Morning MEDtalks with Dr KK Aggarwal 18^th August 2018

AHA advises low-calorie sweeteners may be useful in adults

"On the basis of the available evidence, the [American Heart Association] writing group concluded that, at this time, it is prudent to advise against prolonged consumption of low-calorie sweetened beverages by children,"

"For adults who are habitually high consumers of sugar-sweetened beverages, the AHA writing group concluded that low calorie sweetened beverages may be a useful replacement strategy to reduce intake of sugar-sweetened beverages."

The report was published online July 30 in Circulation and is endorsed by American Diabetes Association (ADA).

An important exception to the recommendation for children is for those with diabetes mellitus. The advisory says that in those who follow a balanced diet and closely monitor their blood glucose, low-calorie beverages may represent a useful substitution in preventing excessive glucose excursions.

The recommendations refer to the six high-intensity sweeteners currently approved by the US Food and Drug Administration (FDA) — saccharin, aspartame, acesulfame-K, sucralose, neotame and advantage — and the two additional high-intensity sweeteners to which the FDA has issued no objection letters — steviol glycosides, obtained from the leaves of the stevia plant (Stevia rebaudiana), and extracts obtained from Siraitia grosvenorii swingle fruit, also known as luo han guo or monk fruit.

Minimal cognitive impairment

There are two kinds of minimal cognitive impairment (MCI). In both, symptoms are not severe, although they can be upsetting and disruptive.

1. Amnestic MCIis memory-specific and is marked by signs like forgetting conversations and misplacing items.
2. Non-amnestic MCIinvolves changes in other brain activities regardless of whether you have memory loss. It may show up as problems with language (you lose your train of thought during a conversation), attention (you have a hard time accomplishing tasks like bill paying), or spatial sense (you cant find your way around a familiar place).

Globally more than 6% of people in their 60s have MCI. The number climbs to more than 37% by age 85. The guidelines published December 27, 2017 in Neurology, note that MCI cases progress to full-blown dementia about 15% of the time among people 65 or older.

Supreme Court:  85% of the principal display area of the packaging of tobacco products should have specified health warnings

The stay on the judgment of the Karnataka High court, which had quashed the Cigarettes and Other Tobacco Products (Packaging and Labelling) Amendment Rules, 2014 (2014 Rules), was made “absolute” by the Honble Supreme Court on 14.08.2018 in the matter titled as Cancer Patient Aids Association versus Union of India, SLP 8786/2018. This would mean that 85% of the principal display area of the packaging of tobacco products’ should have specified health warnings till the matter is decided one way or the other.

A Bench of Chief Justice Dipak Misra and Justice AM Khanwilkar granted leave in appeal against the High Court verdict while ordering that the interim order passed by it “is made absolute”.

The 2014 Rules mandate printing of specified health warnings covering 85% of the principal display area of the products’ packaging.

The Karnataka High Court Bench of Justices BS Patil and BV Nagarathna had struck down the 2014 rules. The said judgment was then challenged in Supreme Court. On January 8 this year, the Supreme Court had stayed the Karnataka High Court verdict while observing that the health of citizens has primacy over business of tobacco companies. In its interim order of January 8, the Court had stated,

“Considering the rivalized submission advanced at the Bar and keeping in view the objects and reasons of the Cigarettes and Other Tobacco Products (Prohibition of Advertisement and Regulation of Trade and Commerce, Production, Supply and Distribution) Act, 2003 and the measures taken by the State, we think it appropriate to direct stay of operation of the judgment and order passed by the High Court of Karnataka…

Though a very structural submission has been advanced by the learned counsel for the respondents that it will affect their business, we have remained unimpressed by the said proponement as we are inclined to think that health of a citizen has primacy and he or she should be aware of that which can affect or deteriorate the condition of health. We may hasten to add that deterioration may be a milder word and, therefore, in all possibility the expression “destruction of health” is apposite.” (Ira Gupta)

Supreme Court: Color stickers should be placed on the windshield of vehicles to give an indication of the nature of fuel being used

In the matter titled as “M. C. Mehta versus Union of India & Others”, Writ Petition No. 13029/1985, the three-Judge Bench of Hon’ble Supreme Court has held that a hologram-based sticker of light blue colour should be used for petrol/CNG vehicles and a hologram-based sticker of orange colour should be used for diesel vehicles.

The Hon’ble Supreme Court has further held that the decision for stickers of light blue colour and orange colour should be implemented in National Capital Region (NCR) by 2^nd October 2018. The relevant portion of the judgment is reproduced hereunder: “It is agreed that a hologram-based sticker of light blue colour should be used for petrol/CNG vehicles and a hologram-based sticker of orange colour should be used for diesel vehicles. Of course, this would be applicable only for the NCR Region. In the meanwhile, the decision for stickers of light blue colour and orange colour should be implemented in the NCR Region by 2nd October 2018 latest.”  (Ira Gupta)

Delhi High Court upholds MCI’s decision on negligence (Source The Hindu)

The Delhi High Court has upheld the decision of the Medical Council of India (MCI) ordering removal of a doctor’s name from the Indian Medical Register for 15 days for negligence during childbirth, which left the mother with permanent paraplegia. Justice Vibhu Bakhru said that the primary duty to identify any complication would rest with the doctor.

The High Court order came on pleas by proprietor of Deepak Nursing Home, Dr Meena Harsinghani who is a gynecologist and obstetrician and her husband Dr Narayan Harsinghani, an anesthetist by profession.

The couple had challenged the MCI’s decision to remove their name for a period of 15 days in Dr Meena’s case and three months in Dr Narayan’s case.

The case stems from a complaint before the Delhi Medical Council (DMC) by a woman, who was admitted to the nursing home for labour pains during her second pregnancy in November 2008. She was under Dr Meena’s care during her prenatal period. After examination, she was informed by Dr Meena that the fetus had passed stool in the uterus and that could be dangerous as the fetus could breathe the stool into his/her lungs.

The pregnant woman was rushed to the operation theatre in emergency. As the anaesthesiologists on the panel of the nursing home were not available, Dr Narayan administered anesthesia in the spine of the woman. 

The woman delivered the baby without any further complications. However, she complained of severe pain in the back. She was examined on the next morning, which was around 14-15 hours after the operation. Subsequently, a consulting neurologist was called in who advised treatment like steroids and physiotherapy and advised an MRI in case of poor response to the steroids. The MRI conducted on the woman found that she had suffered from epidural haematoma. This was a post-spinal anaesthesia complication and had left the complainant with permanent paraplegia.

On the complaint filed by the woman, a disciplinary committee held that the two doctors failed to exercise reasonable degree of skill, knowledge and care, as was expected of an ordinary prudent doctor, in the treatment administered to the woman. It noted that if the complication had been discovered at an earlier stage, the same could have been addressed to a significant extent. It recommended that the names of the couple removed from the State Medical Register for a period of 15 days.

The MCI also stood by the decision of the disciplinary committee, but increased the punishment for Dr Narayan to a period of three months. The High Court upheld the decision of the MCI with respect to Dr Meena, but quashed the portion of the enhancement of punishment in case of Dr Narayan.

Opinion of HCFI Legal Team (Ira Gupta Advocate)

About spinal epidural hematoma

Spinal epidural hematoma (SEH) is an uncommon complication of neuraxial anesthesia. Patients who have received medications affecting hemostasis (e.g., anticoagulant or antiplatelet agents), particularly those having vascular surgery, are at highest risk. Risk is very low in obstetric patients.

Since epidural catheters are often placed just prior to induction of anesthesia, presence of an epidural hematoma may not become apparent until the effects of anesthetics and sedatives have worn off.

The most common presenting symptoms for neurologically significant SEH are progressive motor block, sensory block, or bowel and bladder dysfunction; back pain is a less common presenting complaint.

If an epidural hematoma is suspected, emergent magnetic resonance imaging (MRI) is performed (or CT scan if MRI is contraindicated).

If SEH is detected, urgent consultation with the neurosurgery or orthopedic spine surgery service is necessary for possible decompressive laminectomy since neurologic recovery is more likely if decompression occurs within eight hours of symptom onset (Source: Uptodate.com).

Defence arguments

1. Epidural hematoma is an uncommon complication, but a known complication. The incidence is < 1 in 1.5 lakh in epidural and 1: 2.2 lakh in spinal anesthesia. A known complication is not medical negligence. This can be an error of judgement at most.
2. Neurologic recovery is more likely if decompression occurs within 8 hoursof symptom onset. The emphasis is on the words recovery is “more likely” and not necessarily.
3. If an epidural hematoma is suspected, emergent MRI is performed. Being uncommon, it is often missed in differential diagnosis. In the said case, even the consulting neurologist did not suspect an epidural hematoma on clinical examination and did not advise an “urgent” MRI. The neurologist advised steroids and advised an MRI if there was no response.
4. Since epidural catheters are often placed just prior to induction of anesthesia, the presence of an epidural hematoma may not become apparent until the effects of anesthetics and sedatives have worn off.
5. A survey can be done to find out how many obstetricians would think of this complication in the first few hours. Gynecologists and obstetricians are not expected to diagnose epidural hematoma.
6. Rare complications may not be a part of the informed consent process. In Samira Kohli vs Dr. Prabha Manchanda & Anr. Appeal (civil) 1949 of 2004, date of judgment: 16/01/2008, the Supreme Court of India said, “The consent must be real: that is to say, the patient must have been given sufficient information for her to understand the nature of the operation, its likely effects, and any complications which may arise and which the surgeon in the exercise of his duty to the patient considers she should be made aware of; only then can she reach a proper decision. But the surgeon need not warn the patient of remote risks, any more than an anesthetist need warn the patient that a certain small number of those anaesthetized will suffer cardiac arrest or never recover consciousness. Only where there is a recognized risk, rather than a rare complication, is the surgeon under an obligation to warn the patient of that risk. He is not under a duty to warn the patient of the possible results of hypothetical negligent surgery.”

This view is opposite to that held by the UK Supreme Court in the Montgomery case (Montgomery v Lanarkshire Health Board), which ruled that the doctor has a duty “to ensure that the patient is aware of any material risks involved in any recommended treatment, and of any reasonable alternative or variant treatments.” But, the Montgomery judgement is not applicable in India.

Hoarding to be classified as mental disorder by WHO

Hoarding has been classified as a medical disorder for the first time by WHO. It affects up to 5% of the ­population. Hoarding disorder is characterized by an accumulation of possessions due to excessive acquisition of or difficulty discarding possessions, regardless of their actual value. People perceive a need to save the items and typically experience distress when facing the prospect of discarding things.

The most commonly saved items include newspapers, old clothing, bags, books, and paperwork, but virtually any item can be saved. The nature of items is not limited to worthless possessions, because many individuals acquire and save valuable things too.

Patients who remain resistant to psychosocial interventions, or who lack access to them, can be provided a trial of a serotonin-reuptake inhibiting medication, particularly in patients with comorbid mood or anxiety disorders.

Video to watch: Modern day doctor-patient relationship: TEDx Talk by Dr KK Aggarwal

https://www.youtube.com/watch?v=i9ml1vKK2DQ

Dr KK Aggarwal

Padma Shri Awardee

President HCFI

Vice President CMAAO