Morning MEDtalks with Dr K K Aggarwal

Morning Health Talk:

New Delhi, August 12, 2018:

Clinical signs of impending death

A prospective multi-institutional study reported in Oncologist. 2014;19:681 documented the presence or absence of 10 physical signs every 12 hours from admission to death or discharge for 357 patients with advanced cancer who were admitted to two palliative care units

Five of the signs (high positive LRs, were pulselessness of the radial artery, respiration with mandibular movement, decreased urine output, Cheyne-Stoke breathing and death rattle) that emerged mostly during the last three days of life had both high specificity (i.e., >95% chances that the patient would not die within three days, if the symptom was absent) (listen: https://www.youtube.com/watch?v=LgY8pZgtDjQ). However, sensitivity was limited; these signs were present in fewer than 27% of the patients who died. Thus, clinicians and families cannot rely on vital signs alone to rule in or rule out impending death, and routine monitoring of the vital signs in patients who are imminently dying cannot be recommended.

Indoor air quality

Indoor air quality refers broadly to the quality of air within buildings constructed for nonindustrial business or for residential purposes. Indoor air quality is affected both by indoor emissions and pollutants as well as by outdoor air quality since outdoor air is the source of air circulated within a building.

In-flight indoor pollution

Commercial airline pilots were significantly better at performing advanced maneuvers in a flight simulator when carbon dioxide (CO2) levels on the flight deck (cockpit) were 700 ppm and 1500 ppm than when they were 2,500 ppm, according to new research led by Harvard T.H. School of Public Health. The study published online August 8, 2018 in the Journal of Exposure Science & Environmental Epidemiology indicates that CO2 levels directly affect flight performance of the pilot.

Previous research has shown that CO2 concentrations between 1,000 ppm and 2,500 ppm in office buildings, levels once thought to be benign, negatively impact the cognitive function of employees.

The Four Ds of Negligence

For medical negligence or deviation from the standard of care to be established, the patient must be able to prove the presence of the four Ds

Duty
Dereliction
Damage, and
Direct cause

Duty: The patient must be able to prove that there existed a patient-physician relationship and the physician owed a duty to a patient.

Dereliction: The patient must be able to prove with evidence that the physician failed to comply with the standards expected of his profession.

Damage: That the physician’s breach of duty has led them to suffer injury, either physical or emotional.

Direct cause: The patient should be able prove that the physician is directly related to any injury they suffered.

One Health Clinical Elective program: Harvard is training its medical students at the zoo

Harvard offers a one-month “One Health Clinical Elective program” to its students. Through the One Health Clinical Elective offered each spring, Harvard medical students can spend a month working with different kinds of patients than they are accustomed to, like Sofina, the lemur with type 1 diabetes, or a camel named Cornelius with a fistula draining blood. Throughout the month, students perform annual checkups and vaccinations on zoo inhabitants, and they are always on call, ready to be beckoned to the animal hospital when a water buffalo breaks a metatarsal or an African antelope begins to show acute behavioral changes.

“Too frequently we rely on a certain test or imaging to treat patients,” said Richard Neal Mitchell, MD, PhD, a professor of pathology at Harvard who oversees the program. “At the zoo, it’s a little more like the Wild West, where you don’t have all your resources and you have to use more of your clinical wit to figure out what’s going on,” he said. “It informs the way students practice with people after that because they’ve developed the skills that will allow them to use a stethoscope, a pair of hands, and a mind connected to them to work through different diagnoses.”

The elective is based on One Health initiatives, which aim to promote, improve, and defend the well-being of all species. These practices were frequently executed at the zoo as students studied infectious diseases and how habitat disturbances may result in a loss of biodiversity, which would have negative impacts on human health.

Since the One Health Clinical Elective program started in 2015, all of the students who have taken the elective have gone on to pursue their residencies. But the lessons they have learned will continue to persist in their medical practice, research, and personal lives… (Medpage Today)

Non-aspiration biopsy

“Given the statistically significant deceased rate of non-diagnostic cytopathology with capillary action and the potential for increased pain and complications with larger needles without a proven benefit, needle biopsy of routine thyroid nodules should be performed without aspiration and with smaller needle gauges” (Thyroid, July 2018).

Around the globe

Salt consumption exceeds national and World Health Organization (WHO) guidelines in most countries, but only the highest-sodium diets, such as in China, are linked to clear health risks. Only individuals with a daily salt intake of at least 12.5 g (2.5 teaspoons) were associated with increased blood pressure and a greater risk of stroke (Lancet).
Galafold has been approved by the US FDA as the first oral medication for the treatment of adults with Fabry disease, a rare genetic disorder.
New guidelines from the American Academy of Neurology (AAN), the American Congress of Rehabilitation Medicine, and the National Institute on Disability, Independent Living, and Rehabilitation Research for treating disorders of consciousness say that for people in a vegetative or minimally conscious state caused by brain injury, an accurate diagnosis and ongoing medical and rehabilitative care based on the latest scientific evidence could mean a better chance for recovery (Neurology, August 8, 2018).
Eating a diverse diet is may not be healthy or promote a healthy weight, according to a new scientific statement from the American Heart Association (AHA). Recent evidence from observational studies suggests that greater dietary diversity is associated with suboptimal eating patterns i.e., higher intakes of processed foods, refined grains and sugar-sweetened beverages and lower intakes of minimally processed foods, such as fish, fruits, and vegetables, and may be associated with weight gain and obesity in adult populations. (Circulation, August 9, 2018).

Wear boxers under garments for better fertility

Men who most frequently wore boxers had significantly higher sperm concentrations and total sperm counts when compared with men who did not usually wear boxers, according to new research led by Harvard T.H. Chan School of Public Health and published August 8, 2018 in Human Reproduction. Options included boxers, jockeys, bikini, briefs, and other. The most significant difference in sperm concentration was seen between men who wore boxers and men who wore jockeys and briefs.

“These results point to a relatively easy change that men can make when they and their partners are seeking to become pregnant,” said Lidia Mínguez-Alarcón, lead author of the study and research scientist at the Harvard Chan School.

Ditch the Gluten, Improve Your Health the Harvard way

What is gluten? Gluten is a protein found in many grains, including wheat, barley and rye. It is common in foods such as bread, pasta, pizza and cereal. Gluten provides no essential nutrients. People with celiac disease have an immune reaction that is triggered by eating gluten. They develop inflammation and damage in their intestinal tracts and other parts of the body when they eat foods containing gluten. Current estimates suggest that up to 1% of the population has this condition. A gluten-free diet is necessary to eliminate the inflammation, as well as the symptoms.

According to a survey by the Consumer Reports National Research Center, 63% of Americans believe that a gluten-free diet could improve their mental or physical health. And up to a third of Americans are cutting back on it in the hope that it will improve their health or prevent disease.

Who should avoid gluten? There is at least some truth to the idea that gluten can be harmful. As mentioned, people with celiac disease avoid sickness and maintain much better health if they follow a gluten-free diet. For them, a gluten-free diet is nothing short of essential.

And then there are people described as “gluten-sensitive.” Their tests for celiac disease are negative (normal) and yet they get symptoms (including bloating, diarrhea or crampy abdominal pain) whenever they eat foods that contain gluten. One cause is wheat allergy, a disorder that can be diagnosed by skin testing. But for many, the diagnosis remains uncertain. Some have begun calling this “non-celiac gluten hypersensitivity,” a poorly defined condition about which we have much to learn.

Avoiding gluten makes sense for people with celiac disease, wheat allergy or those who feel unwell when they consume gluten.

What should a gluten-conscious person do? If you feel well and have no digestive symptoms, enjoy your good health! And stop worrying so much about gluten.

But if you have symptoms that might be related to gluten, or if you have significant and unexplained symptoms, talk to your doctor. Symptoms of celiac disease or gluten sensitivity include: