Can the police fire at the feet of a person?

Quite often we see the police fire on a person who is a thief, who is running away and gets unintentionally or accidentally killed by the person personnel.

There is a fundamental principle that the action of the police cannot be more than the amount of punishment the person will get for the crime he has committed. For example, the police cannot produce grievous injury to a simple thief by firing on his leg. Another example is, if a person has abused somebody and is running away, the other person or the police cannot fire on the leg to stop him. So the actions of the police of firing unnecessarily on the leg of the person is not justifiable unless they are firing on a person who has murdered somebody or who is a threat to other persons in the society.

Such people bring bad name to the profession

A patient from Eastern India recently came to consult me. He had brought with him three prescriptions from a local doctor who was a specialist physician, MD and MRCH from UK. He was also a former professor and Head (Medicine) and principal of a medical college. After seeing his prescription, I asked the patient in which language had the doctor written the prescription as I could not make out head and tail of the prescription.

Had it been simply a case of bad handwriting, the name of the patient, age also would not have been legible but the same could easily be read on the top in all the three of his prescriptions.

I could only read the words ‘referred to AIIMS’ in one of the prescriptions which was legible.

Out of curiosity, I asked the patient from where did he buy the medicines. The patient told me that his handwriting could only be understood by a chemist in the neighborhood of the doctor and had to be procured only from that chemist. No other chemist in the whole city would be able to read and give medicines on that prescription.

Such prescriptions bring bad name to the profession.

I would give the benefit of doubt to the medical doctor and not claim that he has a nexus with the chemist but it gives a perception to the people that there is a nexus.

To avoid such perceptions, even if we have the worst handwriting, we should at least write the medicines in capital letters of English so that they are easily understood by all. Internationally, the practice is of electronic prescription but in India, I think, expecting that from all doctors all across the country would be too much. At least the State Medical Councils all across the country should send a circular to all doctors in their jurisdiction to write medicines in ‘BOLD CAPITAL/ UPPER CASE ENGLISH LETTERS’.

(The scanned copy of the prescription are attached and name and address of the doctor have been withheld)

Jayalalithaa to oppose NEET Review

As per newspaper reports, Tamil Nadu Chief Minister Jayalalithaa has written to Prime Minister and is opposing the Union Government filing a review in NEET case in the Supreme Court of India. She says that Government should not oppose Supreme Court India decision as it will take away the independence of State regarding medical education. The split judgment was recently given by the Supreme Court of India where one of the judges on record said that there was no discussion amongst the judges and he had to give his dissent in hurry. There are many States which are opposing NEET and it is likely that many more Chief Ministers will send letters to Prime Minister but in the interest of the medical education in the country, the Government should go ahead with filing a review petition and if they file, they should fight it from the heart and not as a formality. 

Calcium carbide update

1.      The fast ripening of fruits means that they may contain various harmful properties. A commonly used agent in the ripening process is calcium carbide, a material most commonly used for welding purposes. Calcium carbide treatment of food is extremely hazardous because it contains traces of arsenic and phosphorous. Once dissolved in water, the carbide produces acetylene gas. Acetylene gas may affect the neurological system by inducing prolonged hypoxia. The findings are headache, dizziness, mood disturbances, sleepiness, mental confusion, memory loss, cerebral edema and seizures. 

A previously healthy 5 year-old girl with no chronic disease history came to ER with an 8-h history of coma and delirium. A careful history from her father revealed that the patient had eaten unripe dates treated with calcium carbide. (Per H, Kurtoğlu S, Yağmur F, et al. Calcium carbide poisoning via food in childhood. J Emerg Med 2007 Feb;32(2):179-80).

2.      Bharani A, Walia R, Ramteke G, et al. Electrocardiographic abnormalities mimicking acute myocardial infarction in calcium carbide poisoning. Indian Heart J 2006 May-Jun;58(3):288.

3.      Bello F, Seeger A, Bruna CG, et al. Acute arsenic poisoning as contamination of commercial calcium carbide. Rev Med Chil 1987 Apr; 115(4):357-8.

4.      Acetylene is a commonly found industrial agent that, when mixed with oxygen, is used for welding. A case of a 40-year-old male who died of acetylene gas poisoning has been reported. (Williams NR, Whittington RM. Death due to inhalation of industrial acetylene. J Toxicol Clin Toxicol 2001;39(1):69-71).

5.      The primary target organs for arsenic toxicity are the gastrointestinal tract, heart, skin, bone marrow, kidneys, and peripheral nervous system. 

6.      Acute toxicity typically starts in the gastrointestinal system and includes nausea, vomiting, abdominal pain, and diarrhea. These symptoms are soon followed by dehydration, hypotension and QTc prolongation. In severe cases, patients may experience cardiac arrhythmias, shock, acute respiratory distress syndrome, and sometimes death.

7.      In chronic poisoning, the peripheral neurologic complaints and skin manifestations are usually more prominent than the gastrointestinal symptoms. Chronic arsenic exposure is associated with increased all-cause mortality.

8.      Arsenic is rapidly cleared from the blood, so measurement of urinary arsenic either in a 24-hour urine collection or spot urine (along with a creatinine to correct for the concentration of the spot urine) is generally preferable. A concentration greater than or equal to 50 mcg/L or 100 mcg of arsenic per gram creatinine in the absence of recent fish, seaweed or shellfish intake strongly suggests arsenic poisoning. For more accurate assessment, both total and inorganic arsenic species should be measured in the urine. 

9.      To reduce the risk of cancer and other chronic effects, the US Environmental Protection Agency (EPA) lowered the arsenic standard for drinking water from 50 parts per billion (ppb) to 10 ppb, and the US Food and Drug Administration (FDA) has set 10 ppb for bottled water.

In the US, drinking water generally contains an average of 2 mcg/L of arsenic, although 12 percent of water supplies from surface water sources in the North Central region of the country and 12 percent of supplies from ground water sources in the Western region have levels exceeding 20 mcg/L 

10.  People also eat small amounts of inorganic arsenic in their diet. US dietary intake of inorganic arsenic has been estimated to range from 1 to 20 mcg/day. There have also been concerns about elevated arsenic levels detected in some samples of apple and grape juice. Toddler milk formulas containing organic brown rice syrup as a sweetener also have been blamed to be high in arsenic.

Limit the dose of paracetamol to 3250 mg in patients consuming three or more alcoholic drinks a day

Paracetamol is the new suicide drug of the west. According to Consumer Education Campaign" by FDA although paracetamol is remarkably safe when taken at usual therapeutic doses, its overdose has been recognized to cause fatal and nonfatal liver damage. Paracetamol in the US is available as Acetaminophen.

FDA has called for limiting the dosage to 3250 mg for patients consuming three or more alcoholic drinks a day. It also recommends limiting tablet strength for immediate release formulation to maximum of 325 mg and single adult dose to 650 mg. FDA also mentioned that over–the–counter painkillers and fever reducers should carry a warning of liver damage and stomach bleeding.

Paracetamol in India is available in the market as 500 or 1000 mg tablets.

Repeated therapeutic or slightly excessive doses can be toxic to the liver in susceptible individuals, such as alcoholics.

Paracetamol poisoning is the most common cause of acute liver failure in the United States.

In adults (over 12 years), the therapeutic dose is 10 to 15 mg/kg per dose or 325 to 1000 mg per dose in adults, given every 4 to 6 hours, with a maximum recommended daily dose of 4 g in adults.

Toxicity is unlikely to result from a single dose of less than 7.5 to 10 g for an adult (2 tablets four times a day of 1000 mg strength) but can occur with single ingestions greater than 250 mg/kg or those greater than 12 g over a 24–hour period (12 tablets of 1000 mg strength).

Virtually all patients who ingest doses in excess of 350 mg/kg develop severe liver toxicity (defined as peak SGOT or SGPT liver enzymes levels greater than 1000 IU/L) unless appropriately treated. (For 60 kg man it would mean 21 tablets of 1000g strength paracetamol)

In contrast to chronic alcoholics with an isolated ingestion, those chronic alcoholics who ingest multiple supratherapeutic doses (above the therapeutic dose of up to 4 g/day) of paracetamol are at increased risk for liver toxicity. One report from George Washington University showed that 161 regular users of alcohol developed liver toxicity following paracetamol ingestion with therapeutic intent. In the report 54 percent had ingested 6 grams or less per day and 30 percent had taken less than 4 g/day of paracetamol, the overall mortality rate reached 20 percent. Delayed recognition of toxicity and continued use of the drug likely account for much of the morbidity in this patient population.

Following acute overdose, children younger than five years appear to be less susceptible to liver toxicity than older children and adults. The therapeutic dose of paracetamol for children younger than 12 years is 10 to 15 mg/kg per dose, every 4 to 6 hours, not to exceed five doses per 24–hour period (maximum daily dose 75 mg/kg). The minimal toxic dose for a single ingestion is 150 mg/kg for a child.

Toxicity is likely to occur with single ingestions greater than 250 mg/kg or ingestions of greater than 12 g in a 24–hour period. Virtually all children who ingest doses in excess of 350 mg/kg develop severe liver toxicity. In chronic ingestions (multiple supratherapeutic doses), the minimum toxic threshold for children appears to be 150 to 175 mg/kg over two to four days, particularly in the setting of a febrile illness and decreased oral intake. In both adults and children, paracetamol is rapidly and completely absorbed from the gastrointestinal tract, with peak serum concentrations reached from one–half to two hours after a therapeutic oral dose. Peak serum concentrations are reached within four hours following overdose of immediate-release preparations.

Concomitant use of other liver toxic drugs can cause liver damage in the absence of overt paracetamol overdose. The examples are anticonvulsants like carbamazepine, phenobarbital, and anti–TB drugs like INH and rifampin. In addition, drugs like zidovudine (antiviral drug) may potentiate paracetamol liver toxicity. Herbal supplements may potentially amplify paracetamol-induced injury. Patients should be questioned specifically about the use of herbal supplements since they are widely used, but often not mentioned during a routine medical interview.

Fasting or malnutrition predisposes to liver injury. Patients at greatest risk appear to be those who consume multiple excessive doses rather than a single overdose. This scenario is common among children suffering from an acute febrile illness, who may receive multiple doses or prolonged duration of paracetamol.

The outcome of paracetamol intoxication is nearly always good if the antidote, N-acetylcysteine (NAC), is administered in a timely fashion and given within 10 hours of ingestion.

Unlike most other causes of hepatitis, paracetamol-induced hepatitis is acute in onset, progresses rapidly, is characterized by marked elevation of plasma liver enzymes SGPT and SGOT (>3000 IU/L), and is associated with a rising prothrombin time in the blood.

Chronic paracetamol poisoning in the alcohol user is also characterized by markedly elevated liver enzymes (>3000 IU/L), combined with hypovolemia, jaundice, coagulopathy, low blood sugar, and acute kidney failure in greater than 50 percent of these patients.

Olmesartan can cause chronic diarrhea

The US FDA has approved a label change for the AR blocker (ARB) olmesartan to state that the drug can cause an intestinal problem known as sprue-like enteropathy.  The symptoms include severe and chronic diarrhea that results in significant weight loss. Olmesartan is the only ARB known to cause this adverse event. The agency is continuing to monitor the safety of all olmesartan-containing products.

The label change is based on an evaluation of adverse events received by the FDA's Adverse Event Reporting System (FAERS), a published literature case series, and other data. In the FAERS, the agency identified 23 patients who presented with late-onset diarrhea and significant weight loss. All patients improved clinically when olmesartan was stopped. When 10 patients were rechallenged with the drug, the symptoms appeared again.

Patients should be told to contact doctors if they develop severe, chronic diarrhea with substantial weight loss while taking an olmesartan-containing product, even if it takes months to years for symptoms to develop.

Do not ignore anxiety attacks

Do not ignore attacks of anxiety or irritability as these may be an indication of underlying hyperfunctioning of a thyroid, a butterfly–shaped gland in the middle of the neck, located below the larynx (voice box) and above the clavicles (collarbones).

The thyroid produces two hormones, triiodothyronine (T3) and thyroxine (T4) that regulate how the body uses and stores energy (also known as the body’s metabolism). Thyroid function is controlled by a gland in the brain, known as the pituitary. The pituitary produces thyroid stimulating hormone (TSH), which stimulates the thyroid to produce T3 and T4. When the thyroid hyper functions, it produces too much thyroid hormone. When this occurs, the body’s metabolism is increased, which can cause a variety of symptoms.

Most people with hyperthyroidism have symptoms, including one or more of the following:

Anxiety and irritability

Weakness (in particular of the upper arms and thighs, making it difficult to lift heavy items or climb stairs)

Tremors (of the hands)

Perspiring more than normal

Difficulty tolerating hot weather

Rapid or irregular heartbeats

Fatigue

Weight loss in spite of a normal or increased appetite

Frequent bowel movements.

In addition, some women have irregular menstrual periods or stop having their periods altogether. This can be associated with infertility.

Men may develop enlarged or tender breasts, or erectile dysfunction, which resolves when hyperthyroidism is treated.

Ethylene oxide used in baby powder by MNCs can cause allergy, cancer and blood abnormalities in long run

Multinationals should stop treating Indians as guinea pigs, the FDA told the Bombay HC on Friday, while opposing Johnson & Johnson's plea to restart its Mulund facility as reported in TOI. A division bench of Justice S J Vazifdar and Justice M S Sonak, the court heard J&J's plea challenging FDA's order directing closure from June 24.

In 2007, J&J had used ethylene oxide (EtO) treatment for 15 batches of baby powder and did not check for residue. But J&J argued that it had checked three of the batches for residue in 2009, and had found none.

To check for contamination, instead of the steam sterilization treatment, they sent the bottles for EtO treatment to a lab.

After the treatment, they were no checks for residue. As per FDA, the company was required to test each batch they put into the market.

About EtO

·        Hypotension, dyspnea, and chest pain may be produced by sensitivity to the ethylene oxide used as a membrane sterilant [1].

·        Chemicals that have been associated with sporadic spontaneous pregnancy loss include anesthetic gases (nitrous oxide), arsenic, aniline dyes, benzene, ethylene oxide, formaldehyde, pesticides, lead, mercury and cadmium [2].

·        A variety of other medications and agents have been implicated in anaphylaxis or reactions resembling anaphylaxis in susceptible individuals: The sterilization agents EtO and ortho-phthalaldehyde [3]

·        Type A allergic reactions during dialysis are caused by leachable substances from the dialyzer or by contamination with bacterial peptides. A classic cause of this type of reaction is ethylene oxide, which is used to sterilize hollow fiber dialyzers. Reactions to ethylene oxide, which are now uncommon, occur exclusively during the first use, usually when there has been inadequate rinsing of the dialyzer prior to use. IgE antibodies directed against ethylene oxide are present in some cases, particularly those with more severe reactions. One study, found that 16 of 106 unselected patients developed mild allergic symptoms after hemodialysis; 10 of these patients also developed eosinophilia [4]. Two observations suggested an important role for ethylene oxide in this response: allergy to ethylene oxide could be demonstrated in seven of the cases; and the symptoms and eosinophilia were ameliorated in three patients by ethylene oxide-free hemodialysis.

·        Spina bifida patients have been reported to be at increased risk of anaphylactic reactions during general anaesthesia. Following a reaction, latex is often incriminated as spina bifida patients are known to have an increased incidence of latex allergy. Ethylene oxide (EO) has recently been suggested to be an alternative cause.  EtO is a highly reactive gas widely used to sterilise heat-sensitive medical devices, and traces of EtO can be found in many of the same products as latex. [5]

·        There is a link between low dose EtO exposure and breast cancer. [6]

·        For breast cancer the substances classified as "carcinogenic to humans" (Group 1) include EtO. [7]

·        Chronic exposure to EtO causes elevation in the absolute mean number of monocytes and eosinophils and a decrease in the absolute mean number of lymphocytes. There is also an elevation in the percentage of hematocrit and the mean absolute number of the red blood cells, and a decrease in the mean absolute number of platelets, in the exposed group compared with the control group. [8]

References

1.      Nicholls AJ, Platts MM. Anaphylactoid reactions due to haemodialysis, haemofiltration, or membrane plasma separation. Br Med J (Clin Res Ed) 1982;285:1607.

2.      Savitz DA, Sonnenfeld NL, Olshan AF. Review of epidemiologic studies of paternal occupational exposure and spontaneous abortion. Am J Ind Med 1994;25:361.

3.      Ebo DG, Bosmans JL, Couttenye MM, Stevens WJ. Haemodialysis-associated anaphylactic and anaphylactoid reactions. Allergy 2006;61:211.

4.      Röckel A, Klinke B, Hertel J, et al. Allergy to dialysis materials. Nephrol Dial Transplant 1989;4:646.

5.      Anaphylaxis to ethylene oxide - a rare and overlooked phenomenon: Bache S, Petersen JT, Garvey LH. Acta Anaesthesiol Scand 2011;55(10):1279-82.

6.      Mikoczy Z, Tinnerberg H, Björk J, Albin M. Cancer incidence and mortality in Swedish sterilant workers exposed to ethylene oxide: updated cohort study findings 1972-2006. Int J Environ Res Public Health 2011;8(6):2009-19.

7.      Weiderpass E, Meo M, Vainio H. Risk factors for breast cancer, including occupational exposures. Saf Health Work 2011;2(1):1-8.

8.      Shaham J, Levi Z, Gurvich R, et al. Hematological changes in hospital workers due to chronic exposure to low levels of ethylene oxide. J Occup Environ Med 2000;42(8):843-50.

Blood pressure measurement may detect proneness to heart attack

The ankle–brachial index (ABI), a simple, non–invasive 10–minute test should be incorporated into a routine physical exam for diagnosing peripheral arterial disease in the middle aged and the elderly, especially those with heart attack risk factors like smokers, diabetics and the ones with high BP or cholesterol levels.

With the patient in a supine position, the doctor takes blood pressure readings from both arms; he then takes blood pressure readings from both ankles with a sphygmomanometer and Doppler device. ABI value is calculated by dividing the higher systolic pressure in each leg by the higher systolic brachial pressure. 

ABI scores should be interpreted as follows:

·         Greater than 0.90: Normal

·         0.71 – 0.90: Mild obstruction

·         0.41 – 0.70: Moderate obstruction

·         Less than 0.40: Severe obstruction

·         More than 1.30: Calcification of the vessels

Presence of peripheral arterial disease may indicate associated blockages in the heart and proneness to heart attack or paralysis.

FDA puts strict limits on oral ketoconazole use

1.  Oral ketoconazole should never be used as first-line therapy for any fungal infection because of the risk of liver toxicity and interactions with other drugs as per FDA.

2.        Among patients presenting with an acute stroke, women were less likely than men to receive intravenous thrombolytic therapy, which could have to do with delayed arrival at the hospital. In a cohort of patients presenting within 24 hours of stroke onset, IV tissue plasminogen activator (tPA) was used in 11% of women and 14% of men (OR 0.8, 95% CI 0.7-1.0), according to Inger de Ridder, MD, of Erasmus Medical Center University Hospital in Rotterdam, and colleagues. In the subgroup of patients who presented with an acute ischemic stroke within 4 hours of symptom onset, however, the sex difference disappeared (41.6% versus 42.4%, OR 1.0, 95% CI 0.8-1.2), the researchers reported online in Stroke: Journal of the American Heart Association.

3.        There may be an early cognitive benefit for dementia patients starting on 

angiotensin-converting enzyme (ACE) inhibitors for blood pressure control. Patients taking centrally active ACE inhibitors experienced marginally slower rates of cognitive decline compared with those not on the drugs  according to William Molloy, MB, BCh, of the Centre for Gerontology and Rehabilitation at the University College Cork, St. Finbarrs' Hospital, in Cork City, Ireland, and colleagues in the online journal BMJ Open.

4.        In addition to reducing inappropriate antibiotic use and providing better infection 

control in outpatient settings, strategies to control Clostridium difficile infection (CDI) should include further examination of outpatient and household settings and a reduction in proton pump inhibitor (PPI) use, according to an article published in the July 22 issue of JAMA Internal Medicine.

Negative stress may lead to heart disease

Marital disharmony and job dissatisfaction are the two main mental risk factors for the causation of heart attack. Many studies in the past have suggested that there is a strong correlation between a nagging wife and early heart attacks in men. Similarly, literature has shown that work–related stress is related to early onset of high blood pressure, diabetes, stroke and heart attacks.

A study from University College, London has shown that chronically stressed workers have a 68% of higher risk of developing heart disease, especially in people under the age of 50.

Whether stress–related chemical changes or stress–related behavior is linked to heart disease, is yet to be answered. Stress–related lifestyle involves eating unhealthy food, smoking, drinking and skipping exercises.

Chemical changes related to chronic stress are increased levels of cortisol, epinephrine and norepinephrine.

Amongst stress, negative stress is more dangerous than positive stress and amongst negative stress it is jealousy, anger and cynicism which are associated with heart attack.

The answer lies in managing stress by acting on a personal situation and not reacting to it. In children the same type of stress, especially during exam days, can end up with anxiety, insomnia and suicidal attempts.

Negative stress may lead to heart disease

Marital disharmony and job dissatisfaction are the two main mental risk factors for the causation of heart attack. Many studies in the past have suggested that there is a strong correlation between a nagging wife and early heart attacks in men. Similarly, literature has shown that work–related stress is related to early onset of high blood pressure, diabetes, stroke and heart attacks. 

A study from University College, London has shown that chronically stressed workers have a 68% of higher risk of developing heart disease, especially in people under the age of 50.

Whether stress–related chemical changes or stress–related behavior is linked to heart disease, is yet to be answered. Stress–related lifestyle involves eating unhealthy food, smoking, drinking and skipping exercises.

Chemical changes related to chronic stress are increased levels of cortisol, epinephrine and norepinephrine.

Amongst stress, negative stress is more dangerous than positive stress and amongst negative stress it is jealousy, anger and cynicism which are associated with heart attack.

The answer lies in managing stress by acting on a personal situation and not reacting to it. In children the same type of stress, especially during exam days, can end up with anxiety, insomnia and suicidal attempts.

Rivaroxaban as addition to aspirin and clopidogrel for an acute coronary syndrome

For patients who have had an acute coronary syndrome (ACS) and who are taking dual antiplatelet therapy with low-dose aspirin and clopidogrel 75 mg daily, one should add rivaroxaban 2.5 mg twice daily if there are no risk factors for bleeding present.

The duration of treatment with rivaroxaban is approximately one year, as studied in the randomized trial. Patients may reasonably choose to not take rivaroxaban if they are particularly concerned about the bleeding risk. This recommendation does not apply to patients taking either prasugrel or ticagrelor.

(ATLAS 2 ACS-TIMI 51 trial)

Aspirin for the primary prevention of cardiovascular disease and cancer

People above the age of 50 without excess bleeding risk should take low-dose daily aspirin (75 to 100 mg) as per the current recommendations.

Patients who are more concerned about the bleeding risks than the potential benefits (prevention of cardiovascular events and cancer) may reasonably choose to not take aspirin for primary prevention.

Meta-analyses of randomized trials have shown aspirin to reduce the risk of non-fatal myocardial infarction (Arch Intern Med 2012; 172:209) and long-term aspirin use reduces overall cancer risk (Lancet 2012; 379:1602).

A meta-analysis addressing this combined outcome suggests that aspirin use in 1000 average risk patients at age 60 years would be expected to result, over a 10-year period, in six fewer deaths, 19 fewer non-fatal myocardial infarctions, 14 fewer cancers, and 16 more major bleeding events.

Mathematics of weight loss

• To lose one pound by exercising, you need to burn approximately 3,500 calories. (2.2 pound is one kg).
• This can be done by exercising and cutting calories.
• Walking or jogging uses roughly 100 calories per mile.
• One would lose a pound for every 35 miles of walk (provided food intake and other activities are constant.)
• Walking briskly (4 miles per hour) for 30 minutes on five days a week will be equal to walking 10 miles a week. So it would take 3 ½ weeks to lose one pound provided the number of calories stays the same.
• Cutting back by 250 calories a day (½ cup of ice cream or two sugar-sweetened sodas) will lead to a loss of a pound in two weeks.
• By eating 250 fewer calories and walking for 30 minutes a day, it would take a week to lose one pound. (Harvard Newsletter)

FDA to regulate and possibly ban menthol in cigarettes

FDA has issued an Advance Notice of Proposed Rulemaking, which requests information from the public regarding the effects of menthol in cigarettes and possible regulatory options. The comment period will last for 60 days before the FDA makes a decision. If a rule is ultimately proposed, there will be another comment period.

Menthol is associated with increased initiation and greater progression to regular smoking, increased dependence, and reduced success in quitting, particularly among black smokers.

Menthol's cooling and anesthetic properties can reduce the harshness of cigarette smoke and the evidence indicating that menthol cigarettes are marketed as a smoother alternative to non-menthol cigarettes, make it likely that menthol cigarettes pose a public health risk above that seen with non menthol cigarettes.

Menthol -- which makes tobacco smoke more palatable -- helps people to start and continue smoking and makes it harder to stop.

For years, pediatricians have called for the elimination of all flavored tobacco products, including menthol. Candy and other flavors make tobacco products more attractive to children, and it's time to stop manufacturing products that we know will lead many of today's children to nicotine addiction, unnecessary illness, and premature death.

Menthol and other flavors are dangerous in all tobacco products -- whether in cigarettes, cigars, or other types of tobacco.

Aflatoxin, a fungus can worsen AIDS epidemic

As per a study in World Microtoxin Journal and reported in Science Daily, a type of fungus coatin seen on stored corn, wheat, rice and nut may worsen the AIDS epidemic in developing countries.

Aflatoxin is produced by fungus Aspergillus flavas and parasiticus. Chronic exposure to aflatoxin is linked to liver damage and cancer. The study showed that patients who had the highest exposure of the fungus on the rice were six times more likely to have high HIV virus than those in the lower group.

The fungus toxin may suppress immune system or may increase the expression of genes that results in more copies of virus. 

Kidney stones linked to higher heart risk

Bad news for North Indian who live in a stone belt as two large prospective cohort studies have shown that women (not men) with a history of kidney stones have a modestly increased risk of coronary heart disease. The magnitude of the increase ranged between 20% and 50% in the two studies. Similar increases emerged from separate analyses of fatal and nonfatal heart attacks and revascularization. The findings are reported by Dr Pietro Manuel Ferraro, of Columbus-Gemelli Hospital in Rome, and colleagues online in the Journal of the American Medical Association. The findings suggest that women with a history of nephrolithiasis might warrant more scrutiny for signs of heart blockages.

A previous study has indicated that light exercise can lower the risk of kidney stones in women.

Several other studies have identified associations between nephrolithiasis and systemic diseases, including atherosclerosis, hypertension, diabetes, metabolic syndrome, and cardiovascular disease.

In the present study the investigators analyzed data from three large, prospective cohort studies including 45,748 men, ages 40 to 75, and 196,357 women, ages 30 to 55, all without heart blockages at baseline. The studies' data encompassed follow-up of 18 years in women and 24 years in men.

Delhi Medical Association to protest against one year compulsory rural posting

In anticipation of a likely notification of Medical Council of India making one year rural posting compulsory for doctors who are aspiring to do post graduation, Delhi Medical Association is organizing a Dharna on 8^th August, 2013 Thursday outside MCI premises at Dwarka.

A high level Indian Medical Association meeting was held which had representatives from Delhi Medical Association and also medical students, interns and non PG residents.

The Medical Association is demanding that they are not against doctors working in rural areas but they do not want rural posting to be linked to entry to medical education. It can be linked to promotions or new appointments in government jobs.

The Association is planning to have a Dharna of 1 to 4 thousand people on that day.

Dr. Devi Shetty, Former Member, Board of Governors, MCI has also called an All India Students Convention on 29^th July in his native place on the same subject. He is providing free lodging and travel to student leaders to come and attend the convention which is likely to announce its next strategy.

The Medical Association said that there are 40000 students who pass MBBS every year and there are only 25000 for the rural postings. Making rural postings compulsory cannot be the right answer as the government does not have 40000 jobs. If rural posting is made compulsory all 40000 of them will have to apply for the same and if they do not find enough jobs, there will be chaos in the medical profession.

Coronavirus is not a global emergency

As per an alert by World Health Organisation, Middle East respiratory syndrome coronavirus  (MERS) is not a public health emergency of international concern.  So far the deadly SARS-like virus has infected 82 people and killed 45 of them.  

WHO said that the current situation is serious and of great concern but does not constitute the public health emergency of international concern at this moment.  Cases so far has been reported in Jordan, Kuwait, United Arab Emirates, Britain, France, Italy and Tunisia.

Millions are expected to travel to Mecca for Hujj pilgrimage but Saudi Authorities have cut the number of VISAs this year citing safety concern over expansion work at the Mosque site.

India poised to revoke Pioglitazone ban

The Drug Technical Advisory Board (DTAB) has advised the Government to revoke the suspension of the diabetes drug pioglitazone. 

The DTAB met on July 19 and recommended that pioglitazone be put back in the market in India with a box warning about bladder cancer.

The DTAB is an advisory body and the government may or may not accept its advice but it is likely that the recommendations may be accepted. 

Air quality a temporary trigger for MI

Heavy air pollution can trigger acute heart attack in the hours after exposure.

Every 10 µg/m³ increase in small particulate matter and nitrogen dioxide temporarily boosts heart attack risk by 1.2% and 1.1%, respectively, as per a report in the BMJ. The chances of suffering an attack increase by 1.3% in the 6 hours after coming in contact with high levels of vehicle–related pollutants.

The increased risk is seen up to six hours after exposure to typical traffic–related pollutants. The take home message is that breathing in large amounts of traffic fumes can trigger a heart attack within 6 hours following exposure.

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 the instinct of increasing serotonin levels on demand and this makes him one of the best finishing cricketers in the world. 

Can vitamin D treat pain?

Women with dysmenorrhea who take a single high dose of vitamin D suffer much less menstrual pain and have no need of pain medications for any reason for up to 2 months says Antonino Lasco, MD, from the Department of Internal Medicine, University of Messina, Italy. One should use cholecalciferol in these patients, especially when exhibiting low plasmatic levels of 25(OH)D (25–hydroxyvitamin D). The study is published February 27 in the Archives of Internal Medicine.

Doctors should eat breakfast to prevent heart disease

Men who skipped breakfast had a higher risk of coronary heart disease (CHD) compared with men who did not; in addition, compared with men who did not eat late at night, those who ate late at night had a higher CHD risk.

However, these associations appeared to be mediated by body mass index, hypertension, hypercholesterolemia, and diabetes.

Men in middle age and beyond who skip breakfast or eat late at night may be at greater risk of developing coronary heart disease, researchers found.

Male health professionals who said they regularly skipped breakfast were 27% more likely to die during 16 years of follow-up, according to Leah Cahill, PhD, of the Harvard School of Public Health in Boston, and colleagues, who adjusted for diet, demographics, physical activity, television watching, and amount of sleep, reports MedPage. And those who said they ate late at night were 55% more likely to die.

Both relationships, however, fell shy of statistical significance after further adjustment for body mass index, hypertension, hypercholesterolemia, and diabetes, "suggesting that eating habits may affect risk of coronary heart disease through pathways associated with these traditional risk factors," they reported online in Circulation: Journal of the American Heart Association.

The present study provides evidence to support a recommendation of daily breakfast eating by clinicians and health authorities to prevent coronary heart disease.

Previous studies have demonstrated associations between skipping meals and excess weight, dyslipidemia, hypertension, insulin resistance and diabetes, but a possible association with coronary heart disease had not been explored.

Cahill and colleagues examined the relationship between coronary heart disease risk and skipping breakfast and other eating habits using data from the Health Professionals Follow-Up Study (HPFS), an ongoing investigation of male health professionals.

The current analysis included 26,902 men ages 45 to 82 who were free from cardiovascular disease and cancer in 1992, which served as baseline. At that point, 13% reported not eating breakfast and 0.2% said they ate late at night. Through follow-up, there were 1,527 incident cases of coronary heart disease, defined as nonfatal MI or fatal coronary heart disease.

 The number of times the men ate per day was not associated with the risk of coronary heart disease, even though previous analyses of this cohort have shown relationships between eating frequency and weight gain and type 2 diabetes.

A mix of exercise protocol is better

A combination of weight training and aerobic exercise is the best prescription for overweight patients at risk for diabetes and heart disease. Only aerobic exercise is also as good as it reduces weight and takes inches off the waistlines. Just weight lifting alone has very little benefit.

According to a study published in the American Journal of Cardiology, people in the weight–training group gained about 1.5 pounds and those in the aerobic group lost an average of 3 pounds and half an inch from their waists. 

Those who did both weight and aerobic training dropped about 4 pounds and 1 waistline inch. This group also saw a decrease in diastolic lower blood pressure and in a metabolic syndrome score.

Both the aerobic–only group and the combined-exercise group also lowered their levels of bad triglycerides.

SC's NEET logic contrary to constitution bench rulings

(Excerpts from Dhananjay Mahapatra, TNN)

Points

The Supreme Court quashed the single-window admission system for all medical colleges by faulting the Medical Council of India-prescribed National Eligibility-cum-Entrance Examination (NEET) on three grounds. 

1. The majority judgment, authored by former CJI Altamas Kabir and agreed to by Justice Vikramjit Sen, held that NEET violated Articles 19(1)(g), 25, 26 and 30 of the Constitution, which guarantees a citizen freedom to practice any profession and gives freedom to religious and linguistic minority groups to manage their religious affairs as well as educational institutions. 

2. The bench said neither the Medical Council Act, 1956 nor the regulations framed thereunder empowered the MCI to formulate and enforce a single-window admission process for medical colleges. 

3. The court also said NEET could not ensure a level playing field given the disparity in educational standards in different parts of the country. 

Since the Unnikrishnan judgment [1993 (1) SCC 645], the Supreme Court has been peppered with petitions by private medical colleges whose counsel look for interim orders just before admission time every year either for grant of permission from MCI to admit students or to step around the rules. 

Counter Points

The issues dealt by Justices Kabir and Sen were touched upon by larger benches which decided important questions of law. 

1. Unnikrishnan case:  a constitution bench had said education could never be considered trade or commerce under Article 19(1)(g). "We are certainly of the opinion that such activity can neither be a trade or business nor can it be a profession within the meaning of Article 19 (1) (g). Trade or business normally connotes an activity carried on with a profit motive. Education has never been commerce in this country," it had said. 

2. A decade later, an 11-judge bench in T M A Pai [2002 (8) SCC 481] dealt with the subject of 'capitation fee' and whether imparting education could be a trade or business. It had said, "We, however, wish to emphasize one point, and that is that inasmuch as the occupation of education is, in a sense, regarded as charitable, the government can provide regulations that will ensure excellence in education, while forbidding the charging of capitation fee and profiteering by the institution. Since the object of setting up an educational institution is by definition 'charitable', it is clear that an educational institution cannot charge such a fee as is not required for the purpose of fulfilling that object." 

It also had hinted about regulating admissions to private colleges. "Excellence in professional education would require that greater emphasis be laid on the merit of a student seeking admission. Appropriate regulations for this purpose may be made keeping in view the other observations made in this judgment in the context of admissions to unaided institutions," it said. 

3. In the Inamdar case [2005 (6) SCC 637], a seven-judge bench had said a common entrance test (CET) for admissions to medical colleges, including minority institutions, would be ideal and should be conducted by a credible agency, preferably the state machinery. It had also said that a test of this nature, akin to the quashed NEET, would not violate Article 19(1) (g) or the religious rights conferred in the fundamental rights chapter of the Constitution. 

"CET is necessary in the interest of achieving the said objectives and also for saving the student community from harassment and exploitation. Holding of such common entrance test followed by centralized counseling or, in other words, single window system regulating admissions does not cause any dent in the right of minority unaided educational institutions to admit students of their choice. Such choice can be exercised from out of list of successful candidates prepared at the CET without altering the order of merit inter se of the students so chosen," it had said, articulating a vision for transparency sans profiteering in medical education. 

It had said that despite repeated rulings of the apex court against capitation fee, private colleges were indulging in it with impunity and felt that CET could curb this evil.

"If capitation fee and profiteering is to be checked, the method of admission has to be regulated so that the admissions are based on merit and transparency and the students are not exploited. It is permissible to regulate admission and fee structure for achieving the purpose just stated," it had said. 

4. The majority judgment's view that MCI had no jurisdiction to devise and enforce NEET also stands on doubtful legal grounds as a five-judge constitution bench in Dr Preeti Srivastava case [1999 (7) SCC 120] had clearly held that regulations framed by the council were binding on states.

Comments

1. Can it be said that the MCI, set up to ensure excellence in medical education, is barred from infusing transparency and merit into the process of intake of students? 

2. The majority judgment in the NEET case said, "In a single-window competition, the disparity in educational standards in different parts of the country cannot ensure a level playing field." 

Well, if that is the logic, then the court must consider scrapping the Civil Services Examination which through a single-window test chooses officers for IAS, IPS, IFS and other central services. 

Supreme Court to hear PNDT Act new notifications

Govt. of India had issued two PNDT notifications dated 7th Feb 2012 and 4th June 2012. A “Forum for Radiologists/Sonologists” challenged the notification on 29th May 2012 in Delhi High Court. The  petition was dismissed there. The forum again filed review petition on 13th July 2012, which was again dismissed.

Subsequently the forum challenged both notifications Dated 7th Feb. 2012 and 4th June 2012 in Supreme Court. The Hon’ble Supreme Court issued notice to Govt. of India. On 29.01.13 the Govt. of India gave reply to the petition. Next date of hearing in Supreme Court is on 2nd Aug. 2013.

The forum is in process of submitting its counter-reply to the reply by Govt. of India. The forum has invited suggestions for the same.

Similarities between Bihar mid day school poisoning and Spanish toxic oil syndrome of 1982

Forensic tests have confirmed presence of poisonous pesticides in the midday meal served to students of a primary school in Chhapra on July 16, leading to the death of at least 27 children. The cooking oil, used to prepare food at the school, was laced with highly toxic pesticide.

The forensic science laboratory  said the contaminated food contained monocrotophos, an organophosphate insecticide, after experts examined samples of oil from the container, food remains on the platter and remains of food items in the utensils, additional director general of police.

The peak area of the poisonous substance in the oil was more than five times in comparison to the commercial preparation used as pest control. The police are probing how and from where the poisonous substance got mixed in the oil. The postmortem report had confirmed presence of a poisonous substance in the potato-soyabean curry served to the children.

Toxic oil syndrome

Toxic Oil Syndrome or simply Toxic Syndrome (in Spanish: síndrome del aceite tóxico or síndrome tóxico) was the name given to a disease outbreak in Spain in 1981, which killed over 600 people.

The cause was traced to the consumption of colza oil that had been intended for industrial rather than food use. It had been imported as cheap industrial oil and sold as "olive oil" by street vendors at weekly street markets and was therefore used on salads and for cooking. 

The conclusion that oil was the cause for TOS is based on strong epidemiological evidence, since up to now, experimental studies performed in a variety of laboratory animals have failed to reproduce the symptoms of human TOS. None of the in vivo or in vitro studies performed with toxic-oil-specific components, such as fatty acid anilides and esters of PAP, have provided evidence that these markers are causally involved in the pathogenesis of TOS.

The fact that the first cases of the syndrome were located in Madrid, near the U.S. military base in Torrejón de Ardoz, and the secrecy surrounding the huge investigations, spread the idea of a conspiracy. 

Also, several of those affected by the TOS claim they never consumed that oil. Although the oil was mainly sold on street markets, a considerable percentage of the patients were upper class.

Another theory suggests the toxic reaction was triggered by organophosphate poisoning and covered up by the Spanish Government and the WHO.

NEET update

1. IMA TN unit welcomes SC verdict: Point Counterpoint

IMA TN: Conducting tests nationwide simultaneously was not possible as Medical Council of India was not the competent authority and did not have enough manpower and infrastructure.

A: Exams are not being taken by MCI buy by CBSC for UG and NBE for PG. 

IMA TN: There is a possibility of entire examination system collapsing if one person in the council became corrupt.

A: MCI is an elected body and one person getting corrupt can not make any difference. The ministry does not collapse if the minister turns out to be corrupt.

IMA TN:  Government should bring in stringent law and strictly implement the existing law to curb the menace of collecting huge sum of money towards fees by private medical colleges, 

A: that was the purpose of NEET.

2. Lucknow Activists demand probe in NEET decision

Activists have prayed new CJI for an independent enquiry into various allegations including alleged leak of an order on NEET.

1. At 8.36am on 18th July, GS a lawyer from the Supreme Court published an article 'Into the Darkness' on a website 'Bar and Bench'. 

The article stated, "In a little while, on his last day in office, the Chief Justice's court will deliver the much awaited judgment concerning the validity of the national medical entrance test to be conducted by the Medical Council of India. 

For the better part of the last week, senior counsel and junior advocates alike have without compunction shared a story that the appeals by the private colleges will be allowed with a declaration that the MCI has no jurisdiction, and one if the judges will dissent from this view. 

The judgment, it is confidently touted, runs into more than 190 pages and in excess of 300 paragraphs. It is my fervent hope that this tale is false - a figment of some perverse and destructive mind. In a few hours, we will know the truth."

On the same day at 11am, the three Judge bench delivered exactly the same judgment.

3. Report from the Hindustan Times, says...

"Meanwhile, CJI was caught unawares when informed that an article by SC advocate GS - uploaded on a website two hours before the verdict - had leaked the judgment and even mentioned that Justice D would be the dissenting vote. The article talked about "gossip" within court circles that the appeals by private colleges against the NEET would be allowed.  When questioned about the 'leak', CJI said he was surprised and shocked. "What can I say about it?" he said.  The outgoing CJI was on his way to his farewell party when media persons questioned him."

4. Times of India on 19th July titled "Collegiums stalls outgoing CJI's attempt to push judge's appointment to SC" also talks about former CJI Kabir's meeting with the Collegium. It says...  (SOURCE: MONEY LIFE)