Morning MEDtalks with Dr KK Aggarwal 5th September 2018

Could more antibiotics be the key to battling antibiotic resistance? Findings from a new research seems to suggest so. Researchers from the University of California discovered around thousands of four- and five-drug combinations of antibiotics that are more effective at killing harmful bacteria, rather than the traditionally used single drug therapy or at most a combination of two drugs.

Working with eight antibiotics, which have six different mechanisms of action, the researchers analyzed how every possible four- and five-drug combination, including many with varying dosages -- a total of 18,278 combinations in all -- worked against pathogenic E. coli. Results published September 3, 2018 in the journal Systems Biology and Applications show that among the four-drug combinations, there were 1,676 groupings that performed better than they expected. Among the five-drug combinations, 6,443 groupings were more effective than expected. Some of the four- and five-drug combinations were effective at least partly because individual medications have different mechanisms for targeting E. coli.

Plasma brain natriuretic peptide (BNP) is a biomarker for screening ischemic cerebral small vessel disease in hypertensive patients. Plasma BNP level has been suggested to be a useful marker for identifying ischemic cerebral small vessel disease (CSVD) in high risk patients with hypertension. A study published in the August 2018 issue of the journal Medicine (Baltimore) involving 346 hypertensive patients, white matter lesions [β = 0.722; 95% confidence interval (95% CI), 0.624-0.819] and lacunar infarcts (β = 0.635; 95% CI, 0.508-0.762) had an independent association with BNL level, even after controlling for vascular risk factors and clinically manifesting cardiac diseases. Compared with each subtype taken alone, combined white matter lesions and lacunar infarcts were more strongly associated with BNP level. With the cutoff value of 106.4 pg/mL, BNP level had a sensitivity, a specificity, and an area under the curve of 95.2%, 64.9%, and 0.799, respectively, for white matter lesions, whereas the values were 143.0 pg/mL, 81.6%, 73.5%, and 0.848, respectively, for lacunar infarcts.

Twelve people have died of leptospirosis disease in Kerala between August 1 and September 3, while 372 confirmed leptospirosis cases have been reported from the flood-hit state since August 1. Following a review meeting at Kozhikode, the district from where the most number of leptospirosis cases have been reported, Kerala Health Minister KK Shailaja announced three weeks of high alert and said, "Kerala would be on high alert for next three weeks but there is nothing to panic. All hospitals are equipped with enough stocks of medicine. Even though there were wide advisories after the flood, people were reluctant to consume precautionary tablets. As more cases have been reported from Kozhikode district, an isolated war-room will be set up in Kozhikode medical college."

US regulators have rejected Sunovion’s application to market dasotraline for the treatment of attention-deficit hyperactivity disorder.

Taking suo moto cognizance of the death of a 23-year-old engineering student at Sion hospital, the Maharashtra State Human Rights Commission has directed the JJ hospital to set up a panel to probe what led to his death. The commission also pulled up doctors for not providing the family his post-mortem examination report for the last three months, while stating that it is “violation of human rights”.

Delhi State Consumer Disputes Redressal Commission fined a Delhi eye centre of Rs 15 lakh for turning a 43-year-old housewife blind in the left who had come to get cataract operation done. It was alleged that no receipt was issued for the charges paid meant for examination prior to operation, fees for nursing home, medicine and post operation care. Also, no mandatory tests were conducted prior to the operation. The hospital in its submission said that Khanna did not disclose about her having stone and urinary infection and could have been sent to a specialist. The commission relied on the observation of the Delhi Medical Council that held the hospital and the doctor guilty of not keeping the records of cataract surgery and working in a non-registered clinic.

US FDA has approved two new oral treatments for adults with HIV-1 infection in adults with no prior antiretroviral treatment history. Pifeltro contains doravirine (100 mg), a new non-nucleoside reverse transcriptase inhibitor to be given in combination with other antiretroviral medicines.  Delstrigo is a once-daily fixed-dose combination of doravirine (100 mg), lamivudine (3TC; 300 mg) and tenofovir disoproxil fumarate (TDF; 300 mg). Both drugs are to be taken once daily with or without food

Nineteen second year medical college students from Madurai Medical College have been suspended for six months after a complaint of ragging against them were proven to be true.

Cracking the whip on errant colleges for admitting students more than the prescribed seats in MBBS courses, the Medical Council India (MCI) has decided to debar all such medical colleges from admitting students for a year. The decision in this regard has been taken by the MCI on the suggestions of the Ministry of Health and Family Welfare, which has been initiated to bring transparency in the admission process in medical colleges.

Think before you prescribe - Avoid concomitant use of fluoroquinolones with corticosteroids as much as possible: Monitor your patient for signs of tendon injury. The use of broad-spectrum fluoroquinolone antibiotics is associated with serious adverse events. A study conducted in 2012 showed the strong association of fluoroquinolones with increased risk of Achilles tendonitis and tendon rupture, especially in those who also used oral glucocorticoids at the same time (Am J Med. 2012;125(12):1228.e23-1228.e28). In a study from Italy, concomitant use of corticosteroids and fluoroquinolones was associated with a threefold increased risk for tendon rupture and a 43-fold greater risk of rupture of Achilles tendon (Drug Saf. 2006;29(10):889-96).

Patient safety is a very important aspect of delivery of health care. Hence, the use of fluoroquinolones with corticosteroid must be avoided as much as possible, especially in the elderly patients with renal insufficiency or other risk factors, due to increased risk of potentially disabling fluoroquinolone-associated tendinitis (Pharmacy Times. April 11, 2016). Patients receiving this combination should be carefully monitored for any sign of tendon injury. Discontinue the drugs as soon as signs are detected and minimize activity until the symptoms resolve.

FDA black box warnings for fluoroquinolone antibiotics: In July 2008, the FDA mandated the first black box warning for fluoroquinolone antibiotics for increased risk of tendinitis and tendon rupture. Since then, other black box warnings have been issued: August 2013 (peripheral neuropathy), May 2016 (restricting use for certain uncomplicated infections), July 2016 (disabling side effects) and the most recent being in July 2018 (hypoglycemia and mental health side effects including disturbances in attention, disorientation, agitation, nervousness, memory impairment and delirium).

“India has fast-tracked many initiatives aimed at achieving all the core tenets of Universal Health Coverage i.e, strengthening health systems, improving access to free medicines & diagnostics and reducing catastrophic healthcare spending” said Shri J P Nadda, Union Minister of Health and Family Welfare at the inauguration of the ‘71st Session of the WHO Regional Committee for South-East Asia, in New Delhi on Sept. 3, 2018. He further stated that India on its part firmly believes in the objective of attainment of the highest possible level of health, where health is a state of complete physical, mental, spiritual and social well-being and not merely the absence of disease or infirmity.

Patient satisfaction after plastic surgery is influenced by surgeon-related factors such as taking the time to answer questions and including patients in decision-making, while practice-related issues like waiting time and office staff have a much weaker effect on patient satisfaction (Plastic and Reconstructive Surgery, September 2018 issue).

Urging that colorectal cancer screening should begin at 45 years of age, a coalition of 22 public health and patient advocacy groups including American Cancer Society (ACS) has submitted a letter to the US Preventive Services Task Force (USPSTF) asking that the task force reconsider its 2016 guidance, in which it recommends that CRC screening begin at age 50 years and continue until age 75 years. This recommendation is scheduled for review in 2021, but the coalition is asking for earlier action (Medscape).

Dietary supplements also can cause side effects and unwanted interactions with other substances, especially in the older adults. Ronan Factora, MD, of Cleveland Clinic’s Center for Geriatric Medicine says, “Too much of some dietary supplements can be harmful,” says Dr. Factora. “Some can interact with prescription drugs or change how the body metabolizes them.” He lists these examples:

• Excess vitamin A may increase risk of osteoporosis.
• Excess vitamin B6 can produce neurological problems, such as imbalance and peripheral neuropathy.
• Garlic, ginger, ginkgo and ginseng can increase the risk of bleeding in people taking blood thinners.
• John’s Wort, which some take for depression, can cause serotonin syndrome if combined with an antidepressant.
• Echinacea, kava, cinnamon and melaleuca may inhibit or accelerate metabolism in the liver, causing statins, anti-seizure medications or others to either be less effective or potentially produce more side effects.

Patients who develop atrial fibrillation (AF) after transcatheter aortic valve replacement (TAVR) are at higher risk of death, stroke and heart attack compared to patients who already had AF prior to the procedure. About 8% of patients undergoing TAVR that did not have pre-existing AF developed new-onset AF after their procedure (JACC: Cardiovascular Interventions, September 3, 2018)

Video to watch: TEDx Talks

Dr KK Aggarwal: Modern day doctor-patient relationship

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

Dr KK AggarwalPadma Shri AwardeeVice President CMAAOPresident HCFI