Morning MEDtalks with Dr KK Aggarwal 7th October 2018

Dear Colleague

Here are two links for videos to watch. Share them with your colleagues and friends.

1. Vedic Health - A Dialogue with Shri Ashwini Kumar Choubey https://www.youtube.com/watch?v=wdorsM5IZTQ
2. TEDx Video: Doctor-patient relationshiphttps://www.youtube.com/watch?v=i9ml1vKK2DQ

Experts urge Health Ministry to change stance on e-cigarettes (PTI) International experts have called on the Health Ministry to change its stand on electronic cigarettes and legalise safer alternatives to tobacco products available in India.  In a recent advisory, the Health Ministry had asked the states and Union territories to ban the use of Electronic Nicotine Delivery System (ENDS).

ENDS includes e-cigarettes, heat-not-burn devices, vape, e-sheesha, e-nicotine-flavoured hookah and other devices that enable nicotine delivery.  The ministry has adopted a policy on vaping that will harm the health of millions of Indians and protect and entrench smoking, Dr Alex Wodak, former president of the International Harm Reduction Association, said.

“Countries that aim to eradicate tobacco use usually get terrible results. It’s much more effective to try and reduce the initiation and continuing use of tobacco products as well as encouraging less risky options,” Wodak said. Dr Konstantinos Farsalinos, a research fellow at the National School of Public Health, Greece, said nicotine, while addictive, is not particularly harmful.

“E-cigarettes and other vaping products eliminate combustion and provide nicotine in a much cleaner form,” he said. In 2014, Professor Farsalinos and co-author Professor Riccardo Polosa had published a systematic review of the evidence on e-cigarettes.

 “We found they are much safer than cigarette smoking.  The evidence since then has convincingly confirmed this.”  Professor Farsalinos said evidence shows vape products have led millions to quit smoking for good.

“In 2016, I studied the data from the EU and found that vaping had led more than 6 million people to quit smoking and helped millions more cut back.”

Professor David Sweanor, University of Ottawa, said Canada was among the countries that initially tried to ban vaping products but recently switched to actively encouraging smokers to switch based on the science.  “We urge the Indian government to legalize and regulate safer alternatives to the tobacco products currently available in India. E-cigarettes and safer alternatives to India’s high-risk tobacco options should be appropriately regulated,” he said.

Evaluation of out-of-office BP is important for risk stratification in treated patients with normal clinic BP. A systematic review and meta-analysis examining the prognostic value of masked uncontrolled hypertension concluded that the risk of cardiovascular events and all-cause mortality is significantly higher in patients with masked uncontrolled hypertension than in those with controlled hypertension, which was independent of follow-up length and types of studied events. No difference between the prognostic information was observed with masked uncontrolled hypertension detected either by ambulatory BP monitoring (ABPM) or home BP measurement. The meta-analysis involving 30,352 patients included 6 studies using ABPM and 5 using home BP measurement. It suggests that evaluation of out-of-office BP is relevant for risk stratification in treated patients with normal clinic BP (Hypertension, October 2018).

Medical school students in MP to get handwriting classes. Two days after Allahabad High Court fined three doctors Rs. 5,000 each for bad handwriting, Indore’s MGM Medical College announced that it will coach students in handwriting skills, reports TOI. An illegible prescription can lead to confusion and patients may end up with wrong medicines. Also, illegible scrawls often turn into legal disputes in medical insurance claims.

“We are coming up with a training session for students and a seminar session for doctors to improve their writing skills. Handwriting has long been a problem for doctors and it has turned into a social stigma. We want this to end,” said Dr Bindal.

Delhi High Court has issued notice in a petition seeking closure of online pharmacies that are offering drugs and prescription medicines through websites. A single-judge Bench of Justice Vibhu Bakru issued notice to the Central Government, Delhi Government, Central Drug Standard Control Organization and Commissioner of Food & Drugs Administration. The Petition, filed through Advocate Amit Gupta, submits that the sale of drugs and prescription medicines online is illegal and without any mandate of law.

Sale and purchase of drugs is regulated by various legislative enactments and rules, such as the Drugs and Cosmetics Act, 1940, Drugs and Cosmetics Rules, 1945, Pharmacy Act, 1948, Pharmacy Practice Regulations, 2015, Indian Medical Act, 1956, Code of Ethics Regulations, 2002, and Drugs and Magic Remedies (Objectionable Advertisement) Act, 1954. However, “the online pharmacies are not following any of the provisions and are allowed to operate freely”, the petition states. This, the petitioner argues, is in violation of Articles 14, 19 and 21 of the Constitution of India as it results in denial of a level playing field between the online and the offline pharmacies.

The US FDA has approved testosterone enanthate subcutaneous injection for testosterone replacement therapy in men diagnosed with conditions associated with a deficiency or absence of endogenous testosterone. Xyosted, to be available in three dose strengths (50 mg, 75 mg, and 100 mg) is the first FDA-approved subcutaneous testosterone enanthate product for once-weekly self-administration using a disposable autoinjector.

Urologic surgeons at the Cleveland Clinic are the first in the country to successfully perform prostate surgery using a new generation of robot that inserts surgical instruments through a small incision. Surgeons used the Single Port SP Robot from Intuitive Surgical to remove cancerous prostates as well as an enlarged prostate blocking the urinary system through the bladder.

Asiatic lions in Gujarat’s Gir forest dying of Canine Distemper Virus, says ICMR. On Friday, The Indian Council of Medical Research (ICMR) on Friday said that a highly contagious and life-threatening viral infection, which wiped out 30% of the total lion population in East Africa, was responsible for the death of five out of the 23 Asiatic lions in Gujarat’s Gir forest since September 12. In a statement, the apex body in India for the formulation, coordination and promotion of biomedical research, said that it has found that the said five lions were infected by canine distemper virus (CDV). The disease was confirmed after a complete CDV genome test was done by the scientists of ICMR and its main laboratory, National Institute of Virology (NIV) in Pune.

“ICMR-NIV, based in Pune, found CDV responsible for the death of five Asiatic lions in Gir forest... As such for the first time a complete genome of CDV was recovered by NIV. The sequence was compared to available CDV sequences and it was found to be related to the East African strains…” the statement said (HT, Oct. 5, 2018).

 Keto diet may not be safe: Excerpts from Harvard Health Letter (Department of Nutrition at Harvard-affiliated Brigham and Womens Hospital): Low-carb, high-protein diets often grab attention. The Paleo, South Beach, and Atkins all fall into this category. They are also called ketogenic or "keto" diets.  But a true ketogenic diet unlike other low-carb diets (which focus on protein) centers on fat, which supplies as much as 90% of daily calories.

The keto diet is primarily used to help reduce the frequency of epileptic seizures in children.

For weight loss only short-term results are available. We dont know if it works in the long term, nor whether its safe.

The keto diet aims to force your body into using a different type of fuel. Instead of relying on sugar (glucose) that comes from carbohydrates (such as grains, legumes, vegetables, and fruits), the diet relies on ketone bodies (fuel that the liver produces from stored fat).

Burning fat seems like an ideal way to lose pounds. But getting the liver to make ketone bodies is tricky. It requires that you deprive yourself of carbohydrates, fewer than 20 to 50 grams of carbs per day (medium-sized banana has 27 grams of carbs). It typically takes a few days to reach a state of ketosis and eating too much protein can interfere with ketosis.

Because the keto diet has such a high fat requirement, followers must eat fat at each meal. In a daily 2,000-calorie diet, that might look like 165 grams of fat, 40 grams of carbs, and 75 grams of protein.  Some healthy unsaturated fats are allowed on the keto diet — like nuts (almonds, walnuts), seeds, avocados, tofu, and olive oil. But saturated fats from oils (palm, coconut), lard, butter, and cocoa butter are encouraged in high amounts. Protein is part of the keto diet, but it doesnt typically discriminate between lean protein foods and protein sources high in saturated fat such as beef, pork, and bacon.

All fruits are rich in carbs, but you can have certain fruits (usually berries) in small portions. Vegetables (also rich in carbs) are restricted to leafy greens (such as kale, Swiss chard, spinach), cauliflower, broccoli, Brussels sprouts, asparagus, bell peppers, onions, garlic, mushrooms, cucumber, celery, and summer squashes. A cup of chopped broccoli has about six carbs.

Ketogenic diet has numerous risks.

1. It’s high in saturated fat. One is supposed to keep saturated fats to no more than 7% of your daily calories because of the link to heart disease. Keto diet is associated with an increase in "bad" LDL cholesterol, which is also linked to heart disease.
2. If you’re not eating a wide variety of vegetables, fruits, and grains, you may be at risk for deficiencies in micronutrients, including selenium, magnesium, phosphorus, and vitamins B and C.
3. With so much fat to metabolize, the diet could make any existing liver conditions worse.
4. The kidneys help metabolize protein, and the keto diet may overload them. (The current recommended intake for protein averages 46 grams per day for women, and 56 grams for men).
5. The keto diet is low in fibrous foods like grains and legumes. It can lead to constipation.
6. The brain needs sugar from healthy carbohydrates to function. Low-carb diets may cause confusion and irritability.

The popular low-carb diets (such as Atkins or Paleo) modify a true keto diet. But they come with the same risks if you overdo it on fats and proteins and lay off the carbs.

Dr KK Aggarwal

Padma Shri Awardee

President Elect CMAAO

President Heart Care Foundation of India