Morning MEDtalks with Dr KK Aggarwal 28^th August 2018

Indoor pollution and ventilation (Dr KK Aggarwal and Mr JK Jain): Ventilation is the process of exchanging indoor air with outdoor air to create a comfortable indoor environment for humans. Ventilation-related problems account for as much as 60% of indoor air quality problems.

Complaints related to poor ventilation may be due to high concentrations of indoor pollutants with inadequate air exchange, inadequate distribution of ventilated air and ventilation of polluted outdoor air as primary issues. Improper maintenance of heating, ventilation, and air-conditioning can cause lung symptoms and Legionellosis.

In a meta-analysis of six studies comparing symptoms in workers in mechanically ventilated air-conditioned buildings with workers in naturally ventilated buildings, there was a 2- to 3-fold increase in the prevalence of work-related headaches, lethargy, and upper respiratory/mucous membrane symptoms in those working in mechanically ventilated buildings. These symptoms include lethargy and headache in >50% of workers and breathlessness and chest tightness in about 20%. Other common symptoms included dry or itchy eyes and stuffy or runny nose. There is an association between empirically increased ventilation rates and decreased symptoms, including headaches, respiratory symptoms, nose and throat symptoms, and skin complaints

4 doctors booked under IPC 337 and 338 but where is the grievous hurt? Missing a diagnosis is not grievous hurt. In Pune a baby born with deformity, missed on ultrasound. Patient’s prenatal check-ups were done at Ashwamegh Nursing Home. None of the doctors notified that the baby had a deformity. They instead said that the baby was fine and their reports, too, claimed that the child was fit. When the baby was born on November 4, 2016, the baby was born with deformities in his right leg, left hand and had no passage for urine. The father went to the then commissioner of police Rashmi Shukla.

Section 337 in The Indian Penal Code: Causing hurt by act endangering life or personal safety of others.—Whoever causes hurt to any person by doing any act so rashly or negligently as to endanger human life, or the personal safety of others, shall be punished with imprisonment of either description for a term which may extend to six months, or with fine which may extend to five hundred rupees, or with both.

Section 338 in The Indian Penal Code: Causing grievous hurt by act endangering life or personal safety of others.—Whoever causes grievous hurt to any person by doing any act so rashly or negligently as to endanger human life, or the personal safety of others, shall be punished with impris­onment of either description for a term which may extend to two years, or with fine which may extend to one thousand rupees, or with both.

Stent only in culprit vessel. The early benefit of treating the culprit lesion only in patients with acute myocardial infarction complicated by cardiogenic shock was maintained at 1 year in the CULPRIT-SHOCK trial, although with a surprising uptick in rehospitalizations for congestive heart failure. Compared with immediate multivessel percutaneous coronary intervention (PCI), culprit-lesion-only PCI with the possibility for staged revascularization of nonculprit lesions lowered the risk for the primary composite endpoint of death from any cause or renal replacement therapy by 13% at 1 year (p = 0. 048)

Go for CT angio in cases of stable angina. Adding CT coronary angiography (CTCA) to standard care in patients with stable chest pain significantly reduces mortality rates from coronary heart disease or nonfatal myocardial infarction after 5 years, without increasing coronary intervention rates as per Scottish COmputed Tomography of the HEART Trial (SCOT-HEART) presented at the European Society of Cardiology (ESC) Congress 2018 in Munich, Germany and published simultaneously August 25 in the New England Journal of Medicine. Performing CTCA during diagnostic testing was associated with a 41% reduction in the combined primary endpoint: rates of death from CHD and nonfatal MI.

Study raises question on the role of aspirin in primary prevention. In the Aspirin to Reduce Risk of Initial Vascular Events (ARRIVE) trial, aspirin at a daily dose of 100 mg was not seen to reduce the long-term risk for cardiovascular or cerebrovascular events in a trial that randomly assigned more than 12,000 nondiabetic adults with multiple CV risk factors but no history of CV events. Nor was the risk for stroke reduced. But daily aspirin was associated with more gastrointestinal bleeding. The ARRIVE trial was initiated a decade ago to find out answers to long-standing questions about whether aspirin is cardioprotective in a primary prevention setting, in this case in patients thought to be at moderate CV risk.

How should doctors discuss treatment options with older kidney failure patients? A study appearing in published online July 26, 2018 in the Clinical Journal of the American Society of Nephrology identified 4 different approaches to discussing the option of dialysis vs conservative management for older patients with kidney failure for decision-making: Paternalist, informative (patient-led), interpretive (with doctors as guides steering patients towards an optional treatment) and institutionalist (guided by institutional culture and incentives).

Five themes characterized differences between these approaches regarding how nephrologists prioritized the following:

1. Patient autonomy
2. Patient engagement and deliberation (disclosing all options, presenting options neutrally, eliciting patient values, explicit treatment recommendation,
3. The influence of institutional norm
4. The importance of clinical outcomes (such as survival, dialysis initiation,
5. Role of the physician (educating patients, making decisions, pursuing active therapies, managing symptoms).

Two arteries graft better than one artery and one vein, says ART study. After 10 years of follow-up, outcomes were better in patients receiving two arterial grafts in performing coronary artery bypass graft surgery (CABG) than in those receiving a combination of artery and veins as per Arterial Revascularization Trial (ART) study . In the primary endpoint of the study (10-year mortality), 329 CABG patients who were treated randomized to the single arterial graft died during the study period compared with 315 patients who died who were originally assigned to receive two arterial grafts (HR 0.96, 95% CI 0.82-1.12), reported David Taggart, MD, PhD, of the University of Oxford in the United Kingdom.

Wabi sabi is a captivating concept from Japanese esthetics, which helps us see the world in a whole new way. With roots in Zen and the tea ceremony, wabi sabi serves to remind us that everything in nature is impermanent, imperfect and incomplete, so imperfection is the natural state of all things, including ourselves. That takes the pressure off the need to pursue perfection, and allows us to relax into the experience of our lives just as they are. Wabi sabi also encourages us to recognise the gifts of simple, natural living, and to treasure what we already have. Embracing wabi sabi can bring a sense of calm, presence and beauty into your life and help you find happiness right where you are… (Sydney Morning Herald, August 21, 2018)

Yoga sutras: अविद्याअस्मितारागद्वेषाभिनिवेशः क्लेशाः ॥३॥

1. Avidya: Ignorance
2. Asmita or false identification: Identify our self not with the self
3. Raga: Attachments
4. Dvesha: Aversions
5. Abhivinesha: Fear of loss

Video to watch: TEDx Talk

Dr KK Aggarwal: Modern day doctor-patient relationship

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

Dr KK Aggarwal

Padma Shri Awardee

President HCFI

Vice President CMAAO