Morning Medtalks with Dr KK Aggarwal 13th June 2018


Dr KK Aggarwal    13 June 2018

Dear Colleague

Minds Vision

Success is to move on the difficult turns because that is when others are slowing down.

Journal Update JACC

Atrial fibrillation (AF) is a growing global health problem and is associated with significant morbidity and mortality.

Heart failure (HF) develops in up to 40% of patients with AF and is the cause of 15% to 30% of all deaths in this patient population.

However, most of our knowledge of the relationship between AF and HF are based on studies of overt clinical AF, and limited data exist on the association between asymptomatic, subclinical atrial fibrillation (SCAF) and HF.

SCAF refers to short-lasting, asymptomatic episodes of AF that are only detected with continuous, long-term cardiac monitoring. Modern pacemakers and implantable cardioverter-defibrillators (ICD) allow for the accurate capture of SCAF episodes, which have been shown in large cohort studies to be associated with an increased risk of clinical AF and stroke.

Patients with paroxysmal AF may progress from shorter episodes to more frequent, longer, and ultimately sustained episodes, and this appears to be associated with worse clinical outcomes.

In this analysis of data from the ASSERT (Asymptomatic Atrial Fibrillation and Stroke Evaluation in Pacemaker Patients and the Atrial Fibrillation Reduction Atrial Pacing Trial) the authors evaluated the predictors of SCAF progression, defined as the development of at least 1 episode of SCAF >24 h in duration or clinical AF in patients previously monitored for 1 year in which they only experienced SCAF between 6 min and 24 h, as well as the relationship between SCAF progression and HF hospitalization

The study found that in patients with a pacemaker or defibrillator, SCAF progression was strongly associated with HF hospitalization. (JACC Volume 71, Issue 23, June 2018).  The rate of HF hospitalization among patients with SCAF progression was 8.9% per year compared with 2.5% per year for those without progression.

Largest medical compensation in the history

Attorneys for Mercy Hospitals East Communities and Dr. Bryan J. Menges have filed an appeal in the largest malpractice judgment ever handed out by a Franklin County jury.

Last November, Vincent Lowe, 55, Union, was awarded more than $14.2 million in medical negligence damages against two Mercy doctors and two hospital subsidiaries. Lowe presented at Mercy Hospital Washington emergency department with abdominal pain April 30, 2014. Mercy Clinic East Communities accepted him for providing medical, surgical, emergency treatment and services to him. But instead Mercy’s agents, employees and staff breached those duties.

Lowe also sought an amended judgment for an additional $3.3 million in interest on the $14.2 million award.

As per the original judgment Lowe will receive a total of $12,820,990 for past economic damages, past noneconomic damages, future medical damages and future noneconomic damages.

Dr. Bryan Menges, D.O., and Mercy Hospital East Communities will be responsible for $9,259,604, or 65 percent of the total judgment. Dr. James Cassat, M.D., and Mercy Clinic East Communities will be responsible for $3,561,386, or 25 percent of the settlement. Lowe’s 10 percent fault of $1,424,554 was subtracted from the original $14.2 million award.

An amended judgment in February 2018 gave Mercy Hospitals 26 years to pay the more than $12.8 million in damages to Lowe in instalments. Past economic damages of $1,570,990, and $900,000 in past noneconomic damages, will be paid immediately.

Additionally, $900,000 in future noneconomic damages will be split into two payments of $450,000 each paid on an annual basis.

The largest sum of $9,450,000 in future medical damages would be paid to Lowe in periodic instalments as well. He would receive $988,134 immediately, $778,638 each year for years two through five and $707,486 per year for years six through 10.

At year 11, the annual payments will drop to $113,117 annually until the award is fully paid at year 26.

If upheld by the appeals court, the judgment would be the largest medical negligence award in Franklin County history and the second highest of any jury decision.

The top distinction goes to the Doncasters Inc. civil suit in 2006 after a plane crash near Sullivan where the families of seven victims received a total of $48 million in punitive and wrongful death awards by county jurors. (emissourian.com)

Trade Margins in Disposables and Devises

The medical devices industry includes medical disposables and consumables; medical electronics, hospital equipment, surgical instruments; Implants; and diagnostic Reagents. Only 23 of them are notified as drugs and are regulated under Drugs and Cosmetics Act. 

Only Cardiac Stents (DES), Condoms, Intra Uterine Devices and knee implants are included in the National List of Essential Medicines and subject to price ceilings.

Till the government divided them in NLEM and non NLEM the trade margin needs to be fixed to make health care more affordable.

The trade margin is the difference between the price at which the manufacturers/importers sell to trade (price to trade) and the price to patients (maximum retail price).


  1. The journey of trade margins should start from the import price itself. MRP = Landed Cost + % age of Trade Margins (as decided by the government)
  2.  MRP = Price at the First Point of Sale (Stockist) + % age of Trade Margins (as decided by the government) 
  3.  MRP = Landed cost + mark-up due to services rendered + % age of Trade Margins (as decided by the government) 

Delhi Government has opted for the first one and the subject is in the public domain for comments. IMA has also invited comments on this. Let us see the reaction of the stake holders.

Job dissatisfaction and relational disharmony: risk factors for heart attack

Among men with diabetes, coronary heart disease, or stroke — those with a demanding job but little control over decisions (job strain) have a higher risk of dying early. This risk is as great as the risk from smoking, even among the men with a healthy lifestyle and well-controlled blood pressure and diabetes. Interventions like stress management, job redesign, or reducing working hours may help. (June 5 in Lancet Diabetes & Endocrinology).

Maternal Mortality

India has met the Millennium Development Goal target for maternal mortality ratio of 139 per lakh (100,000) live births by achieving 130 by 2015.  At this rate India will achieve SDG target of 70 by 2022, ahead of target timeline of 2030. What can we doctors do?

  1. Institutional delivery
  2.  Maintain Hb > 12 gm%
  3. Screen for syphilis and HIV in mother and father
  4. Immunise the mother
  5. Involve paediatrician at 8th month
  6. Screen for high risk pregnancy
  7. Maintain blood pressure
  8. Check urine exam for proteins
  9. Call ANC patient on 9th of every month

WHO has classified playing video games on the internet as an official mental health disorder.

If you play candy crush read this.

Defined as ‘a pattern of gaming behavior characterized by impaired control over gaming, increasing priority given to gaming over other activities to the extent that gaming takes precedence over other interests and daily activities, and continuation or escalation of gaming despite the occurrence of negative consequences.

To be diagnosed with gaming disorder, the individual must

  1. Experience significant impairment in personal, family, social, educational, occupational or other important areas of functioning
  2. Have experienced this impairment for at least 12 months

WHO advises gamers and parents to be mindful of how much time they, or their children, spend playing online games, particularly if it is to the exclusion of other daily activities, and be alert to changes in their ‘physical or psychological health and social functioning’ which could be attributed to gaming.

Legal Medicine

A WhatsApp message has been circulating that Supreme Court has said that criminal charges are not applicable to doctors. The judgment ifs of 2012 and not new. It is a settled law that unless an intention is proved or there is an element of undisclosed knowledge criminal sections are not applicable to doctors.

Here is the case

Supreme Court of India: CBI, Hyderabad vs K. Narayana Rao on 21 September, 2012:  P.Sathasivam/ Bench: P. Sathasivam, Ranjan Gogoi: CRIMINAL APPEAL NO.  1460 OF 2012

This appeal is directed against the final  judgment  and  order  dated 09.07.2010 passed by the High Court of Judicature, Andhra Pradesh at Hyderabad in Criminal Petition No. 2347 of 2008 whereby the High Court allowed the petition filed by the respondent herein under Section 482 of the Code of Criminal Procedure, 1973 (in short “the Code”) and quashed the criminal proceedings pending against him in CC No. 44 of 2007 (Crime No. 36 of 2005) on the file of the Special Judge for CBI cases, Hyderabad.

Some excerpts

“ 23) A lawyer does not tell his client that he shall win the case in all circumstances. Likewise, a physician would not assure the patient of full recovery in every case. A surgeon cannot and does not guarantee that the result of surgery would invariably be beneficial, much less to the extent of 100% for the person operated on. The only assurance which such a professional can give or can be given by implication is that he is possessed of the requisite skill in that branch of profession which he is practising and while undertaking the performance of the task entrusted to him, he would be exercising his skill with reasonable competence. This is what the person approaching the professional can expect. Judged by this standard, a professional may be held liable for negligence on one of the two findings, viz., either he was not possessed of the requisite skill which he professed to have possessed, or, he did not exercise, with reasonable competence in the given case, the skill which he did possess.”

“ 24) In Jacob Mathew vs. State of Punjab & Anr.  (2005) 6 SCC 1 this court laid down the standard to be applied for judging. To determine whether the person charged has been negligent or not, he has to be judged like an ordinary competent person exercising ordinary skill in that profession. It is not necessary for every professional to possess the highest level of expertise in that branch which he practices.”

25) In Pandurang Dattatraya Khandekar vs. Bar Council of Maharashtra & Ors. (1984) 2 SCC 556, this Court held that “…there is a world of difference between the giving of improper legal advice and the giving of wrong legal advice. Mere negligence unaccompanied by any moral delinquency on the part of a legal practitioner in the exercise of his profession does not amount to professional misconduct”.

“26) Therefore, the liability against an opining advocate arises only when the lawyer was an active participant in a plan to defraud the Bank. In the given case, there is no evidence to prove that A-6 was abetting or aiding the original conspirators.”

“27) However, it is beyond doubt that a lawyer owes an “unremitting loyalty” to the interests of the client and it is the lawyer’s responsibility to act in a manner that would best advance the interest of the client. Merely because his opinion may not be acceptable, he cannot be mulcted with the criminal prosecution, particularly, in the absence of tangible evidence that he associated with other conspirators. At the most, he may be liable for gross negligence or professional misconduct if it is established by acceptable evidence and cannot be charged for the offence under Sections 420 and 109 of IPC along with other conspirators without proper and acceptable link between them. It is further made clear that if there is a link or evidence to connect him with the other conspirators for causing loss to the institution, undoubtedly, the prosecuting authorities are entitled to proceed under criminal prosecution. Such tangible materials are lacking in the case of the respondent herein.”

“28) In the light of the above discussion and after analysing all the materials, we are satisfied that there is no prima facie case for proceeding in respect of the charges alleged insofar as respondent herein is concerned. We agree with the conclusion of the High Court in quashing the criminal proceedings and reject the stand taken by the CBI.

29) In the light of what is stated above, the appeal fails and the same is dismissed.”

Happy Wednesday


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