Saturday, 20 July 2013

Neck Artery Wall Thickness and Plaque Area – a new test to diagnose early heart diseases

Treadmill, stress echocardiography, Thallium and Angiography do not detect early blockages. Treadmill can miss blockages up to 70%; stress echocardiography up to 60%, angiography upto 40%.

Most heart attacks occur because of a plaque rupture in patients with blockages of less than 50%. If the blockage is more than 70% the patient usually presents with heart pain and not massive heart attack.

The only way to detect heart blockages before they cause symptoms or are detected in conventional tests is to measure the wall thickness of the neck artery or the leg artery. Normally, the wall thickness is less than 0.5mm. If the wall thickness is more than 0.75mm, it is suggestive of underlying heart blockages and if it is more than 1mm, it is suggestive of blockages in all three arteries of the heart.

Any thickness of more than 1mm is called as a plaque and a plaque area calculated by high resolution ultrasound is a new marker for heart blockages, progression as well as regression.

If the artery wall is thick in both the neck artery and the leg artery, it is very likely that the patient will also have blockages in the arteries of the heart.

All high risk individuals, therefore, should have their neck and leg artery wall thickness checkup done. Only 2% of patients with blockages in all three arteries of the heart have a neck artery wall thickness of less than 1mm and 94% of patients with a neck artery wall thickness of more than 1.15mm will have multiple blockages in the heart.

Food poisoning with rice dishes

Staph and Bacillus cereus both can cause acute food poisoning within six hours of ingestion of food. B cereus is likely when rice is the culprit

1.         Bacillus cereus is able to persist in food processing environments due to its ability to survive at extreme temperatures as well as its ability to form biofilms and spores. 

2.         B. cereus has been recovered from a wide range of foods, including rice, dairy products, spices, bean sprouts and other vegetables.

3.          Fried rice is an important cause of emetic-type food poisoning associated with B. cereus

4.           The organism is frequently present in uncooked rice, and heat-resistant spores may survive cooking. 

5.         Cooked rice subsequently at room temperature can allow vegetative forms to multiply, and the heat-stable toxin that is produced can survive brief heating such as stir frying

6.          Two distinct types of toxin-mediated food poisoning are caused by B. cereus, characterized by either diarrhea or vomiting, depending on which toxin is involved. The diarrheal toxin is produced by vegetative cells in the small intestine after ingestion of either bacilli or spores. The emetic toxin is ingested directly from contaminated food. Both toxins cause disease within 24 hours of ingestion.

7.          The emetic syndrome is caused by direct ingestion of the toxin.

8.          The number of viable spores and vegetative bacteria that produce diarrheal toxin is reduced by heating, although spores associated with emetic toxin are capable of surviving heat processing.

9.         Cereulide is heat stable and resistant to gastric conditions. 

10.       The ingested toxin itself may therefore cause disease despite sufficient heating to kill B cereus.

11.        The emetic syndrome is characterized by abdominal cramps, nausea, and vomiting. Diarrhea also occurs in about one-third of individuals. Symptom onset is usually within one to five hours of ingestion, but it 
can also occur within half an hour and up to six hours after ingestion of contaminated food.

12.       Symptoms usually resolve in 6 to 24 hours. 

13.       Rice based dishes in particular have been implicated in emetic toxin mediated disease, usually as a result of cooling fried rice dishes overnight at room temperature followed by reheating the next day. 


14.       The infective dose of cereulide required to cause symptoms is 8 to 10 micrograms per kilogram of body weight.

NEET: Review or curative petition?

The government is likely to file review petition which will go the same judges who delivered the judgment. And if it fails there is still another chance to file curative petition.

The concept of Curative petition was evolved by the Supreme Court of India in the matter of Rupa Ashok Hurra vs. Ashok Hurra and Anr. (2002) where the court decided whether an aggrieved person is entitled to any relief against the final judgment / order of the Supreme Court, after dismissal of a review petition. 

The Supreme Court said that in order to prevent abuse of its process and to cure gross miscarriage of justice, it may reconsider its judgments in exercise of its inherent powers. 


For this purpose the Court devised "curative" petition, in which  the petitioner is required to aver specifically that the grounds mentioned therein had been taken in the review petition filed earlier and that it was dismissed by circulation. This has to be certified by a senior advocate. The Curative petition is then circulated to the three senior most judges and the judges who delivered the impugned judgement, if available. No time limit is given for filing Curative petition.

Use painkillers with caution in the elderly



Painkillers can cause stroke via irregular heart rhythm. Non selective non–steroidal anti–inflammatory drugs (NSAIDs) and new generation selective COX–2 inhibitors commonly used to treat inflammation are now linked to an increased risk of irregular heart rhythm called atrial fibrillation (AF), as per a Danish Research of 32602 patients led by Professor Henrik Toft Sørensen at Aarhus University Hospital in Denmark.

These drugs are already linked to increased risk of heart attacks and strokes. And now through AF, the risk gets intensified for stroke and new risk added of heart failure and death.

In the study compared with non users, new users (first drug within 60 days of diagnosis) showed 40% increased risk of AF with non–selective NSAIDS and 70% increased risk with COX–2 inhibitors. This means four extra cases of AF per year per 1000 new users of non–selective NSAIDS and seven extra cases of AF per 1000 new users of COX–2 inhibitors.

The risk was highest in the elderly, patients with chronic kidney disease or rheumatoid arthritis especially on COX–2 inhibitors. NSAIDs should be used very cautiously in older patients with a history of hypertension or heart failure.

What does the cricketing sixth sense in Dhoni mean in medical terms?


Mahendra Singh Dhoni has made it a habit of coming good when the chips are down and feels that his excellent finishing sense has to do with his good cricketing sense, which he is blessed with. 
In the recently concluded triangular series between India, West Indies and Sri Lanka, his contribution proved to be decisive as India won the thrilling final.
What is this excellent finishing skill?  In medical terms, it is called serotonin effect i.e. the levels of serotonin increase in the body, which increase your judgment and your performance improves. 
Those cricketers who used to hit sixes on demand also had the same phenomenon. 
This is also called Chimp Effect. In Chimpanzees, when the head of the family dies, the next person who takes over starts behaving differently because of increased serotonin levels. 

So Dhoni probably has instinct of increasing serotonin levels on demand and that makes him one of best finishing cricketers in the world. 

Friday, 19 July 2013

NEET controversy update: MCI to appeal in NEET matter

Some oncoming issues:

1. What will happen to common exam on DNB?
2. Why common board exam in 10th and 12th?
MCI is likely to appeal against the apex court order on NEET.

Following is the gist of Dr Dave’s order.
1. The order was passed in hurry with one of the judges passing it on the last day of his retirement.
2. Prior to preparation of the draft judgment, no discussion was held on the subject by the three judges.
3. Sections 19A and 20 of the MCI Act permit the MCI to prescribe the minimum standards of medical education.  
4. Section 33 of the MCI Act also empowers the MCI to make regulations to carry out the purposes of the Act. 
5. It  is  a matter of sound common sense that to have doctors well-versed  in  the subject of medicine and having proficiency in their field,  we  should have suitable and deserving  students  who  should  be  imparted good medical education and there should  be  strict  supervision  over  the education system so as to see that the students who are not up to  the mark or are not having the highest  standards  of  education  are  not  declared successful at the examinations.
6. Three should be effective regulations at three different stages
1. The first stage is the admission of the students to medical colleges:  The students who are admitted to the medical course should be suitable and should have the right aptitude so that they can be shaped well into the medical profession after being imparted proper education.   
2. The second stage is with regard to determination of  syllabus  and  the manner of imparting education: MCI should see that proper medical training is given 
3. Finally, the examinations, which the students have to pass to prove their worth as successful students should also be strictly regulated. 
7. NEET to be conducted under the supervision of the MCI, standards of the students at the stage of their admission to the medical colleges would be regulated.
8. Every one understands the importance of quality of input, when something is to be produced, manufactured or developed.  Even when one thinks of manufacturing any article, the manufacturer is conscious about the quality of the input and he would invariably select the best input i.e.  such  raw  material  so  as  to  make  his  final  product excellent.  The principle is not different in the field of education.   If an educational institution wants an excellent output in the nature  of a  well-trained,  well  educated,  well  groomed  professional,  the institution must see that suitable and deserving  students  having  an aptitude for  becoming  good  doctors  are  admitted  to  the  medical college. 
9. If among all good students, there are students who are not up to the mark, who are lagging behind in their studies, who are weak in studies, it would not be possible to educate or groom such students effectively and efficiently. 
10. A weak student may lag behind due to his lower level of grasping or education or training.
11. It becomes the duty of the regulating authority to  see that quality of the students at the stage of admission  is  thoroughly examined and only deserving and suitable students are given admission to the medical colleges so as to make them suitable members of a noble profession  upon completion of their studies.  
12. MCI has introduced the NEET for this purpose only. 
13. NEET is a nationwide common examination to be held at different  places  in  the country so that all students aspiring to have medical  education  can appear in the examination and ultimately, on the basis of  the  result of the examination, suitability and eligibility of the  students  for admission to the medical profession can be determined. 
14. This system is a part of regulation whereby entry to the field of medical education is regulated in such a way that only eligible and suitable students are given admission to medical colleges.
15. If   NEET  is  conducted  under  the  supervision  of  the   apex professional body, it would inspire confidence in the  system  and  in that event, the selection of the students for admission to the medical profession  would  be  on  merit  based  selection. 
16. No extraneous consideration would come into play in the process of selection. 
17. The process of selection would not be  influenced  by  irrelevant  factors like caste and creed, community,  race,  lineage,  gender,  social  or economic standing, place  of  residence  –  whether  rural  or  urban, influence of wealth or power; and admission would be given only to the students who  really  deserve  to  be  well  qualified  physicians  or dentists.   
18. Thus, there would not be any discrimination or influence in the process of selection.  
19. Though the  students can be selected only on the basis of their merit, it would be open  to the States to follow their reservation policy and  it  would  also  be open to the institutions based on religious or linguistic minority  to select students of their choice, provided  the  students  so  selected have secured minimum marks prescribed at the  NEET.   
20. From  and  among those students, who have  secured  prescribed  qualifying  marks,  the concerned institutions, who want to  give  priority  to  the  students belonging to a particular class or  caste  or  creed  or  religion  or region, etc. would be  in  a  position  to  give  preference  to  such students in the matter of their admission  to  the  concerned  medical college.  Thus, the purpose with which the Articles 25, 26, 29, and 30 are incorporated in our Constitution would be fully respected and implemented.
21. Centralization of the selection process under holding the NEET would help the students to appear at the examination from any corner of our nation. 
22. The result of the examination would be published at the same time on one particular day and with the same standard. 
23. There would not be any problem with regard to equalizing marks and merits of different students passing different examinations from different regions or states or universities or colleges. 
24. The process of selection would be equal, fair, just and transparent. 
25. All the students would be in a position to compete from a common platform and the test will have credibility in the eyes of the students and the society. 
26. The students would be benefited because they will not have to appear at different places on different days at different examinations for the same purpose.  
27. The cost of appearing at the NEET would be much less as the aspiring students will not have to purchase several expensive admission forms and will not have to travel to different places.
28. The apprehension that  the  minority  institutions  or  the  educational institutions belonging to special classes would be adversely  affected  because  of the introduction of the NEET is not well founded.  The policy with regard to the reservation can be very well implemented if the NEET is introduced because the NEET would determine standard or eligibility of a student who is to be imparted education in the field of medicine. The institution imparting medical education will have to see that the student to be admitted  is  having minimum standard of suitability and  the  institution  will  be  at  a  liberty to select a student of its choice if it  wants  to  promote  a particular class of persons.   By  admitting  suitable  and  deserving students having  an  aptitude  for  becoming  doctors,  the  religious institutions would be  in  a  position  to  have  better  doctors  for fulfilling their objective.
29. Moreover, the policy with regard to reservation for certain classes, followed by the States would also not be adversely affected.  From the deserving eligible students, who have procured qualifying marks at the NEET and who belong to the reserved classes would be given preference so as to fulfill the policy with regard to reservation.   Thus, the students belonging to the reserved classes would also not suffer on account of holding the NEET.
30. The MCI has power to regulate. Meaning of the  word  `to  regulate'  would  also  include controlling entry of undeserving or weak students into the profession, who cannot be groomed in normal circumstances as  good  physicians  or doctors or dentists.  The term `regulate’ would normally mean to control something by means of rules or by exercise of control over a system. 
31. The above question has been rightly answered by this court in  the  case  of  Dr. Preeti Srivastava and Another vs. State of M.P. and Others (1999) 7  SCC  120 to the effect that norms of admission will have a direct impact on the standards of education.  
This court has observed that the standards of education in any institution or  college  would  depend  upon  several factors and the  caliber  of  the  students  to  be  admitted  to  the institutions would also be one of the relevant factors. 
Moreover,  in view of  entry  25  of  List  III  of  the  Seventh  Schedule  to  the Constitution, Union as well as the States have power to  legislate  on the subject of medical education, subject to the provisions  of  entry 66 of List I of the Seventh Schedule, which deals  with  determination of  standards  in  institutions  for   higher   education.   
In   the circumstances, a State has the right to control education, including medical education, so long as the field is unoccupied by any Union legislation.  By virtue of entry 66 in List I to the Seventh Schedule, the Union can make laws with respect to determination of standards in institutions for higher education. Similarly, subject  to  enactments, laws  made  with  respect  to  the  determination  of standards  in institutions for higher education under power given to  the  Union  in entry 66 of List I of the Seventh Schedule, the State  can  also  make laws relating to education, including technical education and  medical education.  In view of the above position clarified in the case of Dr. Preeti Srivastava  (supra),  the  NEET  can  be  conducted  under  the supervision of the MCI as per the regulations framed  under  the  Act. As stated hereinabove, Section 33 of the Act enables the MCI  to  make regulations to carry out  the  purposes  of  the  Act  and  therefore, conducting the NEET is perfectly legal.
32. In para 36 of the judgment delivered in the case of Dr.  Preeti Srivastava (supra), this Court  has  held  that for  the  purpose  of maintaining standards of education, it is very much necessary  to  see  that  the  students to  be  admitted  to   the   higher   educational institutions are having high caliber and therefore, in the process of regulating  educational  standards  in  the  fields  of  medicine  and dentistry also the above principle should be  followed  and  the  apex professional bodies should be permitted to conduct examinations in the nature of the NEET.  
33. Similar question with regard to having a common test had arisen for admitting students aspiring to become veterinary surgeons. The question was whether it was open to the apex body of the said profession to conduct a common entrance test. Ultimately, the issue had been resolved by this court in the matter of Veterinary Council of India vs. Indian Council of Agricultural Research, (2000) 1 SCC 750.  This court, after considering several issues similar to those which have been raised in these petitions, held that it was open to the concerned regulatory Council to conduct a common entrance test.
34. So far  as  the  rights  guaranteed  under  Article  19(1)(g)  of  the Constitution with regard to practicing any profession or  carrying  on any occupation, a trade or business, are concerned, it is needless  to say that the aforestated rights are not unfettered. 
35. Article 19(6) of the Constitution permits the State to enact any law   imposing reasonable restrictions on the rights conferred by Article 19(1) (g) in relation to the professional or technical qualifications necessary for practicing any profession.  
36.   Rights  guaranteed  to  the  petitioners  under  the provisions of Articles 25, 26, 29 and 30 would not  be violated by permitting the NEET.  It is always open to the petitioners to select a student subject to his being qualified by passing the examination conducted by the highest professional body.   
37.  The apprehension that autonomy of the petitioner institutions would be lost if the NEET is permitted is not true.  The Government authorities or the professional bodies named hereinabove would not be creating any hindrance in the administrative affairs of the institutions.  Implementation of the NEET would only give better students to such institutions and from and among such highly qualified and suitable students, the minority institutions will have a right to select the students of their choice. 
Justice Dave’s final remarks
1. in my opinion, it cannot be said that introduction  of  the  NEET  would  either  violate  any  of  the fundamental or legal rights  of  the  petitioners  or  even  adversely affect the medical profession.  In my opinion, introduction of the NEET would ensure more transparency and less hardship to the students eager to join the medical profession.  Let us see the consequence, if the apex bodies of medical profession are not permitted to conduct the NEET. A student, who is good at studies  and  is  keen  to  join  the medical profession, will have to visit  several  different  States  to appear at different examinations held by different medical colleges or institutes so as to ensure that he gets admission somewhere.   If he appears only in one examination conducted by a particular University in a particular State and if he fails there, he would not stand a chance to get medical education at any other place. The NEET will facilitate all students desirous of joining the medical  profession because the students will have to appear only at one  examination  and on the basis of the result of the NEET, if he is  found  suitable,  he would be in a position to get admission somewhere in the  country  and he can have the medical education  if  he  is  inclined  to  go  to  a different place.  Incidentally, I may state here that learned senior counsel Mr. Gupta had informed the Court that some medical colleges, who are more in a profiteering business rather than in the noble work of imparting medical education, take huge amount by way of donation or capitation fees and give admission to undeserving or weak students under one pretext or the other.   He had also given an instance to support the serious allegation made by him on the subject. If only one examination in the country is conducted and admissions are given on the basis of the result of the said  examination,  in  my  opinion, unscrupulous and money minded businessmen operating in  the  field  of education would be constrained to stop their corrupt practices and  it would help a lot, not only to the deserving students but also  to  the nation in bringing down the level of corruption.

2. For the aforestated reasons, I am of the view that the petitioners are not entitled to any of the reliefs prayed for in the petitions.   The impugned notifications are not only legal in the eyes of law but are also a boon to the students aspiring to join medical profession. All the petitions are, therefore, dismissed with no order as to costs.

Can Iron pills make schoolchildren ill?

Yesterday  21 kids had to be rushed to hospitals across Delhi after they were given iron and folic acid tablets during a government drive against anaemia.

The children, aged 9 to 17, had severe stomach ache, nausea and vomiting

Govt. defense

1.         These are common side-effect found in 1% of cases.
2.          Around 18 lakh pills were administered.
3.         Around 200 students took ill across the city but most of them did not need hospitalization.
4.          Pills were given under a central scheme launched on Monday. 
5.         Delhi government is following the guidelines laid down by the Union health ministry and the drugs are formulated as per government of India's specification which is in use countrywide. 
6.         The drugs provided under the programme were manufactured in June 2013 with expiry date in May 2015 and the drugs have been pre-tested at a government-approved laboratory.
7.          About 56% of Indian girls and 30% of boys suffer from anaemia, primarily a deficiency of essential micronutrients because of poor nutrition. As part of the government programme, around 100mg of elemental iron and 500mg of folic acid would be given to boys and girls. They would also be screened for anaemia.

eMedinews Comments

1.         Estimates are that up to 50 percent of patients complain of nausea, constipation, diarrhea, epigastric distress and/or vomiting after taking various oral iron preparations.
2.         100 mg dose in children may be high as the first dose
3.         In any way police will investigate about the equality of iron pill

Treatment options for such patients:

1. The patient may take an iron preparation containing a smaller dose of elemental iron
2. Or switch over from ferrous sulfate to ferrous gluconate
3. Or switch from a tablet to a liquid preparation, the dose of which (44 mg elemental iron per 5 mL) can be easily titrated
     by the patient
4. Patient may slowly increase the dose
5. The iron may be taken with meals, although this will decrease absorption somewhat.