Morning MEDtalks with Dr KK Aggarwal 28^th July 2018

Prescribing medicines without diagnosis is culpable negligence: Bombay HC

No telephonic consults please- You can go to Jail

Press Trust of India: Observing that prescribing medicines to patients without diagnosis amounted to culpable negligence, the Bombay High Court has turned down the anticipatory bail pleas of a doctor couple booked for the death of a woman patient. The doctors have been booked by the Ratnagiri Police under section 304 of Indian Penal Code (culpable homicide not amounting to murder) after the patient died earlier this year.

“The high court noted that there was no effort to refer the woman to another doctor in the absence of Deepa Pawaskar and she (Deepa) continued to prescribe medicines telephonically.” "There was no resident medical officer or any other doctor to look after the patient in the absence of Dr Deepa and Sanjeev Pawaskar even when the couple knew that they would not be available in the hospital,"

"Prescription without diagnosis would amount to culpable negligence. This amounts to gross negligence from the point of standard of care and recklessness and negligence, which is a tricky road to travel,"

The accused couple, in their pleas, argued that they could not be charged with culpable homicide not amounting to murder and should, at the most, be booked under section 304 (A) (causing death due to negligence).

The high court, however, said that in the present case, the applicants took the risk of doing something with recklessness and indifference to the consequences.

"An error in diagnosis could be negligence and covered under section 304 (A) of the Indian Penal Code. But this is a case of prescription without diagnosis and, therefore, culpable negligence,"

"When a doctor fails in his duty, is it not tantamount to criminal negligence ? The courts cannot ignore the ethical nature of the medical law by liberally extending the legal protection to the medical professionals...,"

"Segregation of reckless and negligent doctors in the profession will go a great way in restoring the honour and prestige of large number of doctors and hospitals who are devoted to their profession and scrupulously follow the ethics and principles of the noble profession," (Excerpts from PTI News)

World Hepatitis Day: “Test. Treat. Hepatitis”

Today is World Hepatitis Day.  The theme this year is “Test. Treat. Hepatitis” Timely testing and treatment of hepatitis B and C can save lives and ultimately eliminate viral hepatitis. Let’s revise some key points about viral hepatitis:

1. Hepatitis B is the most infectious of the three blood-borne viruses: Hepatitis B, hepatitis C and HIV.
2. Absence of jaundice does not rule out acute hepatitis infection, which can present sometimes only with constitutional symptoms such as fever, vomiting, poor appetite, lethargy with high liver enzymes.
3. People at risk for HIV infection are also at risk for Hepatitis B and C infections due to their shared routes of transmission.
4. All people with HIV infection should be tested for hepatitis B and C infections.
5. Progression of liver disease is faster in viral hepatitis.
6. HIV coinfection increases the risk of serious, potentially fatal complications.
7. Hepatitis B can also be transmitted by fomites such as such as finger-stick devices used to obtain blood for glucose measurements, multi-dose medication vials, jet gun injectors, and endoscopes.Hepatitis B virus is 10 times more infectious than hepatitis C virus and 50-100 times more infectious than HIV.
8. The Hepatitis B virus can survive in dried blood for up to 7 days and remains capable of causing infection. This makes hepatitis B a more dangerous infection than HIV.
9. Any blood spills from a person with hepatitis B should be cleaned up with appropriate infection control procedures e.g. wearing gloves, and using an appropriate cleaning product for the surface, such as diluted bleach or detergent and warm water.
10. Any scratch, cut and wound should be cleaned with soap and water and covered with a waterproof dressing or plaster. Expressing fluid by squeezing the wound will not reduce the risk of blood-borne infection.
11. Hepatitis B is preventable; hepatitis B vaccination is recommended for high-risk people or those living with HIV who have tested negative for hepatitis B virus.
12. All unvaccinated persons should be administered hepatitis B vaccine after exposure to blood. If the exposed blood is positive for HBV and the exposed person is unvaccinated, treatment with hepatitis B immunoglobulin is recommended.
13. Hepatitis C virus can survive on environmental surfaces for up to 16 hours. It can also spread from infected fluid splashes to the conjunctiva.

Eschar: A pathognomonic sign of scrub typhus

A painless papule often appears at the site of the infecting mite bite followed by central necrosis, which in turn leads to the formation of a characteristic eschar with a black crust. One or multiple eschars may develop before the onset of systemic symptoms. The frequency of eschars in patients with scrub typhus is highly variable (46-88%). Eschars may be overlooked if a careful clinical exam (including inspection of the genitalia and skin folds under the breast) is not performed.

Missouri court order effect: Drug regulator asks Johnson and Johnson to reveal composition of baby talcum powder

 Central Drug Standard Control Organisation (CDSCO) has asked Johnson & Johnson (J & J) to the share the composition of talcum powder in India. The parent company in US was ordered by Missouri Court to pay $ 4.7 billion as compensation to 22 women who complained that the asbestos fiber in the talcum powder caused them ovarian cancer.

The talcum powder is made of Talc, a clay mineral composed of hydrated magnesium silicate, which uses asbestos fibre (Main ingredient to resist heat).

The lawyers in the US alleged the company knew its talc was contaminated with asbestos (Source: Excerpts from Money control News)

Around the globe

1. There has been great interest in inhibiting sodium-glucose cotransporters (SGLT1 and SGLT2) as a treatment for diabetes. SGLT2 is mainly expressed in the renal tubule and SGLT2 inhibitors can cause glycosuria and thus lower blood glucose. SGLT1 is mainly expressed in the small intestine, and inhibitors for this transporter are being developed that can lower blood glucose peaks.
2. Nearly four million adults in the United States use probiotics or prebiotics products that contain live organisms, according to the National Center for Complementary and Integrative Medicine. The products may be used for a wide range of illnesses, including gastrointestinal conditions, eczema, asthma, infections, weight loss, depression and more.
3. Prescribing hypnotics such as zolpidem (multiple brands), zopiclon (Lunesta, Sunovion), or zaleplon (Sonata, Pfizer) to treat sleep problems in dementia patients significantly increases fracture risk in this vulnerable population, new research shows. These so-called Z drugs were found to increase overall fracture risk by 40% and the risk for hip fracture by 59% (Alzheimers Association International Conference )
4. American Academy of Neurology: People who feel faint, dizzy or lightheaded when standing up may be experiencing a sudden drop in blood pressure called orthostatic hypotension. Now a new study says middle-aged people who experience such a drop may have a greater risk of developing dementia or stroke decades later.
5. PLos: It is well known that glucose levels above or below certain thresholds can cause damage to organs; however, a new study reveals that normal blood glucose levels are often not normal at all; they stray much farther from the healthy ranges than we assumed.
6. Gluten-sensitive people test negative (normal) for celiac disease 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.
7. Mayo Clinic’s new, state of the art, Proton Beam Therapy Facility delivers radiation oncology in a way that promises lower side effects and higher cure rates, often for patients whose cancers cannot be treated safely any other way.
8. The All India Organisation of Chemists and Druggists (AIOCD) has urged Drugs Controller General of India (DCGI) to ensure supply of generic drugs sold at Jan Aushadhi stores to pharmacies which will make generics accessible to patients across the country. 
9. In patients with acute metabolic acidosis, an arterial pH 7.1 to 7.2, and severe acute kidney injury give intravenous sodium bicarbonate therapy, rather than no alkali therapy. Do not give sodium bicarbonate to patients with arterial pH 7.1 or higher if they do not have severe acute kidney injury.
10. In the USA, it is estimated that more than 50 percent of outpatient-prescribed antibiotics are inappropriate, predominantly among patients seeking treatment for acute respiratory infections, which are most often caused by viruses, such as those causing cold and flu. The CDC has stated that to slow the spread of antibiotic-resistant infections the number of inappropriate and unnecessary antibiotic prescriptions in humans and animals must be reduced.

SC slams centre on non-compliance of its order making public institutions disabled-friendly

On 25.07.2018, Hon’ble Supreme Court remarked that Government had to follow the law and order and expressed its annoyance over States not complying with its order. The bench asked Centre to file a fresh affidavit within four weeks giving details of the steps taken so far and the timeline for completing the work as given in its December 15, 2017 verdict. Hon’ble Supreme Court had on December 15, 2017 passed 11 directions which include making the public institutions, transport and educational institutions disabled-friendly. 

Right to dignity, which is ensured in the constitutional set up for every citizen, applies with much more vigour in cases of persons suffering from disability and it was duty of the State and public authorities to lay down proper norms in this regard.

All Government buildings providing any services to public be made fully accessible to differently-abled persons by June 2019 as per provision of Rights of Persons with Disabilities Act, 2016. The same will be applicable to hospitals (Source: PTI).

NGT directs ministry of environment to issue guidelines on violation of environmental norms by educational institutions

NGT Bench headed by NGT Chairperson Justice Adarsh Kumar Goel expressed concern over Air and Noise pollution caused by Schools and other such institutions in contravention to Green Laws and asked the ministry to look into it.

”We consider it appropriate to direct the Secretary, MoEF, to have an interaction by way of video-conferencing or otherwise with the education departments of all the states in association with the pollution control boards concerned or the Central Pollution Control Board to issue appropriate guidelines to take care of the violation of environment norms by different education institutions in the country,” the bench said. The Tribunal directed MoEF to file a Compliance Report by email within eight weeks (Source: Latestlaws.com)

Expert consensus statement calls HIV criminalization unjust

“Expert Consensus Statement on the Science of HIV in the Context of Criminal Law”, a new consensus statement released at the International AIDS Conference in Amsterdam, The Netherlands says that at least 68 countries have laws that specifically criminalize HIV non‐disclosure, exposure or transmission, which worsens the epidemic. The document strongly recommends exercising more caution when considering criminal prosecution; governments and those working in legal and judicial systems should carefully appraise  current scientific evidence on HIV‐related risks and harms to reduce stigma and discrimination and to avoid miscarriages of justice.

Participate in survey on inflammatory bowel disease:  

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Dr KK Aggarwal

Padma Shri Awardee

Vice President CMAAO

President HCFI