Morning Medtalks with Dr KK

1. More early research into a possible male contraceptive pill has been presented here at ENDO 2019: The Endocrine Society Annual Meeting. The results suggest that this pill, a modified testosterone which combines two hormonal activities in one, will decrease sperm production while preserving libido (Christina Wang, MD, of the Clinical and Translational Science Institute at the Los Angeles Biomed Research Institute Torrance, California)
2. From the academic session 2019-20, students admitted to MBBS course would be having new curriculum designed after 21 years by Board of Governors of Medical Council of India (MCI). Apart from other changes, the major ones are--clinical exposure to begin from the first year, and a month-long foundation course. Till now students used to have clinical exposure from second year. Curriculum has introduced new system of elective subjects with which students can pick subjects of their choices.
3. The Medical Council of India (MCI) has ruled that National Eligibility cum Entrance Test (NEET) for aspirants who wish to pursue medicine abroad is mandatory, according to official Gazette notification by the MCI. Students have a reason to rejoice as MCI has extended the validity period of NEET scores to 3 years. Every year, around 7,000 students opt to take up medical courses abroad and go to China, Bangladesh, and Russia to study medicine.

Choosing Wisely ( Critical care: ABLM Foundation)

Don’t order diagnostic tests at regular intervals (such as every day), but rather in response to specific clinical questions.

Many diagnostic studies (including chest radiographs, arterial blood gases, blood chemistries and counts and electrocardiograms) are ordered at regular intervals (e.g., daily). Compared with a practice of ordering tests only to help answer clinical questions, or when doing so will affect management, the routine ordering of tests increases health care costs, does not benefit patients and may in fact harm them. Potential harms include anemia due to unnecessary phlebotomy, which may necessitate risky and costly transfusion, and the aggressive work-up of incidental and non-pathological results found on routine studies.

Don’t transfuse red blood cells in hemodynamically stable, non-bleeding ICU patients with a hemoglobin concentration greater than 7 g/dL.

Most red blood cell transfusions in the ICU are for benign anemia rather than acute bleeding that causes hemodynamic compromise. For all patient populations in which it has been studied, transfusing red blood cells at a threshold of 7 g/dL is associated with similar or improved survival, fewer complications and reduced costs compared to higher transfusion triggers. More aggressive transfusion may also limit the availability of a scarce resource. It is possible that different thresholds may be appropriate in patients with acute coronary syndromes, although most observational studies suggest harms of aggressive transfusion even among such patients.

Don”t use parenteral nutrition in adequately nourished critically ill patients within the first seven days of an ICU stay.

For patients who are adequately nourished prior to ICU admission, parenteral nutrition initiated within the first seven days of an ICU stay has been associated with harm, or at best no benefit, in terms of survival and length of stay in the ICU. Early parenteral nutrition is also associated with unnecessary costs. These findings are true even among patients who cannot tolerate enteral nutrition. Evidence is mixed regarding the effects of early parenteral nutrition on nosocomial infections. For patients who are severely malnourished directly prior to their ICU admission, there may be benefits to earlier parenteral nutrition.

Don’t deeply sedate mechanically ventilated patients without a specific indication and without daily attempts to lighten sedation.

Many mechanically ventilated ICU patients are deeply sedated as a routine practice despite evidence that using less sedation reduces the duration of mechanical ventilation and ICU and hospital length of stay. Several protocol-based approaches can safely limit deep sedation, including the explicit titration of sedation to the lightest effective level, the preferential administration of analgesic medications prior to initiating anxiolytics and the performance of daily interruptions of sedation in appropriately selected patients receiving continuous sedative infusions. Although combining these approaches may not improve outcomes compared to one approach alone, each has been shown to improve patient outcomes compared with approaches that provide deeper sedation for ventilated patients.

Don’t continue life support for patients at high risk for death or severely impaired functional recovery without offering patients and their families the alternative of care focused entirely on comfort.

Patients and their families often value the avoidance of prolonged dependence on life support. However, many of these patients receive aggressive life-sustaining therapies, in part due to clinicians’ failures to elicit patients’ values and goals, and to provide patient-centered recommendations. Routinely engaging high-risk patients and their surrogate decision makers in discussions about the option of foregoing life-sustaining therapies may promote patients’ and families’ values, improve the quality of dying and reduce family distress and bereavement. Even among patients pursuing life-sustaining therapy, initiating palliative care simultaneously with ongoing disease-focused therapy may be beneficial.

Dated: 26 th March, 2019

Current Temperature Status and Warning for next 24 hours

Heat Wave and Temperatures Observed Yesterday (Past 24 hours from 0830 hrs IST of 25 th March to 0830 hrs IST of 26 th March, 2019)

Heat Wave:

Yesterday, No heat wave conditions were observed.

Maximum Temperatures Recorded at 1730 Hours IST of 25th March, 2019:

• Maximum Temperature more than 40.0°C was recorded at a many places over Marathwada and Rayalaseema few places over Vidarbha and at isolated pockets over Madhya Maharashtra and Saurashtra & Kutch, North Interior Karnataka and Kerala. (Annexure-1).
• Maximum temperature departures as on 25-03-2019: Maximum temperatures are markedly above normal (5.1°C or more) at a few places over Saurashtra & Kutch; appreciably above normal (3.1°C to 5.0°C) at most places over Jammu & Kashmir; at isolated places over Gujarat state, Konkan & Goa, Madhya Maharashtra, Madhya Pradesh and Assam & Meghalaya; above normal (1.6°C to 3.0°C) at most places over South Interior Karnataka and Vidarbha; at many places over Kerala, Marathwada; at a few places over Tamilnadu, Konkan & Goa, Madhya Maharashtra, Telangana and Madhya Pradesh; at isolated places over Odisha, Gangetic West Bengal and East Uttar Pradesh. They are below normal (-1.6°C to -3.0°C) at a few places over Himachal Pradesh; at isolated places over West Rajasthan, Punjab, Haryana, Chandigarh & Delhi and Uttarakhand. (Annexure-2).

Yesterday, the highest maximum temperature of 42.4°C was recorded at Khargone (West Madhya Pradesh) over the country.

Heat Wave Warnings for Next 24 hours (From 0830 hrs IST of 26 th to 0830 hrs IST of 27th March 2019):-

Heat wave conditions are very likely to prevail at isolated pockets over Coastal areas of Saurashtra and south Gujarat.