: Low red meat intake, high dietary fiber, normal BMI, vigorous physical activity and no smoking history incrementally reduce the risk of diverticulitis.

Am J Gastroenterol. 2017;112(12):1868-76.

AROUND THE GLOBE WHO recommendations, e.g., when drug intolerability or drug resistance requires changes.

Botulinum Toxin may Help People with bruxism In a study reported January 17, 2018 in Neurology, people with bruxism who received onabotulinum toxin-A injections in their chewing muscles were more likely to improve on assessments of their teeth grinding and clenching symptoms than people who received a placebo injection.

Home Visits may be an Effective Intervention in Reducing Obesity in at-risk Children According to a new study published online January 16, 2018 in Pediatrics, nurse and social worker home visits could be an effective intervention in reducing obesity rates in at-risk populations; 78.3% children who received home visits were at a healthy weight at two years of age compared to 63.6% in the control group.

And, 19.7% of children in the control group were obese vs 3.3% of children in the study group.

President Launches Countrywide Pulse Polio Program for 2018 The Hon. President of India, Shri Ram Nath Kovind, launched the Pulse Polio Program for 2018 by administering polio drops to children less than 5 years old, at the Rashtrapati Bhawan, in the presence of the Union Minister of Health and Family Welfare, Shri JP Nadda and Ministers of State (Health) Shri Ashwini Kumar Choubey and Smt. Anupriya Patel. The Hon. President administered the polio drops on the eve of the National Immunization Day, observed recently. More than 17 crore children of less than 5 years across the country will be given polio drops as part of the drive of Government of India to sustain polio eradication from the country.

Speaking at the function, the Union Minister for Health and Family Welfare Shri JP Nadda said, “We need to remain vigilant and maintain the population immunity and sensitive surveillance till global polio eradication happens as poliovirus is still circulating in other parts of the world which may reinfect us.” In order to mitigate the risk of poliovirus importation, the immunity against polio infection is maintained through National and SubNational Polio rounds along with sustained high quality polio surveillance. To provide additional protection to our children, Government of India has also introduced the injectable Inactivated Polio Vaccine (IPV) into its routine immunization program, Shri Nadda stated.

Shri JP Nadda pointed out that Universal Immunization Program (UIP) is focusing on to protect children from more diseases than ever before and has introduced several new vaccines like Pneumococcal Conjugate Vaccine, Rotavirus vaccine and Measles-Rubella in the recent past. “To further strengthen and accomplish our goals we have launched Mission Indradhanush and encouraged by its success, we have recently intensified the mission in October, 2017 to achieve more than 90% full immunization coverage by 2018,” Shri Nadda elaborated.

Shri Nadda further informed that strengthening of immunization program has significantly contributed to the decline of Infant Mortality Rate from 39 in 2014 to 34 per 1,000 live births in 2016 (as per SRS reports)…

(PIB, MOHFW, January 27, 2018)

Too Few with Stroke of the Eye are Treated to Reduce Future Stroke Too few patients with retinal infarction, or loss of blood flow in the eye, are evaluated for stroke risk or seen by a neurologist, putting them at increased risk for another stroke, according to preliminary research presented January 25, 2018 at the American Stroke Association’s International Stroke Conference 2018 at Los Angeles. One in 100 patients in the study experienced an ischemic stroke within 90 days of a retinal infarction.

First Radiopharmaceutical Approved for Gastroenteropancreatic Neuroendocrine Tumors The US Food and Drug Administration (FDA) has approved Lutathera (lutetium Lu 177 dotatate) for the treatment of a type of cancer that affects the pancreas or gastrointestinal tract called gastroenteropancreatic neuroendocrine tumors (GEP-NETs). This is the first time a radioactive drug, or radiopharmaceutical, has been approved for the treatment of GEP-NETs. Lutathera is indicated for adult patients with somatostatin receptorpositive GEP-NETs.

Four in 10 Cardiomyopathies are Genetic Results of the first European registry focused on adult patients with the various cardiomyopathy subtypes show that 4 in 10 cardiomyopathies are genetic.

Cardiomyopathies are a major cause of sudden death in young people. The study reported January 24, 2018 in the European Heart Journal recommends family screening to prevent early death in apparently healthy relatives.

IJCP Sutra 79: IDSA guidelines recommend confirmatory stool culture and susceptibility testing when culture-independent diagnostic tests are positive for clinically important bacterial pathogens. Clin Infect Dis. 2017;65(12):e45-e80.

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Diabetes and Prediabetes Associated with Faster Cognitive Decline According to findings from the English Longitudinal Study of Ageing published online January 25, 2018 in Diabetologia, prediabetes and diabetes are associated with a faster rate of global cognitive decline - memory, executive function and orientation cognitive tests - over time among individuals aged ≥50 years compared to individuals with normoglycemia.

EMA Recommends New Diabetes Treatments for Approval The European Medicines Agency's (EMA's) Committee for Medicinal Products for Human Use (CHMP) has recommended for approval a biosimilar of insulin glargine and three formulations of ertugliflozin, for type 2 diabetes viz. ertugliflozin monotherapy (Steglatro), fixed-dose ertugliflozin and metformin (Segluromet) and fixed-dose ertugliflozin and sitagliptin (Steglujan).

All are indicated for adults aged 18 years and older with type 2 diabetes as adjuncts to diet and exercise to improve glycemic control.

with the aim of quickly containing the outbreak.

However, the virus continues to spread in parts of the country where people remain largely unprotected.

WHO is supporting the campaign by training thousands of healthcare workers, helping to track cases, and by providing coordination and logistical support … (UN, January 25, 2018)

Working Before and After Stroke is Good for Brain Health Adult stroke patients who are employed prior to and after suffering strokes are more likely than unemployed adults to have healthier minds 2 years post stroke, according to preliminary research presented January 25, 2018 at the American Stroke Association’s International Stroke Conference 2018 in Los Angeles. People who were unemployed before stroke were more than three times (320%) more likely than those who were employed to develop cognitive decline within 2 years from the initial stroke.

Obese Men at Risk of Prostate Cancer Recurrence Following Surgery

Women who have moderate-to-severe iodine deficiency have 46% lower chances, per cycle, of conceiving compared to women with healthy iodine levels, according to a recent study published online January 11, 2018 in Human Reproduction.

Obese men with prostate cancer who underwent radical prostatectomy are at a higher risk of biochemical recurrence (two consecutive prostate-specific antigen [PSA] measurements of ≥ 0.2 ng/mL after prostatectomy), according to data presented at the American Association for Cancer Research Special Conference Obesity and Cancer: Mechanisms Underlying Etiology and Outcomes, held January 27-30 in Austin, Texas.

Largest Yellow Fever Vaccination Campaign in Nigeria’s History Under Way

US FDA Approves Plecanatide for IBS with Constipation in Adults

The Nigerian Government launched a mass vaccination campaign in alliance with the World Health Organization (WHO) recently, aiming to immunize more than 25 million people before the end of this year.

This drive is part of a global effort to eliminate the risk of yellow fever epidemics by 2026, which should be possible if 90% of the population can be reached. The preventive campaign will use vaccines funded by Gavi, the Vaccine Alliance, and will also be supported by the UN Children’s Fund (UNICEF).

The US Food and Drug Administration (FDA) has approved plecanatide 3 mg tablets (Trulance, Synergy Pharmaceuticals) for treatment of irritable bowel syndrome with constipation (IBS-C) in adults. The drug is contraindicated in children younger than 6 years and should be avoided in patients younger than 18 years.

Iodine Deficiency Hampers a Woman’s Chances of Conceiving

Nigeria’s current yellow fever outbreak began in September, and by early January this year, a total of 358 suspected cases had been reported, with 45 deaths.

In late 2017, Nigeria vaccinated more than three million people in an initial emergency yellow fever campaign,

Study Shows Risk of Dementia with Tamsulosin in Older Men with BPH According to a new study published January 9, 2018 in Pharmacoepidemiology & Drug Safety, older men with benign prostatic hyperplasia (BPH) are at greater risk of dementia with tamsulosin compared to alternative medicines for BPH such as doxazosin, terazosin, alfuzosin, dutasteride and finasteride.

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IJCP Sutra 80: In patients with gout and a history of major cardiovascular disease, the rates of heart-related death and death from all causes were greater with febuxostat than with allopurinol. US FDA Drug Safety Communication.

Spiritual Update

You are Born with a Quota, Use it Judicially KK aggarwal

E

veryone is born with a passport with a defined battery life to live up to 100 years after which one has to go back to renew or recharge the batteries.

If the battery is overused or misused and is depleted early, one may have to go back prematurely for recharging, but this time when one comes back, he or she may come back with a different body, which may not be the human one. There are 64 lakhs Yonis as described in the Vedic Literature.

According to the Vedic description if one dies prematurely, there are chances that the rebirth will not be in the same species.

To live up to the time period defined at the time of birth by Dharamaraja one has to follow the principles as described in Yogashastra.

The main principle is the principle of moderation and variety. It says that everything has to be used, if not used will get rusted and if overused will undergo wear and tear.

When using the principles of moderation and variety, it is important to remember that each one of us is born with a fixed quota of everything, a quota of diet, respiration, heart rate and thoughts.

According to swara yoga, one is born with predefined number of respirations to be taken during life. If one consumes them early he will depart for refueling early from the life. To reduce respiratory rate is therefore the basis of postponing aging and prolonging life.

Stimulating the parasympathetic nervous system by learning and practicing pranayama, which is slow and deep breathing, does the same.

One breathes 15 times a minute or 21,600 breaths in a day, or 7884000 (78.84 lakhs) a year or 788400000 (78.84 crores) during life (assuming it to be 100 years). Some yoga books say that a person is born with 33 crore breaths, the same if taken at the rate or 15 per minute would last for 42 years. In fact Pranayama originated on the concept that the breaths of each one of us are

Group Editor-in-Chief, IJCP Group

numbered, that our life-span is dependent on how many times we shall breathe in a given life, and that, as a consequence of this fact, we must reduce the number of breaths so as to live longer.

In Gorakshapaddhati (I.93), it is written that “Due to fear of death even Brahma, the Lord of creation, keeps on practicing pranayama, and so do many yogis and munis. It is recommended that a student of yoga must always control his breath.”

Hathayoga-pradipika (II.39) also writes: “All the Gods including Lord Brahma became devoted to the practice of pranayama because they were afraid of death. We the mortals should follow the same path and control the breath.”

Similarly one is born with a quota of heartbeats with an average of 70/min. Many studies have shown that people who have a higher resting heart rate have more chances of sudden death. The aim therefore is to keep their heart rate slow. This can be achieved either by regular exercise, meditation, AUM Pranayama, or by meditation. In people who run marathons or participate in other athletic activities, the temporary increase in the heart rate during exercise is compensated by the body by adapting the cardiovascular system in such a way that the basal heart rate reduces. The marathon runners may have a heart rate of only 50/min.

The less one eats the more he lives is an Yogic saying, It is said that people who eat once a day are Yogis, twice a day are Bhogis and thrice a day are Rogis. There are enough studies now, which say that 25% reduction in the calories content can increase the life span. Many studies in rodents have also shown the same effect.

The moderation in exercise is to walk 10,000 steps a day. No exercise will end up with obesity and over use with osteoarthritis.

Stress is the excess of thoughts in the mind. Controlling the mind forms the basis of meditation. Samadhi is the state of no thoughts. Practicing meditation 20 minutes twice-daily helps to restrain the mind with resultant state of Turiya where the mind has controlled limited positive thoughts.

(Disclaimer: The views expressed in this write up are my own).

IJCP Sutra 81: Patients undergoing autologous hematopoietic stem cell transplantation (HCT) can receive platelet transfusion for the first sign of bleeding rather than prophylactic transfusions for a platelet count <10,000/µL. J Clin Oncol. 2018;36(3):283-99.

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lighter reading

HUMOR

Lighter Side of Medicine

Stock Broker Patient: “Doctor, what should I do if my temperature goes up five more points?”

Intensivist: “Sell!”

Ponder This: The difference between a neurotic and a psychotic is that, while a psychotic thinks that 2 + 2 = 5, a neurotic knows the answer is 4, but it worries him.

Prisoner: “Look here, doctor! You’ve already removed my spleen, tonsils, adenoids and one of my kidneys. I only came to see if you could get me out of this place!”

Intensivist: “I am, bit by bit.”

From More!

‘Your chance of catching an STD during your period is greater, because the blood changes the PhD level in the vagina’.

Dr. Good and Dr. Bad Situation: A type 2 diabetic patient was prescribed multiple

antidiabetic drugs for controlling sugar levels.

As the Intensivist doctor completed an examination of the patient, he said, “I can’t find a cause for your complaint. Frankly, I think it’s due to drinking.”

You must continue taking your medicine on time

You may switch to a fixed-dose combination. This will help in improving the adherence to treatment

“In that case,” said the patient, “I’ll come back when you’re sober”.

“Doc, it’s Ram, he is in extreme pain” said the coach.

He broke his arm in the fourth quarter.”

“I see,” said the aspiring doctor. “Exactly what part of the arm is that?”

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© IJCP Academy

The doctor was off teaching a class, so one of his new students answered the phone in his office.

The call was from the school’s football coach.

Lesson: Although no difference has been reported between HbA1c levels of patients who receive loose-dose and fixed-dose combination therapy at equivalent dosage, the latter may help in improving adherence and is believed to be more comfortable for the patients.

J Clin Med Res. 2017;9(8):719-24.

IJCP Sutra 82: Fecal microbiota transplantation (FMT) as oral capsules was as good as colonoscopic delivered FMT in reducing recurrent Clostridium difficile infection. JAMA. 2017;318(20):1985-93.

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Indian Journal of Clinical Practice is published by the IJCP Group. A multispecialty journal, it provides clinicians with evidence-based updated information about a diverse range of common medical topics, including those frequently encountered by the Indian physician to make informed clinical decisions. The journal has been published regularly every month since it was first launched in June 1990 as a monthly medical journal. It now has a circulation of more than 3 lakh doctors.

IJCP is a peer-reviewed journal that publishes original research, reviews, case reports, expert viewpoints, clinical practice changing guidelines, Medilaw, Medifinance, Lighter side of medicine and latest news and updates in medicine. The journal is available online (http://ebook.ijcpgroup.com/IndianJournal-of-Clinical-Practice-January-2018.aspx) and also in print. IJCP can now also be accessed on a mobile phone via App on Play Store (android phones) and App Store (iphone). Sign up after you download the IJCP App and browse through the journal.

IJCP is indexed with Indian Citation Index (ICI), IndMed (http://indmed.nic.in/) and is also listed with MedIND (http://medind.nic.in/), the online database of Indian biomedical journals. The journal is recognized by the University Grants Commission (20737/15554). The Medical Council of India (MCI) approves journals recognized by UGC and ICI. Our content is often quoted by newspapers.

The journal ISSN number is 0971-0876 and the RNI number is 50798/1990.

If you have any Views, Breaking news/article/research or a rare and interesting case report that you would like to share with more than 3 lakh doctors send us your article for publication in IJCP at editorial@ijcp.com.

Dr KK Aggarwal Padma Shri Awardee Group Editor-in-Chief, IJCP Group

IJCP Sutra 83: Add on oral azithromycin 500 mg in adults with persistent symptomatic asthma reduces asthma exacerbations and improves quality of life.

Lancet. 2017;390(10095):659-68.

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Information for Authors Manuscripts should be prepared in accordance with the ‘Uniform requirements for manuscripts submitted to biomedical journals’ compiled by the International Committee of Medical Journal Editors (Ann. Intern. Med. 1992;96: 766-767).

Indian Journal of Clinical Practice strongly disapproves of the submission of the same articles simultaneously to different journals for consideration as well as duplicate publication and will decline to accept fresh manuscripts submitted by authors who have done so.

The boxed checklist will help authors in preparing their manuscript according to our requirements. Improperly prepared manuscripts may be returned to the author without review. The checklist should accompany each manuscript.

Authors may provide on the checklist, the names and addresses of experts from Asia and from other parts of the World who, in the authors’ opinion, are best qualified to review the paper.

Covering letter –

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The covering letter should explain if there is any deviation from the standard IMRAD format (Introduction, Methods, Results and Discussion) and should outline the importance of the paper.

Principal/Senior author must sign the covering letter indicating full responsibility for the paper submitted, preferably with signatures of all the authors.

Articles must be accompanied by a declaration by all authors stating that the article has not been published in any other Journal/Book. Authors should mentioned complete designation and departments, etc. on the manuscript.

Manuscript Three complete sets of the manuscript should be – submitted and preferably with a CD; typed double spaced throughout (including references, tables and legends to figures).

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The manuscript should be arranged as follow: Covering letter, Checklist, Title page, Abstract, Keywords (for indexing, if required), Introduction, Methods, Results, Discussion, References, Tables, Legends to Figures and Figures.

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All pages should be numbered consecutively beginning with the title page.

Note: Please keep a copy of your manuscript as we are not responsible for its loss in the mail. Manuscripts will not be returned to authors.

Title page Should contain the title, short title, names of all the authors (without degrees or diplomas), names and full location of the departments and institutions where the work was performed,

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name of the corresponding authors, acknowledgment of financial support and abbreviations used.

– The title should be of no more than 80 characters and should represent the major theme of the manuscript.

A subtitle can be added if necessary.

– A short title of not more than 50 characters (including inter-word spaces) for use as a running head should be included.

– The name, telephone and fax numbers, e-mail and postal addresses of the author to whom communications are to be sent should be typed in the lower right corner of the title page.

– A list of abbreviations used in the paper should be included. In general, the use of abbreviations is discouraged unless they are essential for improving the readability of the text.

Summary – The summary of not more than 200 words. It must convey the essential features of the paper.

– It should not contain abbreviations, footnotes or references.

Introduction – The introduction should state why the study was carried out and what were its specific aims/objectives.

Methods – These should be described in sufficient detail to permit evaluation and duplication of the work by others.

– Ethical guidelines followed by the investigations should be described.

Statistics The following information should be given: – The statistical universe i.e., the population from which the sample for the study is selected.

– Method of selecting the sample (cases, subjects, etc. from the statistical universe).

– Method of allocating the subjects into different groups.

– Statistical methods used for presentation and analysis of data i.e., in terms of mean and standard deviation values or percentages and statistical tests such as Student’s ‘t’ test, Chi-square test and analysis of variance or non-parametric tests and multivariate techniques.

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Confidence intervals for the measurements should be provided wherever appropriate.

Results – These should be concise and include only the tables and figures necessary to enhance the understanding of the text.

IJCP Sutra 84: A 4-food elimination diet for 8 weeks induced clinical, endoscopic and histologic remission in >60% of children with eosinophilic esophagitis. Clin Gastroenterol Hepatol. 2017;15(11):1698-1707.e7.

Discussion –

This should consist of a review of the literature and relate the major findings of the article to other publications on the subject. The particular relevance of the results to healthcare in India should be stressed, e.g., practicality and cost.

References These should conform to the Vancouver style. References should be numbered in the order in which they appear in the texts and these numbers should be inserted above the lines on each occasion the author is cited (Sinha12 confirmed other reports13,14...). References cited only in tables or in legends to figures should be numbered in the text of the particular table or illustration. Include among the references papers accepted but not yet published; designate the journal and add ‘in press’ (in parentheses). Information from manuscripts submitted but not yet accepted should be cited in the text as ‘unpublished observations’ (in parentheses).

At the end of the article the full list of references should include the names of all authors if there are fewer than seven or if there are more, the first six followed by et al., the full title of the journal article or book chapters; the title of journals abbreviated according to the style of the Index Medicus and the first and final page numbers of the article or chapter. The authors should check that the references are accurate. If they are not this may result in the rejection of an otherwise adequate contribution.

Examples of common forms of references are: Articles Paintal AS. Impulses in vagal afferent fibres from specific pulmonary deflation receptors. The response of those receptors to phenylguanide, potato S-hydroxytryptamine and their role in respiratory and cardiovascular reflexes.

Q. J. Expt. Physiol. 1955;40:89-111.

Figures – Two complete sets of glossy prints of high quality should be submitted. The labelling must be clear and neat.

– All photomicrographs should indicate the magnification of the print.

– Special features should be indicated by arrows or letters which contrast with the background.

The back of each illustration should bear the first – author’s last name, figure number and an arrow indicating the top. This should be written lightly in pencil only. Please do not use a hard pencil, ball point or felt pen.

Color illustrations will be accepted if they make a – contribution to the understanding of the article.

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Do not use clips/staples on photographs and artwork.

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Illustrations must be drawn neatly by an artist and photographs must be sent on glossy paper. No captions should be written directly on the photographs or illustration. Legends to all photographs and illustrations should be typed on a separate sheet of paper. All illustrations and figures must be referred to in the text and abbreviated as “Fig.”.

Please complete the following checklist and attach to the manuscript: 1. Classification (e.g. original article, review, selected summary, etc.)_______________________________ 2. Total number of pages ________________________ 3. Number of tables ____________________________ 4. Number of figures ___________________________

Books

5. Special requests _____________________________

Stansfield AG. Lymph Node Biopsy Interpretation Churchill Livingstone, New York 1985.

Indian 1.____________Foreign 1.________________

Articles in Books

2.____________ 2.________________

Strong MS. Recurrent respiratory papillomatosis. In: Scott Brown’s Otolaryngology. Paediatric Otolaryngology Evans JNG (Ed.), Butterworths, London 1987;6:466-470.

3.____________ 3.________________

4.____________ 4.________________

Tables –

These should be typed double spaced on separate sheets with the table number (in Roman Arabic numerals) and title above the table and explanatory notes below the table.

Legends These should be typed double spaces on a separate – sheet and figure numbers (in Arabic numerals) corresponding with the order in which the figures are presented in the text.

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The legend must include enough information to permit interpretation of the figure without reference to the text.

6. Suggestions for reviewers (name and postal address)

7. All authors’ signatures________________________ 8.

Corresponding author’s name, current postal and e-mail address and telephone and fax numbers __________________________________________

Online Submission Also e-Issue @ www.ijcpgroup.com For Editorial Correspondence

Dr KK Aggarwal Group Editor-in-Chief Indian Journal of Clinical Practice E-219, Greater Kailash Part-1 New Delhi - 110 048. Tel: 40587513 E-mail: editorial@ijcp.com Website: www.ijcpgroup.com

IJCP Sutra 85: Metastasis-free survival and time to symptomatic progression were significantly longer with apalutamide in men with nonmetastatic castrationresistant prostate cancer. N Engl J Med. 2018 Feb 8. [Epub ahead of print]

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R.N.I. No. 50798/1990 Date of Publication 13th of Same Month Date of Posting 13-14 Same Month

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