Devotional – The forgotten stone

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The forgotten stone

The stone the builders rejected has become the capstone (Acts 4:11)
Come follow me and I will make you … (Mathew 4:19)

The stone
     It was a large piece of marble, so large that it was called ‘The Giant’. Many sculptors had attempted to work on it but abandoned their efforts. Perhaps the stone was too large to handle, perhaps there were too many ‘faults’ in the piece (faults are natural lines within a rock where it breaks easily when worked upon). Whatever the reason, the sculptors have given up on the lump of marble and so ‘The Giant’ lay collecting dust and garbage, outside the city of Florence, largely forgotten by the people around.
     That was until a young temperamental budding artist sculptor set his eyes on it. This man’s name was Michelangelo Buonarroti and when he saw ‘The Giant’, he felt that it was just the material he wanted. Within the misshapen lump of rock scarred by the chisels of numerous workers, he saw something hidden which he felt he had to bring out.

The artist
And so he worked on it, day and night, over several months. A little chip here, a scrape there, a bit of smoothening here, a bit of roughening there – and what emerged out of his workshop was the magnificent giant figure of David, a piece of sculpture so perfect in beauty, proportion, anatomical detail and balance that it still stands today as a glowing example of what sculpture should be. It occupies a place of pride in Florence and thousands flock to admire it every year.
          This came to be because one man saw something of worth in that piece of rock. ‘The Giant’ had waited, forgotten and abandoned, until it was brought to life and beauty by the hand of a genius who worked on it and fashioned it to become what it was meant to be.
          Perhaps you feel you have been largely forgotten and abandoned by the world around, in despair yet recognizing the potential within. It is time then, to give yourself into the master’s hands who alone can fashion you and transform you to what you are meant to be. Christ was described in the scriptures as the ‘stone that the builders rejected’, yet this stone went on to become the capstone. He knows what it is to be rejected and despised. He is familiar with suffering. Jesus said “Come follow me and I will make you …”. It is for us to follow the master. If we do that he promises to ‘make us’, to fashion us. The process will be painful, it may take many years perhaps decades even but the end result will be something beautiful. Christ – stone rejected. Perhaps you have been rejected.
          Are you willing to yield, are you willing to wait, are you willing to suffer? The master’s hand can transform you.

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Mizoram, our mission field

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Mizoram, our mission field

Dr. Denyl Avinash Joshua, Aizawl Adventist Hospital, Aizawl, Mizoram.


It’s just two months since we set foot on this beautiful land of Aizawl, the capital city of Mizoram, a state in the northeast part of India. We have always wanted to work in a mission hospital and since we heard of the need for paediatric care in this part of the country we felt the leading of God to this place. Mizoram is a beautiful place with nature at its very best. There are scenic views from every hill top and the climate is pleasant compared to the tough summer heat of Vellore from where we have just moved out. The people are friendly and the streets are full of youthful faces. It’s a state with a predominantly Christian population and the artistically decorated streets during the season of Christmas are a sight you don’t want to miss. But amidst this beauty there are challenges every family faces – deprived health care facilities for infants and children, young adolescents taking to drug addiction, alcoholism and tobacco are probably at the highest in whole of India.

We (my wife and I) joined the Aizawl Adventist hospital as a paediatric team. Excited to start our mission journey, we landed in Aizawl on the 12th of November, 2015 and could hardly wait to start our work. The word went around the city through newspaper and other media that two pediatricians had joined the hospital and so day by day the number of children coming to the hospital went up. More pregnant mothers were registering for deliveries.

We were barely trying to equip our paediatric ward when one fine morning a young mother with her husband presented to our emergency. The lady in her third trimester had severe pre eclampsia. Her blood pressures were very high and in spite of treatment her blood pressures were difficult to control. She could no longer continue the pregnancy. At 32 weeks and twin gestation the babies to be born were going to have major complications such as twin to twin transfusion, respiratory distress, necrotising enterocolitis and prolonged admission for preterm care. With two doses of antenatal steroids the decision was made to go ahead with emergency caesarean. Our old Doppler machine could not identify fetal cardiac activity of one of the twins. Expecting only one baby to live, we prepared ourselves to receive only one of the twins. In the theatre we received the first of the twins; though he had a good cry at birth he soon had secondary apnea and needed some respiratory support with which he was getting better but to our utter surprise the second of twins when brought out also showed signs of life. We rushed to share the oxygen support with her and quickly intubated her and started resuscitation measures with fluids and manual ventilation.

What would we do with a 1.7 kg newborn who needs ventilator care since our hospital had just one warmer which was not functioning? We had no resources to treat this little one with the care she actually needed. Thanks to God and our wonderful team of nurses we managed to prepare a makeshift NICU with heaters and thermocol sheets to ward off the chill air in the nights. We frantically contacted other hospitals if there was a possibility to provide ventilator care for the second twin. Sadly there were no newborn ventilators available in the city and the father of the baby who was aware of all that was happening said in Hindi -“Aap se jitna ho sake aap karo, baaki sab Bhagwan ke haaton mein hai” which means “Just do whatever you can; the rest is in God’s hands”. However, here was no way we could let him down. My wife, I and Dr. Eileen our obstetrician, bagged the baby every 2 hours through the day and night. As the next day dawned, we had to resume other work in the hospital too, so we quickly made a 24 hour roster for all staff to bag-ventilate the baby. Every one hour hands would change and somehow again by the grace of God we managed to keep her alive for 72 hours. She had multiple tube blocks and temperature irregularities and needed blood transfusion. In spite of 80 hours of manual ventilation and all possible efforts, her respiratory efforts did not improve and she succumbed to death 80 hours later. We were extremely sorrow stricken as we placed the dead baby in the arms of her father. The mother who was just recuperating asked “Pehla baccha kaisa hai, usko kuch nahin hoga na?” which in Hindi means “How is the first twin, will he be ok?” The first twin, a boy who was on head-box oxygen was doing fine but how could I promise her he would be okay with the limited resources we had. I assured her we would do our best. Prayers were desperately made for this family and the little twin 1. The baby boy was 7 days old when he was noticed to have bounding pulses with tachycardia. Is it a Patent ductus arteriousus – a serious condition where a small vessel in the heart fails to close after birth? With much prayer, and guidance from CMC we started him on injectable Paracetamol for duct closure and also upgraded the antibiotics. Within 24 hours he showed much improvement. Once gain we were at peace.

Our infant warmer wasn’t working. We were using halogen heaters to keep him warm however temperature regulation in this cold climate was quite a challenge. Over 25 days, the baby was weaned off oxygen and started on feeds from nasogastric tube feeds to direct feeds. He started gaining weight and discharged by 26th day. We have followed him up just 2 days ago and it was such a joy to see the parents with a healthy baby in their hands. We praise God for being with us through this challenge and we are assured that through Him we can accomplish greater things in the future. We have a long way to go. We hope that we as a hospital will be able to provide the best medical care to every sick child in Mizoram, combined with the love and compassion of Jesus Christ our Master.

Box 1: Patent ductus arteriosus
           Patent ductus arteriosus (PDA) is a condition usually seen in preterm babies or in association with chromosomal anomalies. Before birth, the two major arteries-the aorta and the pulmonary artery are connected by the ductus arteriosus. This vessel is an essential part of fetal circulation. Within minutes or up to few days after birth the vessel is supposed to close as a part of the normal changes occurring in the baby’s circulation. In some babies however the ductus arteriosus remains open and this opening allows oxygen rich blood from aorta to mix with oxygen poor blood from the pulmonary artery. Babies who have a PDA present with poor feeding, tachypnea, tachycardia, bounding pulses and will have a loud machinery murmur on auscultation in the left second intercostals space. The commonly practised treatments are administration of Indomethacin or Ibuprofen and in some cases surgical ligation of the PDA may be required.
      Ductal Closure With Paracetamol- A Surprising New Approach to Patent Ductus Arteriosus Treatment, by Hammerman et al was published in the American academy of paediatrics where they presented the cases of 5 preterm infants (gestational age: 26–32 weeks; postnatal age: 3–35 days) with large, hemodynamically significant patent ductus arteriosus who had either failed or had contraindications to ibuprofen therapy. Each of these infants was treated with off-label oral paracetamol (15 mg/kg per dose every 6 hours). Ductal closure was achieved within 48 hours in all the treated infants. No toxicity was observed.1
           An article is published by Cochrane database of systematic reviews in March, 2015 on the use of paracetamol for PDA closure as an outcome of two studies conducted in Turkey and China. Two hundred and fifty preterm babies were included to study the efficacy of paracetamol versus Ibuprofen and it was found that the success rate for paracetamol to close a PDA was similar to that of ibuprofen. Adverse events were similar in both groups. Infants who were treated with paracetamol had a reduced duration of needing extra oxygen and a lower risk of hyperbilirubinaemia than those treated with ibuprofen. It concluded that Paracetamol appears to be a promising new alternative to indomethacin and ibuprofen for the closure of a PDA with possibly fewer adverse effects.2

References:
1. Ductal Closure With Paracetamol: A Surprising New Approach to Patent Ductus Arteriosus TreatmentCathy Hammerman, Alona Bin-Nun, Einat Markovitch, Michael S. Schimmel, Michael Kaplan, Daniel Fink, Pediatrics Dec 2011, 128 (6) e1618-e1621; DOI: 10.1542/peds.2011-0359.
2. Ohlsson A, Shah PS. Paracetamol (acetaminophen) for patent ductus arteriosus in preterm or low-birth-weight infants. Cochrane Database of Systematic Reviews 2015, Issue 3. Art. No.: CD010061. DOI: 10.1002/14651858.CD010061.pub2


Dilemma of blood banking

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HELPLESS PATIENTS, HAPLESS DOCTORS- The dilemma of blood banking in peripheral hospitals

D. Samuel Abraham, M.A. B.L., Senior legal Consultant, Christian Medical College, Vellore.

    It was May 2011. In a tiny, remote village near Robertsganj in Uttar Pradesh State, a girl of seven years had met with an accident and was bleeding profusely. The village folk were unaware of first aid measures but managed to bring her in a tractor after a delay of two hours, to a small hospital at Robertsganj. When the doctors present there examined the patient, they realized that a transfusion of blood was essential in order to save the girl; otherwise the girl will surely die within few hours! But, alas! As per the latest amendment in the Drugs and Cosmetics Act doctors are prohibited from transfusing blood from another person (after cross-matching) unless the blood is obtained from a registered blood bank. The nearest blood bank, at that time was at Banaras, 90 Kms away. To get there one would have to travel at least a minimum three hours (one way) over very bumpy roads! The availability of blood was the next question! In the mid of the night, would there be a doctor in a small Government Hospital ready to do the job in that odd hour! The girl was slowly dying before the eyes of the doctors! They are qualified and experienced in their profession to cross-match and transfuse that blood; but this has been made illegal after 1999 and punishable with a minimum one year of imprisonment or up to three years!

The situation was deteriorating by the minute and pricked the conscience of the doctor. A human being was dying in front of the doctor, even though she could possibly be saved if only the doctor ventured to transfuse the blood. A hard decision had to be taken- there were two options; either to save the girl and go to jail; or keep quiet and turn the other side till life slowly ebbed from the body. This small medical team chose the first option. The girl was saved; now she is a grown up teenage girl; but criminal action was initiated and two persons were imprisoned. The case is still going at the Robertsganj Chief Judicial Magistrate’s Court!(1)

It would be important to mention about two deaths even after a new blood bank became operational now at Robertsganj – simply because of lack of timely supply from blood banks!

A patient arrived at Jiwan Jyoti Christian Hospital at 8.00 p.m. on 12th January 2012 with post partum haemorrhage following a live delivery at the nearby Government Hospital. Her B.P was not recordable on admission and she was severely anaemic. She was bleeding and in shock – the surgeon needed to do an emergency explorative laparotomy for which blood was essential. It took the relatives four long hours to obtain one unit of blood with difficulty from the (new) Robertsganj blood bank because it was night time. They managed to bring the blood at mid night but it was too late. The patient died.

A woman had C-section on 16th March 2011 at a rural hospital. After surgery the patient developed Disseminated Intravascular Coagulation and went into shock needing an urgent blood transfusion. Due to her unstable condition, she could not be shifted to another place where the blood bank was situated. Sadly, she expired at 1.35 a.m. on 18th March 2011.

These are just two examples; but thousands die because of the new amendment which virtually prevents medical professional from transfusing blood from another person after cross-matching.

What is the new amendment:


Prior to 1999 (i) blood transfusion could either be made available through services of blood banks (ii) OR can be taken from a donor and after doing proper tests (cross-matching), directly transfused to the patient without “banking” or “storing”. The second method is called Unbanked Direct Blood Transfusion (UDBT). This procedure has saved thousands of dying patients in rural areas by quick, immediate and timely transfusion.

But, the Union of India, brought an amendment in the Drugs and Cosmetics (2nd amendment) Rules, 1999 which changed the definition of blood. It mandated that even mere collection of blood requires a “license for blood bank”. That means a doctor can collect blood from a third person only if his hospital has a license to have “a full-fledged blood bank”. Generally, blood cannot be collected ordinarily just like any other product in a bag; but only in special “collection bags”, which are chemically treated to preserve the blood and prevent clotting. This bag can be obtained only from manufacturers and after the amendment, the chemists were directed not to supply “collection bags” to donors doing UDBT.


What is the consequence:

    The amendment should have been brought only after all the States had adequate number of blood banks- both in the city and rural areas alike.

But at present only cities and metros have adequate number of blood banks whereas in rural areas there are no blood banks. The decision to bring the amendment was brought by decision makers from metropolitan cities like Delhi, Mumbai without taking into consideration the remote and rural areas. The following facts may explain the situation more clearly:

  1. Minister of State Mr. Shripad Yesso Naik informed in the Indian Parliament that 81 districts in the country are without even one functioning blood bank.
  2. The “blood storage centers” brought in alternative for blood banks can be adjudged by the volume of blood they are distributing. They are functioning very badly because the volume of blood is very negligible. In emergencies, they simply say “no blood”; they close their doors leaving the patient in lurch.
  3. In the District of Dhule in the State of Maharashtra, there were 5 blood banks. All of them were located in the District Town having a population of 3 lakhs, leaving the remaining 26 lakh population of the district with no Blood Bank.
  4. Depending on the Distance of peripheral town, the time taken to procure blood from Authorized Blood Banks varied from 6 hours to 15 hours or even more at nights – resulting in valuable life leaving the human body at the rural hospital itself where qualified medical professionals are present; but who could not save the life as their hands are tied by this amendment.
  5. In the year 1988, according to a study, Blood Banks had collected a total of 5500 units of blood out of which only 300 units were sent to periphery where 26 lakhs of people were residing.

  6. A study in the same district reveals:
    1. Out of 40 clinicians (doctors including surgeons, gynecologists and physicians) working in peripheral centers, 39 were still doing UDBT to save the patients (though illegally, risking penalization by law-enforcing authorities).
    2. A study across the country done in October 1999 reveals that all doctors who practice UDBT continue to save women after deliveries and road accident victims within the golden hour.
    3. A study at the rural Sivakasi town in Tamil Nadu State gives the figure that out of 18 doctors, 9 were practicing UDBT even in 2003 and a few such doctors are under prosecuting process even now by the State Chief Drugs Controller U/S 18(1) of the Drugs and Cosmetics Act, 1940.
    4. It is an irony that while acting in good faith, a medical professional has to see valuable human life leaving the body because of non-availability of blood, even when blood is readily available from the victims’ relatives who are with them and are willing to donate. The law however, prohibits this and the doctors try to procure blood from blood banks that are 100 Km away. The patient may die but Doctors become law-abiding citizens!
    5. 74% of Indian population live in rural areas whereas blood bank availability is 10% to 15% only – because rural hospitals cannot spend money in maintaining a blood bank and obtain a license (yes, even this requires money!).
    6. 25% deaths related to child birth and pregnancy are due to bleeding (haemorrhage) and many women die during child birth due to bleeding.
    7. Death due to road accidents mainly occurring away from bigger towns moving vehicles and in rural areas doubled in the last six years.
    8. Surgeons, Obstetricians and other qualified clinicians even when available in rural areas, are greatly handicapped because they cannot give their professional service without availability of blood.

What about other advanced countries?

In the U.S.A, Medical Practitioners who are permitted by law to prescribe and/or administer drugs are empowered to transfuse blood (after cross – matching) because, blood and blood – products are declared as drugs as per law.  In other words, a registered Medical Practitioner who is authorized to prescribe a drug can also transfuse blood to a needy patient.

The law states that, “Practitioners… are licensed by law to prescribe or administer drugs and who manufacture blood products solely for use in the course of their professional practice.” (Title 21 – Food and Drugs – Chapter: 1 – Food and Drug Administration – Subchapter: F – Biologists PART 607 , Sub Part – D – Exemptions (b))

The Hon’ble Supreme Court of India in its land mark judgement recently in Save life Foundation & Anr. Vs. Union of India & Anr in Writ Petition No. 235 of 2012 has observed the following facts in respect of good Samaritans who are willing to give a helping hand to the Road Accident victims. While heavily coming to protect such persons the Hon’ble Court observed:

1.  In England and Wales, the Parliament has enacted the Social Action, Responsibility and Heroism Act, 2015, which provides for certain factors to be considered by the Court while hearing an action for negligence or breach of duty. Section 2 of the Act provides that “the court must consider whether the respondent was acting for the benefit of society or any of its members” (Para – 4) “whether the respondent was acting heroically by intervening
in an emergency to assist an individual in danger” (Page 3, Para-4).

2.  In Iceland, Section 51-D of Civil Law (Miscellaneous Provisions) Act, 2011 provides “that a good Samaritan will not be in negligence for any act done in emergency to help person in serious and imminent danger”.

Accident case requires fastest care and rescue which could be provided by those closest to the scene of the accident” Para- 5.  The letter further states that research shows that a number of the accident victims can be saved if they receive immediate attention” – (para 6), “whereas injured gradually bleeds to death” – (para 7).

What is happening in armed forces?

UDBT is legal in Armed Forces.
The Armed Forces in a remote area of combative operations felt the need of UDBT or else, they may lose their most trained and loyal war veterans. They cannot afford to wait for Blood Bank facilities – mostly because of urgency and availability issues in remote outposts. The Union Cabinet has decided to exempt all the provisions of Chapter IV of the Drugs and Cosmetics Act, 1940 and rules framed under (Sub-section 30 in 4.1.2001).

Conclusion:

The public at large, all the voluntary organizations in the country, the medical associations of India and all similar organizations should join in one voice to pressurise the officials and authorities including the members of Parliament and Ministers to take immediate remedial measures to save millions of poor illiterate in the rural villages especially the underprivileged women who are mostly affected by the enforcement of this amendment.
     This will also give relief to thousands of medical professionals who are serving in the rural areas who have sacrificed their personal pleasure in serving the rural community, from unwanted litigations just because they act like a good Samaritans in good faith.
     Doctors prosecuted in a criminal case because of this amendment have to stand side by side in the Magistrate Court in the place ear-marked for an accused person like a pick pocket or a murderer. .A civilized society by no stretch of the imagination should place a respected, service-minded doctor, who has saved valuable lives, on the same level as a criminal offender, simply because of violating certain rules while acting in good faith.

References:

1. Cr. Case No.2745 of 2011 u/S 18/27 & 18-A/28 of Drugs & Cosmetics Act – In the Court of Chief Judicial Magistrate, District – Sonebhadra.
2 Trends in Maternal Mortality: 1990 to 2010
3.Drugs and Cosmetics (2nd Amendment) Rules, 1999 published on 05 April 1999 vide GSR 245(E) dt.5.4.1999
4. 1st Amendment of Drugs and Cosmetics Rules, 1945 published on 4 January 2001 vide GSR 6(e).

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THE BONDAGE OF ALCOHOLISM

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THE BONDAGE OF ALCOHOLISM

Dr. Arun Kumar Gautham

‘And always night and day, he was in the tombs, crying out and cutting himself with stones’. Mark 5:5

I was done for the day. I picked my bags and was trudging along the changing room when I received a call regarding a sick patient. I left my medical paraphernalia and ran to the Emergency Department. The resuscitation room was abuzz with activity and emotion. I was envious of these physicians who dealt with high voltage scenarios round the clock. I had to jostle for space among the crowd to reach the man I was called to see.

Thirty year old Ravi* lay in an ill-fitting trolley with blue bed sheet over him. The head end of the trolley was elevated to give his lungs some breathing space. The IV drip flowed like a rivulet into his neck. The monitor attached screamed for attention, displaying deranged parameters in yellow and red. Ravi was breathing at a frantic pace. He was also rolling in pain. I introduced myself and he was coherent enough to decipher my poor Tamil and reply. I had a cursory look at the emergency chart.  On arrival, his blood pressure was not recordable. Six litres of saline, a dose of high end antibiotics, and infusion of dopamine had helped him recover to his present state. Apparently he was still in distress. He blurted out his history in broken lines even as he struggled to catch his breath.

Ravi was a daily wage labourer. On the days he was lucky to get some work, he was paid… most days he would just stay at home. For the last 20 days he developed pain and swelling in his right leg. Initially he neglected it but as the pain became an impediment to his basic chores he visited a doctor. A preliminary scan of the leg showed that a blood clot had formed in one of the large veins and this had developed a secondary infection. A dose of over-the-counter medicines did not work, steadily pushing Ravi to this present predicament. Before I rolled his wheeled stretcher to the ICU, I enquired his wife about his habits. ‘He consumes alcohol’, she said in a dejected voice.

Through the corridors of the hospital, along the wards of radiology and neurosurgery, I took him to the surgical ICU. I put him in bed no 2. My senior relieved me from my shift and I went home. Over dinner, Ravi flashed through my mind. I was amazed to see that 6 of the 13 beds in surgical ICU were occupied by patients of road traffic accidents and all were under the influence of alcohol. Five among them at that time were on ventilators and drugs without which their circulation would fail. Three of them had sustained head injury and two were on tracheostomy. The biggest tragedy was that all of them (except one) were below the age of 40.

The next day I reached the ICU with a special curiosity to know what happened to Ravi. In the night he was taken for an emergency surgery. His leg was too infected to be saved. They had to remove his leg and part of his thigh (above knee amputation). The attending doctor told me that he may need a higher amputation as there was still a mass of infected tissue threatening his life. In the ICU, Ravi was intubated and was being ventilated by a machine with tubes popping out of his mouth, nose, neck and bladder.

Moments later, a whisper wafted into my ears, “Bed no. 2 – the relatives want to take the patient away, against medical advice.” I was shocked, but felt that the relatives could be cajoled to stay after a counselling session. The surgeon, the ICU consultant, the nurses…they all tried to reason but were not able to change the mind of a frail old man in a lungi and crumpled shirt with a beard ill-kempt and voice trembling. He was Ravi’s father. As a last ditch attempt, the chief of ICU himself wanted to talk to the old man. Ravi was too young to give up hope on. His vitals were stable. His heart had calmed down and his support requirement had come down since the time of admission. Ravi was improving. Leaving the hospital at that moment would be an unwise idea.

I just wanted to see how the encounter between my chief and the old man would go. I accompanied Dr. SM and sat on a sofa facing Ravi’s father and brother in law. The father was firm and clear that he wanted to leave. We asked him why. He had a heart breaking story to tell.

Ravi was married 10 years ago. He has 3 daughters to feed. But like millions of families that are ravaged by alcoholism, Ravi’s family also faced its brunt. He was a chronic alcoholic spending all he had on drinks. He would not take care of his family. His children were out of school. His poor wife had to face the mental anguish of a practically useless husband and the physical assault and battery the inebriated mind would perpetrate. The last ten days were worse. He just lay on his bed consuming bottles of alcohol aided by his friends who brought the needful. The entire family was supported by the meagre wages of Ravi’s old father.

It was not that Ravi’s father did not understand the gravity of the current situation. He himself said, ‘I know that he’ll die. I know that he will not cross the hospital premises alive. I just have to show his body to his mother. All my life I spent my money on him. He did not change. He will not change. Now he does not even have a leg. I have his three daughters to tend to. I cannot waste my last resources on him. The story is over sir. Just let us go.’ Saying this he fell over my chief’s legs and began to wail inconsolably.

We let Ravi go. When the intern who accompanied Ravi to the vehicle returned, I asked him how Ravi was. He said he felt no pulse during the transfer into the vehicle. The bondage of alcoholism had extracted yet another young life.

It is to stories like these that doctors need to stand up to. It is bondages like these that have to be broken before families and society can be blessed with wholesome life. What is the mandate of health care professionals in a society mired in the darkness of alcoholism? Are the problems of our patients purely medical or are they social and economical also? Is it ethical to confine ourselves to mere medical care rather than make an effort to address issues like alcoholism which directly contribute to life-destroying illness? What is the distance we are willing to go – will we go the second mile to raise our voice against these issues?

In the pages of the Gospel there is an episode captured where the disciples of Jesus are unsuccessful in driving out evil spirits while Jesus does it. Disciples ask Him how he was able to. Jesus says, “This can happen only through prayer and fasting.” May be we should look at the big picture and discern. May be we should pray for people like Ravi, against TASMAC and the minds that are bent on expending long lives for ephemeral highs.

The Tamil
Nadu
State
Marketing
Corporation
(TASMAC) is a company owned by the Govt. of Tamil Nadu, which has a monopoly over wholesale and retail vending of alcoholic beverages in the Indian state of Tamil Nadu
. The monopoly trade has led to widespread irregularities like adulteration, corruption, overpricing and black marketing in the retail outlets. It has also led to increased complaints about disturbances created by drunk patrons from residents in areas where the retail outlets are situated. Alcoholism is growing at a rate of 8% p.a. in Tamilnadu. Tamilnadu is also the state with largest sale of alcohol by volume. The present state government was elected with total prohibition as one of its manifestos. Whether, this will come to be remains to be seen.)

*Names have been changed to protect identity, but the stories still remain the same…


Dr. Arun Kumar Gautham is a Post-graduate registrar, Department of Anaesthesia, Christian Medical College, Vellore.

The science and art of prescribing

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The science and art of prescribing – Precious pearls from experienced clinicians

Interview with Dr. George Joseph, Professor, Department of Cardiology, Christian Medical College, Vellore. Source: Reprinted from Pharmacy Bulletin, Feb 2016, a publication of the Pharmacy Service (DISH), CMC, Vellore.

Dr. George Joseph, MBBS, MD, DM, FCSI

Writing a good prescription is an art as much as it is a science. Traditional text books describe a disease and will tell us what drugs should be prescribed. But we will have to, of necessity, learn the art only from a senior who has accrued years of experience by treating patients. In this new series of interviews, we hope to garner some useful tips on developing good prescription writing skills from some of the senior clinicians in our institution and present it to our readers. We believe this will be a tremendously useful exercise that can challenge us to change our prescribing patterns to better ways. Read on and be challenged. Dr. George Joseph has been prescribing since 1982 when he was graduated as a physician in CMC. Today he is a senior consultant cardiologist in CMC and heads cardiology unit-1. He describes his principles, strategies and emphasis on prescribing apart from few advices for junior prescribers.

What principles do you follow to ensure that your patients get the best medications?

Many things, but the first is the use of generic names and avoidance of trade names. I always ensure that a drug is prescribed by its generic name. If brand name is required, I prefer writing it in brackets. Secondly, since many prescribers are unsure of the composition of combination products, I insist that when a combination product is prescribed, the generic composition be written alongside with the dose of each component drug. This will help other prescribers who peruse the patient’s notes to quickly understand what drugs the patient is on and in what dose. And moreover, since it is hard to remember all the combination products and since their composition also varies frequently, writing down the individual components becomes important both in the patient chart and prescription.

Sometimes, the combination product may not be available in CMC and in such cases, the individual drugs may be given separately if the dose of each component is written. Though I avoid combination products as far as possible, if the patient is already on a combination product and is doing well on it, I simply continue it. Secondly, as far as possible I simplify multiple-doses-a-day drug regimens. If the medications are spread throughout the day, like three or four times a day, the patient tends to be noncompliant. The availability of long acting forms can be used to simplify the regimen. Sometimes when patients come to me with a huge list of medicines, may be 10 or 15, I try to reduce the number of drugs to as few as possible and simplify the dosing schedule. This will improve adherence and the costs as well. Thirdly, I always consider the side-effects of drugs. For example, patients often complain of insomnia which physicians tend to ignore, but could sometimes be the side-effect of drugs such as the commonly-prescribed statins.

I frequently make use of the CMC intranet (Medclick/Online drug information) to check the side-effects of drugs and advise patients accordingly. Smartphones with web browsers also allow a quick check of the side-effects of drugs. Despite our busy schedule, an extra minute spent looking up drug side-effects can result in a huge relief for the patient. A patient who was on nitrate therapy came to me with intolerable headache which he had suffered for quite a while. Despite consulting many doctors in his town, including some specialists, nobody told him that nitrates can cause headache. Similarly, amlodipine commonly causes pedal edema and physicians often start such patients on diuretics thinking that this is a new unrelated problem. We should take time to check the side-effects of the drugs we prescribe and warn the patients about the common ones.

Apart from what you mentioned earlier, what other things do you emphasize to your patients when you prescribe drugs?

A very common error that occurs in prescribing drugs for patients with chronic conditions is when he or she is given a prescription, say for one month, and then he/she assumes that the medicines have to be taken for just for one month and then stopped. Because of this, very important medicines are stopped and the physician will not see the expected clinical outcome. To prevent this, the duration the drug has to be continued should be emphasized to all patients when they are prescribed a new drug. Tell them that they have to take this medication lifelong, though the prescription is only for one month. Another thing I emphasize when dealing with patients on multiple drugs is to avoid the common practice of writing CST (continue same treatment) on the chart. The problem with CST is that it tends to be repeated by the same or other physicians for many visits, and over time no one knows when these drugs were started and for what reason. Even the names and dosage of the drugs tends to go wrong. I think it is important to write the whole list of medications, if not every time, at least on alternative visits. In the midst of their busy schedules many physicians do not want to spend the time or take the extra effort to write down the whole list of drugs and their dosage. However, use of ‘CST’ tends to result in medication errors in the patient.

How do you improve medication compliance in patients?

We can suspect poor drug-compliance if the expected clinical outcome is not achieved, for example the blood pressure does not come down. To ensure compliance, the medicines prescribed should be affordable to the patient. So I discuss the anticipated monthly cost of the drug with the patient before prescribing it. The second thing is to check if the patient is noncompliant due to side-effects of prescribed drugs. So I ask patients about common drug side-effects, especially if I am not seeing the desired therapeutic effect. The third problem to overcome is poly-pharmacy and frequent dosing. Aim to simplify. Simple regimens like once or maximum twice daily dosing will improve patient compliance.

How do you prescribe a new drug in the market to your patient?

Usually new drugs are very expensive. They seldom come cheap. I go for new drugs when the old drugs are not sufficiently effective, have inconvenient dosing schedules or other problems (such as need to monitor INR periodically in patients on vitamin K antagonists) or are not tolerated by the patient, while simultaneously considering the affordability of the patient.



What can doctors do to avoid being negatively influenced by drug companies/representatives?

As far as drugs are concerned, I have stopped seeing medical representatives. I consider it poor use of my time having to hear about 10 different brands of a drug such as atorvastatin or clopidogrel. Whenever I need an update on new drugs I browse the web or read reviews. I have completely stopped seeing pharma representatives and have no pharma day or pharma time.

Which one do you prefer, electronic or paper prescription? Why?

I prefer paper prescribing mainly because I have a physician assistant. I spend quite some time writing the drugs, their dose and their schedule in the patient’s chart using generic names and do so legibly so that anyone can follow it without making errors. Then the physician assistant will transcribe the same to a paper prescription and after my verification and signature it goes to the patient. If it is electronic, I have to write it once in the chart and then again type it in an online prescription. This doubles the time required for a prescription for me. It is vital to write a very clear and detailed prescription in the chart so that everyone including the physician assistant and subsequent prescribers can read it correctly.

What advice would you give for younger doctors with regard to prescribing drugs?

I insist on drug names being spelt correctly. For example, the new antihypertensive drug cilnidipine is often misspelt clinidipine. Similarly metoprolol is often written as metaprolol. When I see such errors I bring this to the notice of the prescriber. More importantly, I insist on prescribing using generic names. Since the composition of combination products vary and is hard to remember, it is important to write down the generic names with doses of the individual drugs in combination products.

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Ida Scudder

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Ida Scudder

The history of medical work in India would not be complete without the mention of a young American lady who blazed a pathway of pioneering medical service and education in south India in the early 20th century. Born to Dr. John Scudder the second and his wife Sophia, Ida Scudder was a third generation medical missionary of the Reformed Church in America. Her grandfather Dr. John Scudder was the first American medical missionary in India and his son (her father) continued the medical work in Ranipet (in the state of Tamilnadu). Ida Scudder, his youngest child was born on December 9th 1870.2 The only girl among five brothers, young Ida watched her parents battle against sickness and famine in their medical ministry and learnt to face the grim facts of life and death even at a very early age.
At the age of eight, Ida was sent to her native U.S.A where she spent most of her childhood, away from her parents who stayed on in India. Happy, cheerful and full of youthful vigor, the young Ida was very clear that she would never work in India as a missionary like her parents. However, during a later visit to India to look after her ailing mother, she had an experience that radically transformed her outlook and the course of her life. It was to transform the lives of countless natives who would benefit from the medical legacy that blossomed out of this experience.

The three knocks

While in India, Ida found herself alone at her home in Tindivanam one evening because her father had gone out on a medical call. In the silence of the evening, she heard a knock on the door. It was a high caste gentleman. His wife was very sick because of a difficult childbirth and he requested Ida to come and help. Ida suggested that her father would attend to the problem when he returned since she was not a doctor. The man refused to allow a man to treat his wife. He said, “She had better die than have anything like that happen.” Ida pleaded with the man but he simply refused and walked away. That very night, two more men knocked on the door, one after the other, requesting her to come to their home and help their wives who were having difficulty in child birth. In both cases, the men refused to have her father, touch or even see the face of their wives. And so they walked away. Ida Scudder could not sleep that night – very close to where she stayed, three young women were dying simply because there was no woman doctor to help them.

Early the next morning, she heard drum-beats signaling the death of one of the women. She soon came to know that all three women had died in the night. To young Ida Scudder, this was an epiphany, a clear call from God. She made a promise to her parents to study medicine and come back to care for the women of India. She kept her promise, went back to the U.S.A. and started her medical studies. This was at a time when a woman studying medicine was a rarity. Male students were often patronizing or derisive in their attitude and in one instance a senior doctor even advised her to cut off her hair, dress like a man and study medicine. She went on to complete her course, graduating from Cornell Medical College, New York City in 1899.1 On January 1st 1900, Ida Scudder set foot in Vellore once again, this time as a qualified doctor to begin what would become a lifetime of service to her adopted country of India.

Vellore- from ‘Roadside clinics’ to a medical college

    Ida Scudder started her work in Vellore by using a room in her bungalow, as a dispensary. Little did she know that this single bedded dispensary would slowly grow to a 2500 bedded hospital that would go on to become a premier institute for medical service, education and research in India, impacting the lives of millions within and outside the country.

As a doctor, Ida Scudder was not content to wait for sick patients to come to her. Instead she ventured out to the villages, first in a bullock cart and then in a Peugeot car, treating the sick on the wayside, in the dusty villages, even performing dental extractions and minor surgeries under the shade of a tree. This principle of reaching out to the population was a hallmark of her service which would pass on to those who carried on the work later. With the help of friends and donors in the U.S.A. she opened the Mary Taber Schell hospital in 1902 with wards facilities for in-patients. (Presently this serves as the ophthalmology wing of CMC Vellore.)
Her surgical and medical skill, dedication to patients and most of all, her compassion resulted in large numbers of men and women filling up the hospital every day. She showed initiative and courage in trying new treatments and new surgeries as soon as they were available. She was especially skilled in surgeries on women and was ever keen to keep abreast with the latest, even innovating and devising surgical gynecological techniques. The real battle was however not against disease but against superstition and ignorance, however Dr. Ida was up to the task. Soon the little hospital was not only full but overcrowded with patients on the beds, on the floor and under the beds.

The vision of Dr. Scudder was quality and compassionate medical care to all, especially to the vulnerable group of women and children. She was convinced that Indian women would have to be trained to provide medical treatment to other women and so began a program at her hospital to instruct women nurses. This expanded into the first nursing school in India in 1946. Realizing that hospital work was not enough to meet the great need around her, she started dreaming of a medical college. By July 1918, this dream was fulfilled and the first batch of seventeen women students started their training in what came to be known as Christian Medical College (CMC), Vellore.

CMC Vellore grew steadily over the years. It moved from being a modest hospital for women and children to a premier medical college of independent India. The hospital that had begun as a one room clinic became the first in India to perform open heart surgery, neurosurgery, renal transplants, and bone marrow transplants. It led the way in neglected areas such as leprosy work, community health, rehabilitation, and mental illness4. It was in Vellore that Dr. Paul Brand revolutionized the treatment of Leprosy related deformities by developing reconstructive procedures using tendon transfer techniques. The institution carries the distinction of training prominent physicians and surgeons in various specialties, who went on to develop their respective fields in India. The alumni of this institution around the globe carry on this legacy.
Dr. Ida Scudder continued to keep in touch with patients even after she had retired from active medical practice, until she breathed her last on May 23rd 1960. Thousands filled the streets of Vellore to pay their last respects to their ‘Aunt Ida’.

Medical missionaries have had a tremendous impact in the field of health in India and their contribution is on par with those who furthered the science of medicine with their discoveries. Dr. Ida Scudder perhaps may not figure in the list of prominent scientific contributors to the field of medicine. She rather gave of herself in an act of selfless service, daring to leave a comfortable life full of possibilities to work in an obscure, dusty little town in India- an act that would significantly impact and shape the course of medical service and education in India. Her aim in starting a medical college was not only to train Indian women and men in medical practice but also to instill in them the ideals of Christian service. In Dr. Ida Scudder’s own words regarding CMC Vellore, she said, “We are not building a medical college; we are building the kingdom of God”.

References:

  1. Jeffery, MP. Ida S. Scudder of Vellore, India. Mysore City, India: Wesley Press, 1951.
  2. Scudder, DJ. A Thousand Years in Thy Sight: The Story of the Scudder Missionaries in India. New York: Vantage Press, 1984.
  3. Wilson, DC. Dr. Ida. New York: McGraw-Hill, 1959.

George, RM. Calling, Conflict and Consecration: The Testament of Ida Scudder of Vellore. Christian Journal for Global Health. Available at http://journal.cjgh.org/index.php/cjgh/article/view/10/82

Medicine and law – July 2016

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Medicine & The Law

‘Medicine and the Law’ is a forum where readers can ask questions pertaining to legal issues they may face during the course of their medical practice. The answers and clarifications are have been kindly provided by D. Samuel Abraham, (M.A., B.L., M. Phil., PGDPM), Legal Advisor to Christian Medical College, Vellore.

Q1. As general practitioners, we always face some embarrassing situations. One such situation is being asked to certify death of a patient who has never been treated by him/her. Such patients are always going to super specialty hospitals for various diseases. When they are discharged and reached a stage of no return, they approach us to certify death. What should be done on such cases? How can a doctor who does not know the background (either family or medical) give a certificate of death due to natural causes? Please guide.

Answer: I appreciate this question which has been in the minds of several doctors in the present day’s situation. Let me clarify the matter:

I have thoroughly gone through the various provisions of Registration of Birth and Death Act, 1969 and the rules framed by States. I have also gone through the Indian Medical Council Act and the rules framed by it. Nowhere I can find that Registered Medical Practitioners/Hospitals/Nursing Homes can issue Death and Birth “Certificate“. The law used the word “Information or report of births and deaths“, so that these reports can be taken to the file of the Registrar for registration purposes.

Only the general public has named this information or report of births and deaths given by the Doctors as Death or Birth Certificate. Let me put the point straight. ONLY the authorized official by law who is “the Registrar” can issue Death or Birth Certificate and NOT by any persons including Medical Practitioners. As the Medical Practitioners are present while there is a birth or death, they are expected to give information or report of death together with additional form which is called “MEDICAL CERTIFICATE OF CAUSE OF DEATH“. This is mandated only for Hospitals/Nursing Homes NOT for public who report this to the Registrar office.

On the basis of above facts the following observations are derived,

1. A Medical Practitioner can issue intimation of death together with Medical Certificate of Cause of Death to the Registration Official. Normally in a city like Bengaluru, this person would be the Commissioner of Corporation of Bengaluru who alone is the authority to issue Death or Birth Certificate.

2. I would advise that Doctor who has not given treatment to a particular patient not even once, should avoid in giving intimation because, he cannot identify the person.

For example, when the doctor is not able to identify the person with the particular name he cannot correlate with the dead body and the name attached to that body. Only, if the doctor knows a person and his name, then only can he issue an intimation or report of death. However, when a patient approached your hospital even at the terminal stage and if he dies in your hospital, with available records and identification with the relative you can send intimation to the Statutory Authority which is part of your duty as the cause of action arises in your hospital.

Your contention that it may not be possible for a doctor who does not know the background to give a certificate of death due to natural causes is correct and acceptable.

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Q-2. For those patients brought with trauma related wounds without confirmatory history of cause of trauma, is it medico legally desirable to take photographs for record and have those available for medico legal scrutiny (before the wounds are dealt with by suturing, stapling or other means)?
        This is to avoid the situation where there is a contention or alternate claim regarding the nature of wound at the time of admission by either party.
         On occasions when the patient is cleaned up and wounds are sutured, there is hardly any real-time evidence of the injury at the time of admission?

Answer: Yes. You have every right to take photograph for record about the wounds and nature of wounds and total number of wounds received by a victim of a road accident before giving treatment. But you should be cautious that the photographs should be kept under the proper custody. Because, if it is published or printed for any reason, the patient would be entitled to sue you for publishing the same without his permission.

At the same time, it is agreeable that your observations are correct and the photos with wounds would speak volume before the trial court about the condition of the patient rather than pages of written report about the wounds.

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MEDICAL NEWS

WHO REPORT – Alarming medical scenario in India
A study titled ‘The Health Workforce in India’, published in June 2016, revealed an alarming situation while looking at the quality and distribution of medical practitioners in India.

    The results showed that more than half of the doctors (57%) don’t have any medical qualification, and in rural areas, just 18.8 per cent of allopathic doctors are qualified.

    Almost one-third (31 per cent) of those who claimed to be allopathic doctors in 2001 were educated only up to the secondary school level and 57 per cent did not have any medical qualification.

The situation was far worse in rural India, where just 18.8 per cent of allopathic doctors had a medical qualification.

    Interestingly, female healthcare workers – 38 per cent of the total – were found to be more educated and medically qualified than their male counterparts. For instance, among allopathic doctors, 67 per cent of females had a medical qualification compared to 38 per cent of males.

    The data for each district in the country from the 2001 census were specially extracted for this study, which provided a comprehensive picture of health workers in each district.

    The study revealed that the density of doctors in India was 80 doctors per lakh population compared to 130 in China. Ignoring those who don’t have a medical qualification, the the density of all doctors — allopathic, ayurvedic, homoeopathic and unani — at the national level fell to 36 doctors per lakh population. As for nurses and midwives, India had 61 workers per lakh population compared to 96 in China. The number reduced tenfold to 6 per lakh population, if only those with a medical qualification were considered.

Sources:
The Hindu, July 18, 2016, The health workforce in India
Human Resources for Health Observer – Issue No. 16, available at http://www.who.int/hrh/resources/hwindia_health-obs16/en/

CME IN IMAGES – July 2016

PDF Version

CME IN IMAGES
(Test your knowledge – Answers next page)

Case 1

 

A 50 year old male presented to the emergency department with 5 day history of abdominal distension and not passing stools and flatus. On examination he was dehydrated, pulse rate was 100/min and blood pressure was 110/80mm of Hg. His abdomen was grossly distended with a tympanic resonance. On digital rectal examination the rectum was collapsed. This is an x-ray of the abdomen.

Questions:

  1. What is the diagnosis ?
  2. What is the characteristic sign seen here ?
  3. What are the treatment modalities ?

 

Case 2


A 55 year old male who was a chronic smoker, presented with gradually worsening dyspnea and pedal edema of 6 months duration. He was a hypertensive for 10 years and had rheumatoid arthritis for 2 years. On examination he had tachycardia and tachypnea. His blood pressure was 160/100 mm hg. Cardiac examination revealed cardiomegaly ; there were crepitations on auscultation in the inter scapular and infra scapular lung fields on both sides.

Questions:

  1. Describe the clinical finding on general examination? (Clue: Look at the ear lobe)
  2. What is this sign called?
  3. What is the clinical significance of this sign?
  4. What is the postulated hypothesis behind the same?
    1. What are the other visible age related signs associated with increased risk of myocardial infarction?

 

ANSWERS


Sigmoid volvulus with ‘coffee bean’ outlined (compare with previous page)

Case 1:
By Rajat Raghunath, Department of General Surgery, CMC Vellore

  1. Sigmoid volvulus
  2. ‘Coffee bean’ sign or the bent inner tube sign – The ‘coffee bean sign’ is a classic plain x-ray finding of sigmoid volvulus. As the obstructed sigmoid colon fills up with air, it forms two air-filled compartments with a double wall in between, in the shape of a coffee bean (see image on right). An air-fluid level may be seen in each segment of dilated bowel on upright radiographs. Because the volvulus is located at the sigmoid colon, the “coffee bean” arises from the pelvis, and it may occupy the entire abdomen.
  3. Non operative treatment – endoscopic decompression. Operative management -sigmoidectomy or Hartmann’s procedure

Discussion:
Sigmoid volvulus: refers to torsion of a segment of the sigmoid colon which occurs when an air-filled loop of the sigmoid colon twists about its mesentery. This leads to obstruction of the lumen and in severe cases, to impairment of vascular perfusion.

Clinical features:

  • Most patients with sigmoid volvulus present with the insidious onset of slowly progressive abdominal pain, nausea, abdominal distension, and constipation. Vomiting usually occurs several days after the onset of pain. The pain associated with sigmoid volvulus is usually continuous and severe, with a superimposed colicky component during peristalsis.
  • Due to the insidious presentation, the majority of patients usually present three to four days after the onset of symptoms. Acute presentation may be seen in approximately 17 percent of patients – sudden onset of acute severe pain, obstipation, and vomiting. Rarely, compromise of the blood supply to the sigmoid colon may result in gangrene, peritonitis, and sepsis.
  • The diagnosis may be missed in elderly patients because the symptoms may be ill-defined. Younger patients may have an atypical presentation with recurrent attacks of abdominal pain with pain free periods in between because of spontaneous detorsion.
  • On physical examination the abdomen is distended and resonant on percussion, with tenderness to palpation. In some cases there may be emptiness in the left iliac fossa . Fever, tachycardia, hypotension, abdominal guarding, rigidity, and rebound tenderness are absent in the early stages of the disease, but if present are indicative of perforation and/or peritonitis.

When to suspect a volvulus:

  • The condition must be suspected in patients with abdominal pain, nausea, abdominal distension, and constipation/obstipation and a physical examination that reveals a distended and tympanitic abdomen.
  • The diagnosis of a sigmoid volvulus is established by imaging. Plain x-ray has an accuracy of 30-90%. CT abdomen will help in difficult cases and may provide further information.

Management: The goal of treatment is to relieve the obstruction and prevent recurrence. Endoscopic decompression should be attempted in hemodynamic stable patient. A patient who is hemodynamically unstable or suspected to have bowel gangrene should undergo operative intervention. This may involve a sigmoidectomy or Hartmann’s procedure.

References

  • Sigmoid volvulus. A four-decade experience. Mangiante EC, Croce MA, Fabian TC, Moore OF 3rd, Britt LG Am Surg. 1989;55(1):41.
  • Treatment of sigmoid volvulus: a single-center experience of 952 patients over 46.5 years. Atamanalp SS Tech Coloproctol. 2013 Oct;17(5):561-9. Epub 2013 May 1.
  • An algorithm for the management of sigmoid colon volvulus and the safety of primary resection: experience with 827 cases. Oren D, Atamanalp SS, Aydinli B, Yildirgan MI, Başoğlu M, Polat KY, OnbaşO Dis. Colon Rectum. 2007;50(4):489.
  • Uptodate (http://www.uptodate.com/contents/sigmoid-volvulus)

Case 2

By Ajay Kumar Mishra*, Anu Anna George**

*Department of General Medicine,** Department of Dermatology, Venereology and Leprosy, Christian Medical College and Hospital, Vellore

  1. Diagonal pre- auricular crease in bilateral earlobes, which runs backward from the tragus at a 45-degree angle across the lobule to the rear edge of the auricle.
  2. Presence of this diagonal ear lobe crease [DELC] is called as Frank’s sign1
  3. This sign has been found to be an independent risk factor for coronary artery and cerebrovascular diseases.2 This patient’s ECG revealed sinus tachycardia with left ventricular hypertrophy. His Echocardiogram revealed left ventricular hypertrophy and global hypokinesia of the left ventricle with an ejection fraction of 42 %. He was diagnosed to have ischemic dilated cardiomyopathy with decompensated cardiac failure. He was treated with appropriate failure medications, antihypertensive agents, lipid lowering agents and antiplatelet agents.
  4. The two hypothesized pathophysiological mechanisms behind the same are
    1. It indicates premature aging with loss of dermal and vascular elastic fibers1
    2.
     Higher circulating free radical oxidative stress and increase in intima-media thickness of blood vessels.2

    A prospective cohort study including 10,885 individuals had established the above finding to be an independent risk factor for coronary artery disease. This finding had shown a moderate sensitivity (approximately 48%) and specificity (approximately 88%)3

  5. Presence of frontoparietal baldness, crown top baldness and xanthelasma3

References:

  1. Griffing G . Images in clinical medicine. Frank’s sign. N Engl J Med 2014; 370:e15
  2. C.-H. Lo, W.-S. Lin. (2015) Frank’s sign. QJM 108, 745-746
  3. Christoffersen M, Frikke-Schmidt R, Schnohr P, Jensen GB, Nordestgaard BG, Tybjærg-Hansen A. Visible age-related signs and risk of ischemic heart disease in the general population: a prospective cohort study. Circulation2014; 129:990–8.

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THE AHA 2015 GUIDELINES

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THE AHA 2015 GUIDELINES for CPR and ACLS.

Dr. Mathew Varghese Nellimootil, Department of Emergency Medicine, Christian Medical College, Vellore

The American heart association (AHA) revised and published its evidence updates on management of cardiac arrest – The AHA 2015 Guidelines for CPR and ACLS. The 2015 guidelines for Adult cardiac arrest resuscitation is given in Figure 1. The key features, recommendations and some important changes in this revision when compared to the earlier edition (ACLS 2010) are discussed below.

Key features and changes in Adult BLS and CPR Quality:

  1. Emergency response system (ERS) activation may be done without leaving patients side (by using a mobile).
  2. Recommended sequence for single rescuer is C-A-B to reduce delay to first compression.
  3. Single rescuer compression:breath – 30 compressions to be followed by 2 breaths.
  4. Chest compression rate – CPR rate is 100 -120/min not exceeding 140/min (as this may be harmful).
  5. Depth of at least 2″ (5cm) not greater than 2.4″ (6cm). Deeper compressions may be harmful.

Key Changes in Adult ACLS:

  • Vasopressin has been removed from the algorithm.
  • Administer epinephrine as soon as possible after onset of cardiac arrest due to a non-shockable rhythm
  • To consider low EtCO2 after 20 min of CPR along with a combination of other factors to terminate CPR.
  • Steroids bundled with vasopressin and epinephrine may provide benefit in treating in-hospital cardiac arrest
  • Early provision of epinephrine in patients with non-shockable rhythm.
  • Routine lidocaine use is not recommended. It may be initiated after ROSC from VF/VT.
  • Beta blocker may be initiated after hospitalization from cardiac arrest due to VF/VT.
  • Extracorporeal CPR (ECPR) may be considered in select cardiac patients in settings where it may be implemented rapidly

The recommendations in this update are based on an extensive evidence review process by the International Liaison committee on Resuscitation (ILCOR) between 2010 and 2015. The evidence was evaluated using the standardized methodological approach proposed by the Grading of Recommendations Assessment, Development and Evaluation (GRADE) working group.

Classes of recommendations:

  • Class I– Strong , Benefit >>> Risk– 25%
  • Class IIa – Moderate, Benefit >> Risk – 23%
  • Class IIb – Weak, Benefit ≥ Risk – 45%
  • Class III – No Benefit (Moderate), Benefit = Risk – 2%
  • Class IV– Harm (Strong), Risk >Benefit – 5%

Adjuncts to CPR and ACLS:

The following other recommendations were made (Grade of evidence in brackets):

  • Oxygen dose during CPR:

    Maximal inspired O2 concentrations may be used as the detrimental effects due to hyperoxia are unlikely to occur. (IIb). (Continued next page)

Figure 1: ACLS 2015 Update – Adult cardiac arrest resuscitation1


Adjuncts to CPR and ACLS (continued…)

  • Monitoring physiologic parameters during CPR

    Reasonable use of physiologic parameters (quantitative waveform capnography, arterialrelation diastolic pressure, arterial pressure monitoring and central venous oxygensaturation) to monitor and optimize CPR quality, guide vasopressor therapy and detect ROSC but precise numerical targets for these parameters have not been specified. (IIb)

  • Ultrasound during cardiac arrest may be used – usefulness not established.
  • Bag-mask ventilation vs advanced airway during CPR – no significant difference in survival.
  • Assessment of tracheal tube placement by continuous waveform capnography in addition to clinical assessment is recommended as the most reliable method of confirming and monitoring correct placement of an ETT(I). Reasonable alternatives are no waveform CO2 detector, esophageal detector device, or US by an experienced operator (IIa)
  • Ventilation after an advanced airway placement at the rate of 1 breath every 6 seconds(IIb)
  • Defibrillators are recommended to treat atrial and ventricular arrhythmias (I) and biphasic defibrillators are preferred to monophasic (IIa)
  • Giving single shock is reasonable as opposed to stacked shocks (IIa)
  • Amiodarone may be used VF/VT not responsive to CPR, defibrillation and vasopressor therapy (IIb)
  • The routine use of Magnesium is not recommended for adult patient (III)
  • Standard dose epinephrine (1mg q3-5minutes) may be used for patients in cardiac arrest (IIb)
  • Routine use of lidocaine after a cardiac arrest is not recommended (IIb)
  • High dose epinephrine is not recommended for routine use (III)
  • Vasopressin offers no advantage as a substitute for epinephrine in cardiac arrest (IIb)
  • Use of steroids for CPR in out of hospital(OHCA) is not recommended (IIb)
  • In Hospital Cardiac arrest (IHCA), combination use of intra-arrest vasopressin, epinephrine, methylprednisolone and post-arrest hydrocortisone may be considered (IIb)

Reference:

1. Link MS, Berkow LC, Kudenchuk PJ, Halperin HR, Hess EP, Moitra VK, Neumar RW, O’Neil BJ, Paxton JH, Silvers SM, White RD, Yannopoulos D, Donnino MW. Part 7: adult advanced cardiovascular life support: 2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2015; 132(suppl 2):S444–S464

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breast cancer screening – USPST recommendation

PDF Version

Effectiveness of breast cancer screening – USPST recommendation

Source: Effectiveness of Breast Cancer Screening: Systematic Review and Meta-analysis to update the 2009 U.S. Preventive Services Task Force Recommendation. Ann Intern Med.2016;164:244-255.doi:10.7326/M15-0969. Summary by Ajay K. Mishra, Assistant Professor, Department of Medicine, Christian Medical College, Vellore.



Clinical question:
Is mammography screening for women effective in reducing mortality rates.

Authors’ conclusion:
Advanced breast cancer is reduced with screening mammography of women aged 50 years or above. Mortality due to breast cancer is generally reduced, however the reduction is small and is not statistically significant for all age groups.

Background:

Mammography screening for breast cancer has been recommended for women over the age of 40 years based on several studies in the past. In 2009, the U.S. Preventive Services Task Force (USPSTF) recommended mammography screening for women aged 50 to 74 years once every two years. They also recommended that patients between the age group of 40-49 years would require individualized assessment. However, screening has can result in unnecessary interventions in many cases. A previous Cochrane1 study comparing 5 trials had shown that women randomly assigned to screening were more likely to undergo surgeries like mastectomies and lumpectomies and radiation therapy. The usefulness of breast cancer screening is still an unsettled question. The current study aimed to review the available data, in order to see whether the current recommendations have any effectiveness or impact in reducing mortality secondary to breast cancer.

Study design:
This systematic review2 of included all studies published in English journals in Cochrane and MEDLINE till June 4, 2015. Of the 12070 abstracts identified only 38 studies met inclusion criteria for key questions in this report [14: RCT/24: Observational study]. This study also included 5 systematic reviews of 62 studies. Overall this review included over 600 000 women.

Results:
Most of the RCTs [8/14] were identified to be fair in study design, methodology and results. Across all trials the follow-up times of cases were from 11.2 to 21.9 years.

Reduction in advanced breast cancer

On estimating the role of screening in identifying Stage III or IV breast cancer detection, there was reduced risk for those aged 50 years or older [RR: 0.62].

    There was no difference with screening for women aged 39 to 49 years (RR: 0.98].

Breast cancer related mortality

Mortality due to breast cancer is generally reduced, however the reduction is small and is not statistically significant for all age groups.

    Risk reduction was 25% to 31% for women aged 50 to 69 years in observational studies of mammography screening.

All-cause mortality
For all age groups, there was no reduction in all-cause mortality with screening. The combined Relative Risk of 0.99 was consistent with this. Results were similar for all the age groups [0.99 for 39 to 49 years], [1.02 for 50 to 59 years],[0.97 for 60 to 69 years], and [0.98 for 70 to 74 years].

Table 1: Relative risk for breast cancer mortality

Age group
Relative risk for breast cancer mortality No. of deaths prevented per 10,000 women over 10 years
39 to 49 years 0.92 3
50 to 59 years 0.86 8
60 to 69 years 0.67 21
70 to 74 years 0.80 13

Response of the clinician:
The details of when to start screening, interval of screening, age at which screening has to be stopped have not been established. Screening for breast cancer with mammography should be individualised and encouraged for patients with family history of breast or ovarian cancer [Breast Cancer Risk Assessment Tool] can also be used to identified patients under risk. Patients above the age of 50 years can be explained regarding the benefits and drawback of screening before mammography. At the present scenario as the patient herself is anxious and has requested for a mammography it should be performed after counselling the patient.

Reference

1. Gøtzsche PC, Jørgensen KJ. Screening for breast cancer with mammography. Cochrane Database of Systematic Reviews 2013, Issue 6.

2. Effectiveness of Breast Cancer Screening: Systematic Review and Meta-analysis to update the 2009 U.S. Preventive Services Task Force Recommendation. Ann Intern Med.2016;164:244-255.doi:10.7326/M15-0969.