Morning Medtalks with Dr KK Aggarwal

Morning Health Talk ;

New Delhi, May 10, 2018 ;

Short CMEs

US FDA approved 1-liter bowel cleansing preparation for colonoscopies. The solution is Plenvu (polyethylene glycol 3350, sodium ascorbate, sodium sulfate, ascorbic acid, sodium chloride, and potassium chloride for oral solution) a polyethylene glycol-based (PEG) preparation.

Two recent studies published in MicrobiologyOpen and Journal of Applied Microbiology have shown antimicrobial properties of several essential oils (vapour or local application)

Thyroid nodule evaluation in patients over age 70 support conservative management. Most thyroid nodules 1 cm or larger in older patients confirmed with ultrasound or fine needle aspiration are benign. And the few that turn out to be high-risk thyroid cancers are very likely to also be identified on imaging and cytology prior to surgery. (M. Regina Castro, MD, an endocrinologist with the Mayo Clinic, in Rochester, Minnesota)

Medico Legal Issue

• Delhi Medical Council (DMC), looking into the case in which a new born was allegedly wrongly declared dead by the Max Hospital in Shalimar Bagh, has given a clean chit to the hospital, ruling out any medical negligence on its part. The hospital did not issue a death certificate for the boy who had some heart beat for about four-five hours”, as the family had signed the ‘Do Not Resuscitate (DNR)’ document, even after being counselled by doctors about resuscitation
• Gujarat State Consumer Disputes Redressal Commission held a Rajkot doctor negligent and his service deficient in a case of a woman suffering from P Falciparum Malaria. The woman died during treatment. The commission held that the doctor gave outdated treatment (exchange blood transfusion and quinine). The doctor has been asked to pay over Rs 13 lakh with interest and cost of litigation to victim’s family.
• Medtalk View Point: Difficult to understand why quinine was taken as an outdated treatment.  Nvbdcp.gov.in

1. 4.3 Treatment of malaria in pregnancy The ACT should be given for treatment of P. falciparum malaria in second and third trimesters of pregnancy, while quinine is recommended in the first trimester. Plasmodium vivax malaria can be treated with chloroquine.
2. Such cases of falciparum malaria should be given alternative ACT or quinine with Doxycycline. Doxycycline is contraindicated in pregnancy, lactation and in children up to 8 years. Treatment failure with chloroquine in P. vivax malaria is rare in India
3. 6.4 Specific antimalarial treatment of severe malaria Severe malaria is an emergency and treatment should be given promptly. Parenteral artemisinin derivatives or quinine should be used as specific antimalarial therapy. Intravenous route should be preferred over intramuscular.
4. Quinine: 20 mg quinine salt/kg body weight on admission (i.v. infusion in 5% dextrose/dextrose saline over a period of 4 hours) followed by maintenance dose of 10 mg/kg body weight 8 hourly; infusion rate should not exceed 5 mg/kg body weight per hour. Loading dose of 20 mg/kg body weight should not be given, if the patient has already received quinine. NEVER GIVE BOLUS INJECTION OF QUININE. If parenteral quinine therapy needs to be continued beyond 48 hours, dose should be reduced to 7 mg/ kg body weight 8 hourly

Exchange transfusion — Exchange transfusion has been proposed as a means of removing infected red blood cells from the circulation, thereby lowering the parasite burden and replacing with unparasitized cells.

WHO guidelines indicate that it is not possible to make any recommendations regarding the use of exchange transfusion based on the available evidence. The CDC no longer recommends exchange transfusion for treatment of severe malaria previously, the US Centers for Disease Control recommended exchange transfusion for patients with parasite density >10 percent and end organ complications (Infect Dis Clin North Am 1993; 7:547).  But the  American Society for Apheresis (ASFA) supports exchange transfusion as an adjunctive therapy for patients with severe malaria (J Clin Apher 2016; 31:149.)

The Seattle times: A federal appeals court ruled the husband of a Naval Hospital Bremerton nurse who died in March 2014 after giving birth at the hospital cannot sue the Navy for medical malpractice. Court documents say the 33-year-old mother started bleeding profusely after what seemed like a normal birth. The hospital conducted an autopsy and determined the woman bled to death from an amniotic fluid embolism rather than medical negligence. (Lesson: In every unexpected, unusual, unnatural or unexplained death insist on virtual or normal post mortem

Clinical

I saw a patient today who was advised permanent pacemaker. He had severe bradycardia. We found sleep apnoea and Holter showed night bradycardia.

Here is the literature search: Becker H, Brandenburg U, Conradt R, Köhler U, Peter JH, Ploch T, von Wichert P: Pneumologie. 1993;47

In 5-10% of patients with sleep apnoea, AV conduction block or sinus arrest up to several seconds can be demonstrated. 10 consecutive patients (9 m, 1 f) between 28-56 years of age (mean value 43.4 y) were studied. The diagnosis of sleep apnoea and nocturnal heart blocks during the first visit at the outpatient department were the only selection criteria. Repetitive II degrees and III degrees AV conduction blocks were diagnosed in 2 patients (pts) and sinus arrest of 2 to 11 s in 8 pts at the study without therapy. 89.2% of heart blocks occurred during REM-sleep. In 8 pts a complete reversal of heart blocks could be demonstrated during nCPAP. In 2 pts heart blocks persisted at a reduced number during REM-sleep, mainly during ineffective nCPAP. In 80% of our pts nCPAP leads to a complete reversal of heart blocks. The indication for pacemaker implantation must be established on an individual basis.

Social Health

Raji (name changed) has just got married. Working as a maid in a house, 23-year-old Raji was suffering from rheumatic heart disease due to which two of her heart valves got damaged. She would become breathless on exertion and her echocardiogram suggested that both her left sided heart doors (valves) were leaking, putting pressure on the right side of her heart. This was when she contacted the Sameer Malik Heart Care Foundation Fund. Thanks to her employer and the HCFI, Raji got both the valves replaced at the in September 2014.

In cases of rheumatic heart disease, the mean rate of progressive valve narrowing is approximately 0.1 cm2/year, if not operated in a timely manner. Progressive leaking of valves can lead to worsening of hemodynamic status and ultimately to clinical symptoms. Leaking begets leaking is the law. In principle, corrective surgery should be performed during the transition from a compensated to decompensated phase of the disease (that is, before the decompensated phase is established). Further damage to the valves can only be prevented through prevention of further attacks of sore throat called rheumatic sore throat. For this, the patient must be given injectable penicillin every 21 days till the age of 35.

However, timely treatment and sponsoring surgery are just the treatment part of this disease. The other angle to this also needs to be addressed – that of being able to lead a normal life, get married, and have children. For women, such issues can become a huge barrier to marriage. Most families will say no to a girl who has got two of her heart valves replaced. Not everyone may be as lucky as Raji to find a boy willing to marry despite all of it.

However, Raji is yet to cross another obstacle. With her condition, hemodynamic changes during pregnancy can result in cardiac decompensation. The management of pregnant women with prosthetic mechanical valves is complicated due to the increased risk of prosthetic valve thrombosis and thromboembolism related to the relative hypercoagulable state and difficulty managing anticoagulation during pregnancy. Women with older mechanical valves (ball-and-cage valves, single tilting disc), mechanical valves in the mitral valve position, multiple mechanical valves, arrhythmias, and those with a history of thromboembolic events are at higher risk of valve thrombosis than others.

Public Health

ICMR has come out with a standard protocol for treatment and management of type-2 diabetes

The guidelines will be a rule book for physicians

The guidelines are open for public consultation.

Screening should be performed in all individuals who are more than 30 years of age.

Children and adolescents aged 18 years and below should be screened for diabetes if they are overweight and have risk factors such as family history in first degree relatives, signs of insulin resistance, hypertension or dyslipidaemia.

Spiritual

Do not believe in anything simply because you have heard it. Do not believe in anything simply because it is spoken and rumored by many.

Dr KK Aggarwal
Padma Shri Awardee
Vice President CMAAO
President HCFI