Issue 164 May 2017megaphone

M o n t h l y N e w s l e t t e r f r o m I n d i a n M e d i c a l A s s o c i a t i o n , C o c h i n B r a n c h

IMA House, J.N. International Stadium Road, Palarivattom P.O., Cochin 682 025 Ph : 9961648800, 92495 78466 Email : imacochin@gmail.com Website : imacochin.org Pr in ted & publ ished by IMA Cochin for c i rcu la t ion among IMA members only . des igned & produced by p ixe l s tud io@0484-2806301

Treasurer Dr. Najeeb K.H. esI Hospital, athani

Chengamanad, ernakulamMob: 94464 78042

najeebhamzadr@gmail.com

seCreTaryDr. Madhu V.

Consultant anaesthesiologistGovt. General Hospital, Cochin - 682 011

Mob: 98471 91057, 94463 91057drmadhuv@gmail.com

PresIdenTDr. M. Narayanan

san Children’s ClinicMamangalam, Cochin - 682 025

Mob : 93886 37109drmn63@gmail.com

FORTHCOMING EVENTS

MONTHLY MEETING24th May 2017 | Wednesday

7.55 pm Meeting called to order8.00 pm Scientific Session TIPS & TRICKS IN THE DIAGNOSIS AND MANAGEMENT OF CHILDHOOD ARTHRITIS Dr. Suma Balan, Consultant Paediatric Rheumatologist & Associate Professor, Dept. of Rheumatology, AIMS, Kochi

9.00 pm Business matters9.10 pm Vote of Thanks9.14 pm National Anthem9.15 pm Dinner

Prof. Dr. Vasantha Nair (Convenor) Dr. Ramesh Shenoy (Co-ordinator)

CCS Meet for May 2017 Date : 25th May, Thursday Venue : Renai Medicity

CCS Meet for June 2017 Date : 8th June, Thursday; Venue : Sunrise Hospital

Co-ordinator : Dr. Rajeev Jaydevan (984710 2221)

23rd June BASIC LIFE SUPPORT to ADVANCED CARDIAC LIFE SUPPORT 25th June Venue : IMA House, Cochin

18th June RADIOLOGY BASICS by KREST & IMA Cochin Venue : IMA House, Cochin

Co-ordinator : Dr. Subramaniam (9847370440)

Valet parking facility

available

Friends,It’s time for IMA Kerala State Branch elections. Since its very inception in 1957, IMA Kerala State Branch has grown to phenomenal heights - in glory and strength. Unfortunately with the rise in strength of IMA, there has also been a rise in adversary events and problems in our day to day practice. We need able leaders to guide us and surmount these problems. Many stalwarts have made their mark in the history of IMA Kerala State and the cream among them made their way to the coveted post of President of IMA Kerala State Branch. Cochin Branch (then known as Ernakulam Branch) was fortunate enough to contribute the founder President in 1957. Since then 58 Presidents from various branches were honoured to guide this Association, of which only two were from Cochin. Sadly after 1977, for the last forty years no one from Cochin Branch was considered for the post of the President of IMA KSB. Not that we lacked able leaders, but we continued to be strong soldiers of IMA.It’s high time for IMA Cochin to stake a claim to have a State President from our own Branch. During the past few weeks our own leaders were searching for the best person to be projected as our candidate. We wanted a fearless fighter with unblemished track record and proven leadership qualities. Our consensus has centered onto our own Past President, Dr. Sunny P. Orathel. His valuable contribution during his stint as Secretary and President of the Cochin Branch, Joint Secretary of the Kerala State Branch. Secretary of the Kerala IMA Pension Scheme and CWC Member of the National IMA speaks volumes of his potential. Dr. Sunny is considered as one of the best State President KGMOA ever had in its history. We are sure that Dr. Sunny is capable of guiding IMA KSB as well, though this era of turbulence to the pinnacle of glory. No election is easy and therefore we have to fight as a great team. To make our dream to have a President from Cochin Branch, we need total support from each one of you. Casting your vote for him alone will not be enough. You have to put your best foot forward to mobilize support from your friends across Kerala. If each one of you can motivate ten of your friends in various parts of Kerala to vote for Dr. Sunny in August 2017, our dream will become a reality. Cochin Branch will have a State President after a long gap of 40 years. We are confident in your power. Please use it to make IMA Cochin really proud. Excel and Enjoy,Jai IMA!!!Dr. M. NarayananPresident, IMA Cochin

IMA Kerala State Branch election is on the wayMake IMA Cochin really proud !!

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COCHIN WIMA ACTIVITIESGeneral Body Meeting was held on Friday 7th April at IMA House. Adv. Leela Mukundan addressed the WIMA members. Next meeting will be held on 9th June 2017.

ActivitiesHealth Talks : Dr. Chitrathara took class at Mulavucaud. Role of fortified complementary feeding and iron deficiency anaemia and the need to deal with it - Talk to paediatricians of Tripunitura by Dr Manju.Social Awareness Programmes : Dr. Manju - Danger signs in neonatal illnesses and its management - Class to nursing staff on 7.4.2017. Dr. Parvathy Vijayakumar - Saturday clinic for house surgeons at GH Ernakulam on HIV AIDS.Important Day observed : Dr. Manjula V.D., on the World Health Day at Government Medical College Ernakulam.Medical Camp : Dr. Nandini - 5th March at Hotel Diana Heights, Ekm; Dr Shreeja Srinivas - Blood sugar check up on womens day at Centre Square Mall for the public.Social Services : Dr. Parvathy Vijaya Kumar visited Uriyampetti Adivasi Colony with Ernakulam Karayogam to distribute provision kits and clothes, wheel chair to a physically disabled child, school bag and accessories to anganvadi children.

Adv. Leela Mukundan addressing WIMA members

Anti corruption meeting by Dr Sundari G.Menon

Dr. Parvathy Vijayakumar - Class on adolescent health at IMA hall, Aluva for adolescent girls by KGMOA

Dr. Gracy Thomas as President of COGS

Cancer awareness class at Vaduthala arranged by EDRAC on 9.4.2017 by Dr. Chitrathara

Dr. Mumtaz Khalid Ismail honoured at Haritham Jeevanam for the initiation and implementation

of free meals for patients through Dietary dept. of General Hospital – 30.4.2017

obituary

Dr. C.P. Nandakumar (former Professor of Cardio Thoracic in Calicut Medical College) expired on 17.4.2017. He is survied by wife Mrs. Hemalatha, and son Sankar Nandakumar.

Dr. K.J.S. Rajiv, Consultant Psychiatrist,

expired on 9.5.2017. He is survied by wife

Dr. Asha J. Mathew, and daughter Shilpa.

April CME : TOPIC 1) Coronary artery disease in the young - Dr. Nigil Cleetus; 2) Role of exercise in the prevention of non communicable diseases - Dr. Paul T. Francis; 3) Diftheria - Dr. Rakesh P.S.

Chief Minister Shri Pinarayi Vijayan being received at IMA House.

On 24th April General Hospital Erankualm observed Black Day protest against attack

on doctors

National Neonatology Forum Ernakulam Branch inauguration. Dr. T.V. Ravi (President),

Dr. Johny V.F. (Secretary) and Dr. Rojo Joy (Treasurer)

Dr. Rajeev Jayadevan mentoring class for school children at CSA hall Angamaly

on 4th April 2017

Dr. Abraham Varghese installed as President of General Practitioners Forum by IMA Cochn President. Secretary

Dr. George Varghese and Treasurer Dr. Mahadevan. Mr. Antony Pulickan inaugurated the GPA activities for

2017-18

World Health Day observed differently - dr. Abraham Varghese with spine Injured Persons Welfare Association, Kottayam.

Get together of children who survived cancer - Organised by Cochin Cancer Society

Dr. Parvathy & team visited Uriyampetti Adivasi colony, distributed provisions and clothes to all

families; school bags and study materials

Dr. Abraham K. Paul at Global Health Meet at Noida, Delhi on 18.04.2017

World Health Day - Inauguration by Hon’ble Mr. Justice Devan Ramachandran; Theme presentation by Dr. M. Chandrasekharan Nair, Consultant Psychiatrist, Nair’s Hospital

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Summary of CCS meeting at VPS Lakeshore Hospital on 6th AprilChair : Dr. Paul Puthuran HOD of Dept. of Medicine Lourdes Hospital KochiA total of 5 cases were presented. The judges were Dr. Vasantha Nair & Dr. Jayakumar of Amrita Hospital Kochi

The first case was presented by Dr. Mohammed Iqbal of Rheumatology Dept. who reminded us that a good clinical history and examination would have prevented an elderly lady`s blindness in a case of temporal arteritis where an immediate institution of steroids would have helped her. The next case was presented by Dr. Cibi Issac of Cardiology Dept. wherein he gave an important take home message of looking for renal artery stenosis in a patient with recurrent pulmonary edema with a normal ECHO and ECG findings.The third case was presented by Dr. E.M. Haris of Ophthalmology Dept. about a tragic story of a young girl who lost her vision in one eye following an unusual complication of a viper bite despite adequate anti venom treatment due to central retinal artery thrombosis with macular infarction. The fourth case was presented by Dr. Krishna Kumar Dept. of Spine where a happy ending of a mistaken diagnosis of disseminated malignancy progressing to paraplegia finally turned out to to be tuberculosis which on surgery and Anti tuberculosis treatment resulted in a full recovery.The final case was presented by Dr. Datson George of Urology Dept. of a foreign national who had undergone a neobladder surgery using an ileal loop followed by development of hydronephrosis and multiple stone formation. He was subjected to 2 surgeries and 3 endoscopic treatments all of which failed following which he came to India. Then using a flexible ureteroscope through an existing PCNL as the ureteric orifice could not be identified all the stones were successfully fragmented by crushing and laser showing that with advent of endoscopes minimally invasive procedures will be the gold standard for treatment. This case was considered the best presentation. - Dr. Jose Francis

Diphtheria Reemerged in ErnakulamAfter a long gap, diphtheria has reemerged in Ernakulam district, even causing death of a 16 year old boy. Diphtheria is a toxic infection caused byCo-ryne bacterium diphtheriae, an exclusive human pathogen, with affinity to mucous membranes and skin, and occasionally by C. ulcerans. It is spread by airborne drop-lets, or direct contact with respiratory/skin exudates. After an average incubation of 3-4 days it produces signs and symp-toms. These are due to the strong toxin it produces, which has far reaching effects on the heart, kidneys, nervous system, in addition to severe local inflammation and necrosis. In and endemic situation, diphtheria gen-erally affects children below 15 years. As more and more children have become protected with Diphtheria toxoid vaccina-tion, the affected segment has shifted up into adolescents and young people mostly. Declining rates of immunization can cause the infection to shift down again into the pediatric age groups also increasingly.

Cardiovascular disease is the leading global cause of death, accounting for 17.3 million deaths per year, a number that is expected to grow to 23.6 million by 2030.Nearly 10% of all patients hospitalized for AMI are <45 year old. Studies report that ACS in young is a disease of men. About 25% of ACS in India occurs under the age group of 40 years and 50% under the age group of 50 years.

Difference of Young Mi from ElderlyYoung patients are more likely to have a histo-ry of smoking and dyslipidemia, but less likely to have other co morbidities such as diabetes mellitus, hypertension, or prior coronary ar-tery disease and have fewer diffuse atheroscle-rotic coronary arteries. Cigarette smoking is uniformly the most com-mon risk factor in young MI, with an incidence ranging from 70% to more than 90%.

Asian Population Vs The Rest of The World

People of Asian Indian origin tend to get MI at a younger age in addition to more complex coronary artery abnormalities. First MI attack occurs in 4.4% of Asian women and 9.7% of men at an age less than 40 years, which is 2- to 3.5- fold higher than in the west European population.

How india Leads the World in Young MiIn the Western population, incidence of CAD in the young is up to 5% as compared to 12 to 16% in Indians.In Great Britain the first AMI among Indians at age less than 40 years is re-ported 10 times higher than local Whites .In Singapore, mortality from CAD below 30 years of age is 10 times higher in Indian than Chinese population of the same age group.Angiographically, Indians have 15 times higher rate of CAD than Chinese and 10 times high-er rate than local Malays below the age of 40 years. The postinfarction course is also worse in Indians as compared to whites.This is re-flected by threetimes higher rate of reinfarc-tion and twotimes higher rate of mortality

Reason for the Rise in Young Mi in indiansThe prevalence of risk factors is on the rise in young adults and children. Smoking, which has been traditionally recognised as the most common risk factor for heart disease, has been shown to be increasingly prevalent in young adults and adolescents. Obesity is a growing concern among young adults and children and it has increased signifi-cantly in the past two decades.

Diagnosis is based on the clinical features, (pseudo-membrane, ‘bull neck , paucity of general symptoms, ) immunization his-tory, culture results, and toxin production studies. Culture of Throat swabs -- Two dry swabs (double swabs) together in one tube (for culture and staining) are to be taken, and sent to the nearest Govt. Medical Col-lege Microbiology lab, or theRegional Pub-lic Health LabA General case is defined as an upper respi-ratory tract illness characterized by sore throat, a low grade fever, and an adherent membrane of the tonsil(s), pharynx, lar-ynx, and/or nose and need to be immedi-ately notified to Public Health authorities (0484373616, 8301880556)Diphtheria antitoxin is available with Dis-trict Medical Office and will be issued to all private hospitals if requested.Crystalline penicillin i.v.1.5 L U/Kg/Day , divided 6 hrly or 500 mg 6 hrly orally /iv x 14 days or oral Erythromycin 40 mg/Kg/day divided 6 hrly, after food x 14 days are the antibiot-ics of choice.Contacts requireErythromycin 40 mg/Kg/

Metabolic syndrome and insulin resistance were found in two thirds of young people with MI in India .

New risk factorsLipoprotein a (Lpa) is now recognised as an independent risk factor for CAD. It is a genetic risk factor. It is not affected by any level of life-style modifications like changes in diet and ex-ercise. Lp a is tentimes more atherogenic than LDL C.Indians worldwide demonstrate a triad of high triglycerides with high LDL C levels and low HDL levels. This triad combined with high levels of lipoprotein (a) constitutes the deadly lipid quartet.Higher levels of ApoB are reported in one third of Indians males. This factor in combina-tion with low levels of HDL and hypertriglyc-eridaemia results in formation of small dense LDL which increases the risk of CAD more than three times.The LDL cholesterol types are described as phenotypes A, B, or C, which are genetically de-termined. Patients with LDL phenotypeB have predominantly small and dense LDL particles which constitute an important risk factor for CAD. A 75% prevalence of phenotypeB is seen in Asian Indians in contrast to 25% in White population.

Hyper homocysteinemiaHomocysteine causes vascular damage by its deleterious effects on endothelial functions and its prothrombotic, prooxidant, and mito-genic effects. The risks are comparable with the cigarette smoking and dyslipidaemias.

infections and CADChlamydia pneumoniaeis considered as an important risk factor for CAD. This is proven because high antibody titres to chlamydia lipo-polysaccharide are found in patients of AMICocaine use among young adults and can result in MI in the younger population.

Angiographic Findings in Young Mi• Increased prevalence of normal coronary

arteries (up to 18%) and minor coronary artery abnormalities were found in the CASS study.

• Single vessel disease was found in 38% of subjects

RevascularisationCoronary angiography is generally performed in most of the patients with MI. The success rate of percutaneous procedures is high in younger

day divided 6 hrly, after food x 10 days and Td vaccine depending on their age and im-munization status. Contacts need to be un-der surveillance for 10 days.Td vaccination Schedules are as follows --1. Infants and children 0 -7 years:- to im-munize as per National immunization Schedule /( catchup with DPT one dose in missed vaccination cases)2. Children 7-10 years:- in immunized, only one dose of Td at 10years; in unimmunized and partially immunized ,three doses at 0, 1 and 6th months recommended3. Children 10-16 years: three doses at 0, 1 and 6th month. The above is recommended initially in con-tacts and schools of the diphtheria cases.4. Adults: for general public, at present only for contacts of cases at 0, 1 and 6th months.5. All health care workers as per defined risk: at 0, 1 and 6th monthsGovernment of Kerala interim guidelines is available in http://arogyakeralam.gov.in/docs/diphtheria/DIPHTHERIA_guideline.pdf

patients approaching 93%.CABG carries a bet-ter success rate in younger patients. Survival rates were found to be 92% at five years and 86% in 10 years respectively in patients less than 40 years,58 compared with 75% and 58% for patients over 65 years old.

PrognosisYoung patients with MI have a more favorable prognosis than older patients.The incidence of cardiogenic shock, stroke, and left ventricular dysfunction is lower in young patients, prob-ably accounting for their better outcome.MI in younger patients does carry a better prognosis if appropriately treated. In contrast with popular belief, mortality in young patients with MI is as high as 30% at 15 year follow up. There is importance of secondary preventive measures in all young patients admit-ted with MI as the long term mortality can reach up to one third if not treated appropriately.

PreventionIt is mandatory to have high index of suspicion of CAD in our population particularly in those who present with atypical symptoms. Evalua-tion of conventional risk factors like hyperten-sion, diabetes mellitus, obesity, dyslipidaemia, and smoking must be done in men from the age of 30years onwards and in women of postmeno-pausal age. Triglycerides, LDLC, and HDLC esti-mations must be a part of routine evaluation. In major hospitals evaluation of newer risk factors, namely Lp(a) ,apolipoproteins, fibrino-gen, hyperhomocysteinaemia, PAII, and hyper-insulinaemia must be done.In asymptomatic individuals with background of coronary risk factors, after the age of 30years, investigations including stress ECG/stress echo/stress thallium must be periodi-cally performed. In subjects with evidence of exercise induced reversible ischaemia, coro-nary angiography must be carried out. In symptomatic individuals mandatory coro-nary angiography must be done to delineate the culprit lesions for timely and appropriate intervention.Between 1965 -1990, CAD mortality had de-creased by 60% in Japan and Finland and by 50% in USA, Canada, France, and Australia. This had been possible by focussing on pub-lic education programmes for modifying the known risk and by targetted treatment of high risk population.Let us hope that this achievement of the devel-oped countries becomes a lesson and an inspi-ration for the physicians and the policy makers in India.

Diphtheria Reemerged in ErnakulamDr. Rakesh P.S., Asst.Professor, Dept. of Community Medicine, AIMS, Kochi

Myocardial Infarction in Young AdultsDr. Nigil Cleetus, Interventional cardiologist, Ernakulam Medical Centre

For SaleUsed Laboratory equipment. Laboratory being shut down.

for details, Please contact :

Dr. Vijaya @ 94471 00577

Groom wanted

An Orthodox Girl from Muvattupuzha (25 yrs), having completed MBBS from

MOSC Medical College, Kolenchery, seeks proposal from suitable boys, preferably of the same profession.

Ph : 9447330288; 0485-2207454

nd thrdDate: 22 , 23 & 24 JUNE 2017

Venue: IMA Cochin, Kaloor

Department of Emergency Medicine, KIMS Cochin

For Registrations Contact: +91 8893148748

KIMS Cochin & IMA Cochin

PRESENTS

Basics Life Support (BLS)&

Advanced Cardiac Life Support (ACLS)2015 Guidelines

IMA Cochin Movie Club

Lion is a 2016 biographical film directed by Garth Davis and written by Luke Davies, based on the non-fiction book ‘A Long Way Home’ by Saroo Brierley with Larry Buttrose. The film stars Dev Patel, Rooney Mara, David Wenham and Nicole Kidman.

The film, which had its world premiere at the Toronto International Film Festival on September 10, 2016, was given a limited release on November 25, 2016, by the Weinstein Company before opening generally on January 6, 2017. It was released in Australia on January 19, 2017 and in the United Kingdom on January 20, 2017.

Regular shows at 8.00 pm on last Friday & Saturday of every month at Home theatre, IMA House       You are invited. No charges

Movie of this Month May 26 & 27 |8.00 pm

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H a r i t h a m J e e v a n a m No Horn Day - 26th April 2017Programme inaugurated by Mr. P. Vijayan IPS, IG Mid Zone at S.N. Fuels, Edappally. IMA Cochin in association with

SCMS Group of Institutions and Young Indians conducted awareness programmes.