Monday 25 April 2016

IMA’s views on how NICD Coolers can help tackle the malaria menace

When Europe can be free of malaria, why can't India? - IMA’s views on how NICD Coolers can help tackle the malaria menace New Delhi, April 25, 2016: Dengue and Chikungunya have become important outbreak prone vector-borne diseases in the country. Outbreaks result in loss of working man-hours, long period disability in patients after initial recovery from diseases like Chikungunya, mortality in patients suffering from dengue hemorrhagic fever, which directly affect the economy of the society. The mosquitoes transmitting these viral diseases are found breeding in domestic/peri-domestic containers including desert coolers. The conventional desert coolers are being used in many parts of the country as cooling devices in houses, offices and industrial establishments during the summer months. They hold water for long period and they have become the potential breeding grounds for dangerous mosquitoes in absence of adequate control efforts. A study carried out in Delhi area revealed that these conventional coolers contribute to more than 50% of the breeding places of dengue vectors. This happens for the following reasons: The water tank of the conventional coolers is open type that attracts mosquitoes for egg laying and results in prolific breeding of Aedes aegypti mosquitoes and transmits dengue/Chikungunya viruses. Weekly larviciding or cleaning is required to prevent breeding of mosquitoes inside the cooler, which is often not practiced. Standing water in the cooler, when not in use, particularly during monsoon season, has high potential for the breeding of dengue vector mosquito and thus increases the risk of disease transmission. In order to overcome the above problems, a mosquito-proof desert cooler (NICD Cooler) has been designed in 2009. The NICD cooler is a patented item and registered with National Research Development Corporation (A DSIR enterprise, Ministry of Science and Technology). Speaking about the same, Dr SS Agarwal – National President IMA & Padma Shri Awardee Dr KK Aggarwal – Honorary Secretary General IMA said, “Eradication of malaria is a key goal of the IMA. Last week, the WHO declared the European region free of malaria with zero cases of malaria reported in the year 2015. When Europe can be free of malaria, why can't we? IMA believes that through concentrated efforts, we can fight the mosquito borne disease responsible for a large number of preventable deaths in our country. Awareness on hygiene and sanitation, disease prevention as well as community management of the disease is key. The development of unique products like the NICD coolers aimed at tackling the malaria menace must be encouraged. Together we must take a pledge to make India a malaria free country.” The NICD cooler has the following advantages over the conventional desert coolers: Water tank of the NICD cooler is completely covered to prevent the entry of mosquitoes in to the water tank for egg laying. There is thus no risk of disease transmission due to coolers. No weekly cleaning of the water tank is required. No chemical larvicide is required to kill mosquito larvae. It can be conveniently installed in high-rise buildings. Even standing water in the cooler, when not in use, has no risk of mosquito breeding.

Loneliness and isolation may increase risk of CHD and stroke

Loneliness and isolation may increase risk of CHD and stroke A review of 23 papers and 181,006 total patients, in April 18 edition of the journal ‘Heart’ has shown a 29% increased risk for incident coronary heart disease (CHD) and 32% increased risk for stroke for people with loneliness and social isolation. Loneliness often contributes to impaired coping methods, isolation affects self-efficacy, and both have been associated with decreased physical activity and increased smoking. The pooled relative risk (RR) for incident CHD was 1.29 for the participants who reported having high loneliness or social isolation scores vs those with low scores (95% confidence interval [CI], 1.0 - 1.6). There were no significant differences between those who reported just loneliness and those who reported just social isolation. The study was funded by the National Institute for Health Research, Research Trainees Coordinating Center.

NICD Cooler to take care of malaria

NICD Cooler to take care of malaria Dengue and Chikungunya have become important outbreak prone vector-borne diseases in the country. Outbreaks result in loss of working man-hours, long period disability in patients after initial recovery from diseases like Chikungunya, mortality in patients suffering from dengue hemorrhagic fever, which directly affect the economy of the society. The mosquitoes transmitting these viral diseases are found breeding in domestic/peri-domestic containers including desert coolers. The conventional desert coolers are being used in many parts of the country as cooling devices in houses, offices and industrial establishments during the summer months. The conventional desert coolers hold water for long period and they have become the potential breeding grounds for dangerous mosquitoes in absence of adequate control efforts. A study carried out in Delhi area revealed that more than 50% of the breeding places of dengue vectors are contributed by these conventional coolers because of the following reasons: • The water tank of the conventional coolers is open type, which attracts mosquitoes for egg laying, which results in prolific breeding of Aedes aegypti mosquitoes and transmit dengue/Chikungunya viruses. • Weekly larviciding or cleaning is required to prevent breeding of mosquitoes inside the cooler, which is often not practiced. • Standing water in the cooler, when not in use, particularly during monsoon season, has high potential for the breeding of dengue vector mosquito and thus increases the risk of disease transmission. In order to overcome the above problems, a mosquito-proof desert cooler (NICD Cooler) has been designed in 2009. The NICD cooler is a patented item and registered with National Research Development Corporation (A DSIR enterprise, Ministry of Science and Technology). The NICD cooler has the following advantages over the conventional desert coolers: • Water tank of the NICD cooler is completely covered to prevent the entry of mosquitoes in to the water tank for egg laying. There is thus no risk of disease transmission due to coolers. • No weekly cleaning of the water tank is required. • No chemical larvicide is required to kill mosquito larvae. • It can be conveniently installed in high rise buildings. • Even standing water in the cooler, when not in use, has no risk of mosquito breeding. Eradication of malaria is a key goal of the WHO. Last week, the WHO declared the European region free of malaria with zero cases of malaria reported in the year 2015. When Europe could be free of malaria, why can't we?

Sunday 24 April 2016

Prevention of water-borne diseases

Prevention of water-borne diseases
New Delhi, April 24, 2016Safe water is essential for  the prevention of most water and food-borne diseases like diarrhoea, typhoid and jaundice. These diseases are 100% preventable. All of them can be life-threatening if not prevented, diagnosed or treated in time. Transmission of parasitic infections can also occur with contaminated water.
Raising awareness about the same, Dr SS Agarwal – National President IMA & Padma Shri Awardee Dr KK Aggarwal – Honorary Secretary General IMA & President HCFI said, “According to a report by the United Nation, over 1 lakh people in India die of water-borne diseases annually. This situation is preventable and the medical fraternity can play a great role in educating the masses about the direct relationship between maintaining water hygiene and health. One of the major reasons for the high disease incidence is that about 70 per cent of water supply in our country is majorly polluted with sewage effluents. It is high-time a joint effort was made to keep our surroundings clean and water uncontaminated.”

A few tips which can help prevent water borne diseases include:

·      Travelers should avoid consuming tap water.
·      Avoid ice made from tap water.
·      Avoid any food rinsed in tap water
·      Chlorination kills most bacterial and viral pathogens.
·      Chlorination does not kill giardia or amoeba cysts
·      Chlorination does not kill Cryptosporidium.
·      Boiled/Treated/Bottled water is safe.
·      Carbonated drinks, wine and drinks made with boiled water are safe.
·      Freezing does not kill organisms that cause diarrhea. Ice in drinks is not safe unless it has been made from adequately boiled or filtered water.
·      Alcohol does not sterilize water or the ice. Mixed drinks may still be contaminated.
·      Hot tea and coffee are the best alternates to boiled water.
·      Bottled drinks should be requested without ice and should be drunk from the bottle with a straw rather than with a glass.
·      Boiling water for 3 minutes followed by cooling to room temperature will kill bacterial parasites.
·      Adding two drops of 5% sodium hydrochloride (bleach) to quarter of water (1 liter) will kill most bacteria in 30 minutes

All you need to know about Asperger Syndrome

All you need to know about Asperger Syndrome New Delhi, April 23, 2016: Asperger syndrome (AS) is an autism spectrum disorder characterized by significant impairments in social interaction, social communication, and restricted patterns of interest in the presence of intact language. The condition has genetic roots. The incidence of the disease has been found to be on a rise globally making awareness generation crucial. Disease estimates across countries range from 1 in every 250 children to 1 in every 10,000. It is four times more likely to occur in males than in females and usually is first diagnosed in children between ages 2 and 6, when communicative and language skills are emerging and settling. The symptoms of Asperger's syndrome vary and can range from mild to severe. Children with Asperger's syndrome generally have difficulty interacting with others and often are awkward in social situations. They generally do not make friends easily and face have difficulty initiating and maintaining conversation. They also often develop odd, repetitive movements, such as hand wringing or finger twisting. A child with Asperger's syndrome may develop rituals that he or she refuses to alter, such as getting dressed in a specific order. They also avoid making eye contact when speaking with someone and have problems understanding language in context and are very literal in their use of language. Speaking about the same, Dr SS Agarwal – National President IMA & Padma Shri Awardee Dr KK Aggarwal – Honorary Secretary General IMA said, “Asperger syndrome is a form of autism. It is a lifelong disability that affects how a person makes sense of the world, processes information and relates to other people. It is often described as a 'spectrum disorder' because the condition affects people in many different ways and to varying degrees. In most cases the condition remains hidden given that it is difficult to diagnose just by looking at a person’s outward appearance. The main issues faced by those suffering from the condition are in social communication, interaction and imagination. With the right support and encouragement, people with Asperger syndrome can lead full and independent lives and must not be judged and discriminated against. In fact those found to be suffering from the condition are also found to be exceptionally talented or skilled in a particular area, such as music or math”. Diagnosis of the disease can be done through various ways. Many individuals with Asperger’s have low muscle tone and dyspraxia, or coordination issues. Although there are no tests for Asperger's syndrome, the doctor may use various tests -- such as X-rays and blood tests -- to determine if there is another issue or physical disorder causing the symptoms. In addition to this, he or she will also base the diagnosis on the child's level of development, speech and behavior, including his or her play and ability to socialize with others. At present, no cure for Asperger's syndrome exists. However therapy is found to help improve functioning and reduce undesirable behaviors. A few ways in which the condition can be managed include: • Special education structured to meet the child's unique educational needs • Behavior modification through strategies for supporting positive behavior and decreasing problem behaviors. • Speech, physical, or occupational therapy designed to increase the child's functional abilities. • Social skills therapies

ACS updates guidelines regarding overlapping surgeries

ACS updates guidelines regarding overlapping surgeries The American College of Surgeons (ACS) has updated its guidelines with regard to the practice of one surgeon performing in two surgeries scheduled at the same time as part of a document ‘Statements on Principles’, revised by ACS April 12. • ACS advises against concurrent or simultaneous surgeries and defines them as those in which "the critical or key components of the procedures for which the primary attending surgeon is responsible are occurring all or in part at the same time." • A primary attending surgeon's involvement in concurrent or simultaneous surgeries on two different patients in two different rooms is not appropriate. But overlapping surgeries are different, and may be appropriate. For instance, if key or critical elements of the first operation are finished, freeing up the primary attending to start an operation in another room while others finish the first operation. • As part of the preoperative discussion, patients should be informed of the different types of qualified medical providers that will participate in their surgery (assistant attending surgeon, fellows, resident and interns, physician assistants, nurse practitioners, etc.) and their respective role explained. If an urgent or emergent situation arises that require the surgeon to leave the operating room unexpectedly, the patient should be subsequently informed. • The guidelines are important in clarifying the differences between concurrent, overlapping, multidisciplinary and sequential operations. • Patients have a right to know these details. Most patients will have few, if any, concerns with overlapping surgeries as long as their surgeon is present for the critical portion of the operation and they are informed, and agree to, the surgeon who will be performing the noncritical portions of their operation. • Surgeons will need to have discussions about what 'critical portion of the operation' means and who might be performing some of the noncritical portions of the operation.

Saturday 23 April 2016

IMA reacts on various reports in media about medicine in India

IMA reacts on various reports in media about medicine in India Of late, there have been unfavorable reports in the media about the status of medicine and healthcare in India. • A story reported April 21, 2016 in the Hindustan Times, ‘Just 4 institutes account for a third of India’s research output’ by Sanchita Sharma, said that India has the best and the worst medical education in the world, according to a review of the world’s largest database of peer-reviewed literature. Four medical colleges in India are among the top 10 global institutions that published the most research between 2004 and 2014, while around 60% of the country’s 579 medical institutions have published no research in a decade. Only 25 (4.3%) institutions published more than 100 papers a year and, among them, accounted for 40.3% of India’s total research output of a little over 100,000 papers in the decade. In comparison, the annual research output of the Massachusetts General Hospital was more than 4,600 and the Mayo Clinic was 3,700. The All India Institute of Medical Sciences, with more than 1,100 annual publications, ranked third. Dr Samiran Nundy, Dean, Ganga Ram Institute For Postgraduate Medical Education & Research (GRIPMER) and the author of the study said, “What’s most shocking is that 332 (57.3%) medical colleges had not a single publication during this period. The states with the largest number of private medical colleges did the worst, with more than 90% of the medical colleges in Karnataka and Kerala having no publication at all.” GRIPMER was ranked 11th in the list of institutions that published the most research. According to the journal Current Medicine Research & Practice, between 2005 and 2014, the total research output in the country was 101,034 papers. All the institutions surveyed were either recognised by the MCI or the National Board of Examinations, the two bodies that regulate medical education in India. The MCI’s 2015 guidelines require at least four research publications for the post of an associate professor and eight for the post of a professor. Dr K Srinath Reddy, president, Public Health Foundation of India said that there is a need to incentivise quality research, which is an “indicator of an institute’s quality of education and clinical care”... • Max Bearak reported in The Washington Post on April 21, 2016 that most medical colleges in India are “very bad”. In his report, “How bad are most of India’s medical schools? Very, according to new reports” he says that though India produces some of the world's best doctors, from reputable institutions in and out of the country and it has 579 medical colleges and teaching hospitals, the highest in the world. However, recent studies have cast serious doubts on the quality and ethics of the country's vast medical schooling system. The most recent revealed that more than half of those 579 did not publish even a single peer-reviewed research paper in more than a decade (2005-2014), and that almost half of all papers were from just 25 of those institutions. Dr Samiran Nundy, a senior GI surgeon in Delhi and author of one such study told The Telegraph that these findings support long-standing suspicions that for many private colleges in the country, medical education is just a business. AIIMS was the most productive medical college in India. In the 10-year period that Samiran Nundy and his colleagues examined, AIIMS published 11,300 research papers. For context, that is about a quarter of what Massachusetts General Hospital produced in the same time frame. A four-month-long probe by Reuters found that since 2010, "at least 69 Indian medical colleges and teaching hospitals have been accused of such transgressions or other significant failings, including rigging entrance exams or accepting bribes to admit students," and that "one out of every six of the country’s 398 medical schools has been accused of cheating, according to Indian government records and court filings." In a country with the world's heaviest health burden, and highest rates of death from treatable diseases like diarrhea, tuberculosis and pneumonia, corruption at medical schools is an extremely pressing issue. The Indian Medical Association estimates that nearly half of those practicing medicine in the country do not have any formal training, but that many of those who claim to be qualified may actually not be. The 2011 court case against a man, Balwant Arora, was one of the earlier indications of the massive levels of fraud. Arora brazenly admitted to issuing more than 50,000 fake medical degrees at around $100 apiece from his home, saying that each of the recipients had "some medical experience" and that he was doing it in service to a country that desperately needs more doctors. He had served four months in jail in 2010 for similar offences. The number of private medical colleges has grown rapidly in India. Now, there are 215 private colleges and 183 public colleges as against 100 public colleges and 11 private in the year 1980. Last January, an article by Jeetha D'Silva in the British Medical Journal reported that many private medical colleges charged "capitation" fees, which are essentially compulsory donations required for admission. “Except for a few who get into premier institutions of their choice purely on merit, many students face Hobson's choice — either pay capitation to secure admission at a college or give up on the dream of a medical degree,” he wrote. The original article titled “The research output from Indian medical institutions between 2005 and 2014” by Samrat Ray, Ishan Shah, Samiran Nundy was published online April 18, 2016 in the journal Current Medical Research & Practice. Background: The research output from Indian medical institutions is generally regarded to be poor but there have been no previous studies to document this especially after the recent proliferation of 263 medical colleges, mainly in the private sector and under the aegis of the National Board of Examinations, as well as the 316, mainly public sector, colleges under the Medical Council of India. Methods: Using the SCOPUS database we analyzed the research output from 579 Indian medical institutions and hospitals between 2005 and 2014, including the contributions of individual states and compared the output of Indian medical institutions with some of the leading academic centers in the world. Results: Only 25 (4.3%) of the institutions produced more than 100 papers a year but their contribution was 40.3% of the country's total research output. 332 (57.3%) of the medical colleges did not have a single publication during this period. The states which had the largest number of private medical colleges fared the worst with more than 90% of the medical colleges in Karnataka and Kerala having no publication at all. In comparison, the annual research output of the Massachusetts General Hospital was 4600 and the Mayo Clinic 3700. Conclusion: The overall research output from Indian medical institutions is poor. This may be because medical education has now become a business and there is little interest in research which is not thought to be a profitable activity. We believe that a drastic overhaul of Indian medical education is necessary similar to that initiated by Flexner in the USA in the beginning of the last century. IMA Views • There has been a systemic attack on the quality of Indian doctors for more than a decade. • Our doctors are best in the world; there is no doubt about it. • We are aware of quacks and IMA is fighting against it. Witch doctors exist all over the world. • Private medical colleges do not mean that medical education is inferior. Most colleges in the US are private. • Fee in US private colleges is far more than any standards of Indian education. • Every PG, whether DNB or MCI based education, cannot clear his/her exam without a thesis. This means that more than 25000 theses are cleared every year. Is this not research? • Unlike in the US, most of these theses stay in the library of the university in print form and do not get translated in Indian Medlar. • There are over 3000 medical associations in the country, where doctors present their data and work done. There is no central registry. That does not mean that doctors are not compiling their data. • Not getting published in Medline, Pubmed, or any other international database does not mean Indian researches are inferior or bad. • West only analyses researches published in international databases. • For example, way back in 1983, my research on leprosy and immunology got never published. • In India, you cannot get promotion without research papers, only these research papers may get noted during compilation. • About 80% of research in the the private sector does not get published. Their research gets limited to presenting in conferences. And these presentations do not get included when compiling these reports. • We should all react to such International reporting, which degrade our doctors. • To augment quality research in postgraduate medical education, the MCI has made it mandatory since 2010 that every postgraduate student registered for the Degree in a medical college under the ambit of MCI permitted / approved / recognized for the said postgraduate course in his / her three years period of study has to present a scientific poster in first year, scientific presentation in second year and research publication out of thesis for the said degree, which is a condition precedence for appearance at the theory, practical, viva-voce examination. • Further, in the year 2015, the medical council has made it mandatory for every medical college to have a ‘Research Cell’ for the purposes of promotion of quality research in the said institution (Dr Vedprakash Mishra, Chairman, Academic Committee, Medical Council of India).

Friday 22 April 2016

Heart Care Foundation of India celebrates World Earth Day 2016


Heart Care Foundation of India celebrates World Earth Day 2016
Hosts inter-school activities for over 200 students jointly with Indian Medical Association, the Ministry of Earth Sciences, Govt. of India and H.M.DAV Sr Sec School Daryaganj

New Delhi, April 22, 2016: Heart Care Foundation of India, a leading national non-profit organization jointly with Indian Medical Association, the Ministry of Earth Sciences, Govt. of India today celebrated World Earth Day. On the occasion, various inter school activities were organised at H.M.DAV Sr. Secondary School, Daryaganj, the co-host school. The theme for this year’s celebrations was “Caring Mother Earth” and students from 20 schools were seen participating in competitions including slogan writing, painting and model display. The underlying message of the event was the importance of preserving one’s environment and its close link with living a healthy life.

Speaking at the event, Dr K K Aggarwal, President, Heart Care Foundation of India and Hon. Secretary General, Indian Medical Association said, “We at Heart Care Foundation of India have been celebrating World Earth Day since almost three decades. This year we have dedicated ourselves to raising awareness about how preserving one’s environment is key to preventing diseases and living a long and healthy life. The 21st century is being faced with environmental emergencies such as global warming, increase in the occurance of natural disasters, changing weather patterns that can have disastrous consequences in the future. It is the duty of every person to live an environment friendly life by saving water and electricity, using solar options where possible and reducing noise pollution. We need to promote good practices such as walking and cycling instead of using cars to move around when possible, using public modes of transport and reducing pollution which is the leading cause of lifestyle diseases in today’s date and age. We are thankful to Ministry of Earth Sciences abd H.M. DAV School for their relentless support and hope that we can together continue to make a difference.”   

Co-host of the event Shri R K Tiwari, Principal, H.M.DAV School, Daryaganj, said, “We are glad to be associated with Heart Care Foundation of India for the event. Children are the future of our country. Considering the serious environmental concerns that the world is facing, it is important to create awareness among them about ways to protect our surrounding. We always believe in propagating futuristic thinking for our students. Today’s activities would make the students think about the various environmental problems and come up with means to tackle them.”

Different competitions for students belonging to middle (6th to 8th) and senior classes (9th to 12th standard) were held. Students from middle classes participated in a painting competition and slogan writing. The young artists displayed imagination at its best and their painitngs will be displayed around the school for others to see and learn. Senior school students designed models, created paintings displaying important save environmental practices as well as wrote catchy slogans. Winners from each category were awarded and participation certificates were handed over to each and every participant.


Salient features of Malaria in India

Salient features of Malaria in India

Dr A.C.Dhariwal: Director,  National Vector Borne Disease Control Program,

Directorate General of Health Services, Ministry of Health & Family Welfare

1. Malaria is endemic throughout India except in areas located 5000 ft above sea level.
2. It is largely prevalent in 16 states of India including 7 North-Eastern states. These are Odisha, Jharkhand, Chhattisgarh, Madhya Pradesh, Assam, Tripura, Arunachal Pradesh, Manipur, Meghalaya, Mizoram, Nagaland, Andhra Pradesh, Gujarat, Maharashtra, West Bengal and Karnataka.
3. Intensity of transmission varies from area to area. The areas having conducive geo-ecological and climatic conditions, inaccessible terrains, poor infrastructure, lack of health seeking behavior, poor availability of health services and high vector load have high disease burden and high mortality rates.
4. The districts which have predominant tribal population are the most affected due to poor availability of health services & lack of health seeking behavior.
5. Main plasmodium species causing malaria in India are P.vivax and P.falciparum, each responsible for 50% of the cases in the country.
6. Malaria incidence has been brought down from 2 million cases annually during the last decade to around 1 million cases annually during the beginning of current decade   and it has been contained at that level for the last 3 years. Similarly annual deaths due to malaria have also declined during this period.
7. 152 Districts have been identified as high endemic.
8. During the year 2014, there was an increase in total cases and deaths due to Malaria as compared to the year 2013. A total of 11 States/ UTs reported case rise in 2014 as compared to the previous year. The major states which reported increased malaria include- Odisha, Madhya Pradesh, Chhattisgarh, Maharashtra, Andhra Pradesh, Tripura, Meghalaya and Mizoram.
9. Some of the main reasons identified for this upsurge are increased surveillance since the introduction of Bivalent Rapid Diagnostic Test (RDT) in 2013 and focal outbreaks such as in the states of Tripura, Madhya Pradesh, Maharashtra, and Meghalaya.
10. With the ultimate goal of bringing down malaria incidence to the level that it is no more a public health problem, National Vector Borne Disease Control Programme is taking intensive malaria control measures.
11. To achieve effective control of malaria, the programme aims at early case detection through active, passive and sentinel surveillance and prompt & complete treatment of all the detected cases.
12. As per National Drug Policy for Treatment of Malaria- 2013, all fever cases suspected of malaria are to be investigated by microscopy or Rapid Diagnostic Test (RDT) for malaria.
13. Although microscopy is the Gold standard test for malaria but in remote, inaccessible areas, during malaria epidemic, for travelers and military forces bivalent RDTs are being recommended and used to detect malaria.
14. NVBDCP recommends only Antigen-based Bivalent RDTs  (Pf and Pv.) for diagnosis of malaria.
15. As per the National Drug Policy (2013), P.vivax cases are to be treated with chloroquine for three days and Primaquine for 14 days.
16. As per the National Drug Policy (2013), P. falciparum cases are to be treated with Artemisinin Combination Therapy (ACT) i.e Artesunate 3 days + Sulphadoxine-Pyrimethamine 1 day and single dose Primaquine on day 2.
17. However, in NE states all Pf cases are to be treated with ACT-AL (Artemether-Lumefantrine combination) + Primaquine on day 2.
18. All severe cases should be treated with injection Artesunate followed by complete oral ACT course i.e of three days.
19. The referral services are being strengthened for the management of severe cases. The referral mechanism under NHM is being used for referring cases.
20. Special measures are being taken for epidemic preparedness and rapid response, through co-ordination with IDSP.
21. To reduce the risk of Transmission, Integrated Vector Management is being done through Indoor Residual Spraying  (IRS) in selected high risk areas with API>2 (-~80 million pop./annually), Use of Long Lasting Insecticidal Nets (LLINs) and use of larvivorous fish and source reduction.
22. Other important Supporting Interventions of the program include Behaviour Change Communication/ Information, Education & Communication (BCC/IEC), capacity building and Inter-sectoral collaboration and NGO or Public Private Partnerships.
23. In urban areas > 60% of the population seeks health services from private sector and other public undertaking and organized sectors. Their involvement in the programme is of paramount importance.
24. To ensure timely action, actual disease burden, reporting from all the sectors needs to be captured and monitored.
25. Any confirmed malaria case not responding to treatment within 72hrs. may be suspected for resistance. Such cases should be given alternative anti-malarials and should be reported to the programme for detailed investigation.

Top health stories of 2015: Revisiting the year 2015

REVISITING THE YEAR 2015

Dr K K Aggarwal

Medicine is a rapidly changing field with many new researches and breakthroughs coming up every day, which shape day to day practice. The year 2015 too saw several advances in medicine and release of new and/or updated guidelines. Here is a quick snapshot of some researches that made the headlines in the year gone by. This by no means is a complete list. Our readers are welcome to add to this list…

  • The landmark SPRINT or Systolic Blood Pressure Intervention Trial showed that a more intensive strategy of managing BP reduces the risk for death and cardiovascular events when compared with a strategy that lowers systolic blood pressure to the conventional target of 140 mm Hg. Treating high-risk hypertensive adults aged 50 years and older to a target of 120 mm Hg significantly reduced cardiovascular events by 30% and all-cause mortality by nearly 25%. The study funded by the National Institutes of Health (NIH) was stopped early because of the benefit of the intensive strategy.
  • The FDA approved two new lipid lowering drugs, human monoclonal antibody PCSK9 (proprotein convertase subtilisin/kexin type 9) inhibitors - alirocumab and evolocumab - for patients with familial hypercholesterolemia (FH) and for patients at high or very high risk for CV events who are unable to reach LDL targets despite maximally tolerated statin therapy.
  • The EMPA-REG OUTCOME study, a cardiovascular-outcomes trial, for the first time, showed superiority of the diabetic drug empagliflozin (Jardiance), sodium glucose cotransporter-2 (SGLT-2) inhibitor in reducing the rate of cardiovascular death, nonfatal MI, and nonfatal stroke among individuals with type 2 diabetes and established cardiovascular disease with 38% reduction in CV death and 32% reduction in all-cause mortality.
  • The US Food and Drug Administration (FDA) approved the combination tablet valsartan/sacubitril (Entresto, Novartis) for the treatment of patients with heart failure. It is the first approved agent in the angiotensin receptor-neprilysin inhibitor (ARNI) class and exerts its effect within and beyond the renin-angiotensin system. Besides reducing heart failure deaths, Entresto also reduces heart failure hospitalizations.
  • A head-to-head comparison of the everolimus-eluting stent with a bioresorbable scaffold (Absorb, Abbott Vascular) against a conventional everolimus-eluting cobalt-chromium stent (Xience, Abbot Vascular) in the ABSORB III trial, the two devices yielded similar rates of target lesion failure (TLF) at 1 year; 7.8% vs 6.1%, respectively. TLF is a composite end point that included cardiac death, target vessel MI, or ischemia-driven target lesion revascularization.
  • novel oral anticoagulant (NOAC) reversal agent received FDA approval this year. The dabigatran reversal agent idarucizumab (Praxbind, Boehringer Ingelheim) is the first reversal agent approved specifically for dabigatran (Pradaxa Boehringer Ingelheim). In November, the New England Journal of Medicine published results of the factor Xa reversal agent andexanet alfa, which safely reversed the anticoagulant effect of apixaban and rivaroxaban in older volunteers.
·         The Institute of Medicine (IOM) gave a new name to chronic fatigue syndrome, systemic exertion intolerance disease or SEID, highlighting the role of exertion in aggravating the symptoms. IOM also defined clear and simpler diagnostic criteria for SEID
o   A substantial reduction or impairment in the ability to engage in pre-illness levels of occupational, educational, social, or personal activities, that persists for > 6 months and is accompanied by fatigue, which is often profound, is of new or definite onset (not lifelong), is not the result of ongoing excessive exertion, and is not substantially alleviated by rest
o   Post-exertional malaise
o   Unrefreshing sleep
Plus, at least one of the following: Cognitive impairment or orthostatic intolerance
  • The FDA announced a new policy for blood donations by gay men overturning a lifetime ban that dates to 1983. It allows gay men to donate blood and excludes only those whose last sexual contact with another man occurred in the 12 months prior to donation. But, the ban remains in place for commercial sex workers and people who use injection drugs. People with hemophilia or related clotting disorders are also still barred from donating blood for their own protection due to potential harm from large needles used during the donation process.
  • The American Cancer Society (ACS) updated its breast cancer screening guidelines for women at average risk of developing the disease. ACS now recommends that women should start annual screening with mammography at age 45, not 40 as recommended earlier. At age 55, women can transition to screening every 2 years instead of annually. 
  • An update of the American College of Obstetricians and Gynecologists (ACOG) cervical cancer screening guidelines recommends that women aged between 30 and 65 years and at "average risk" for cervical cancer should be co-tested with cytology and HPV testing every 5 years, or screening with cytology every 3 years. It does not recommend HPV co-testing for women younger than 30 years.
  • Dirty endoscopes, particularly duodenoscopes used in endoscopic retrograde cholangiopancreatography topped the list of health technology hazards in ECRI Institute's Top 10 list for 2016. Poorly cleaned flexible endoscopes prior to disinfection can increase the risk of transmitting infections.  Outbreaks of multidrug resistant bacteria have been linked to duodenoscopes despite following proper reprocessing instructions.
  • The WHO issued “Early Release Guideline” on when to start antiretroviral therapy and on pre-exposure prophylaxis (PrEP) for HIV. The two major recommendations are: Initiation of antiretroviral therapy (ART) in adults with HIV irrespective CD4 cell count, use of daily oral pre-exposure prophylaxis (PrEP) as a prevention option for people at substantial risk of acquiring HIV infection. The comprehensive guidelines are expected to be released in 2016.
  • Immunotherapy has been identified as the game changer for oncology with studies demonstrating cancers like non-small cell lung cancer (NSCLC), breast cancer, multiple myeloma responding to immune checkpoint inhibitors. Earlier in the year, FDA approved Opdivo (nivolumab) to treat patients with advanced squamous NSCLC whose disease progressed during or after platinum-based chemotherapy. In October, FDA expanded the use of Opdivo to also treat patients with non-squamous NSCLC. 
  • The FDA approved new formulations for delivering carbidopa/levodopa for patients with Parkinson’s disease. Rytary is an extended-release capsule formulation of carbidopa-levodopa for the for the treatment of Parkinson's disease (PD), postencephalitic parkinsonism and parkinsonism that may follow carbon monoxide intoxication or manganese intoxication. Duopa, enteral suspension for the treatment of motor fluctuations for people with advanced Parkinson's disease and is administered using a small, portable infusion pump that delivers carbidopa and levodopa directly into the small intestine for 16 continuous hours via a percutaneous endoscopic gastrostomy procedure with jejunal extension.
  • The American Heart Association (AHA) new guidelines for Cardiopulmonary Resuscitation (CPR) and Emergency Cardiovascular Care (ECC)emphasize on quick action, proper training, use of technology and more teamwork - from bystanders to dispatchers, emergency responders to healthcare providers - to increase survival from cardiac arrest. The new compression rate is 100–120 a minute, while earlier it was “at least 100.” The new compression depth is 2–2.4 inches for adults and adolescents; it had been “at least 2 inches.
  • The WHO report classifying red meat and processed meat as carcinogenic created controversy and panic. The International Agency for Research on Cancer (IARC), the cancer research agency of WHO classified the consumption of red meat as ‘probably carcinogenic’ to humans and processed meat as ‘carcinogenic’ to humans. Eating 50 gm portion of processed meat daily increases the risk of colorectal cancer by 18%. However, the WHO later tried to ease the panic by emphasizing that the findings only confirmed recommendations made back in 2002, which advised people to reduce their consumption of these products to reduce the risk of cancer.
  • The American Academy of Pediatrics (AAP) endorsed a recommendation for early introduction of peanut-containing foods in to the diets of infants at high risk of peanut allergies. This current consensus statement from 10 medical organizations in Europe and the United States is based on findings of the Learning Early about Peanut Allergy (LEAP) randomized trial, which found that the early introduction of peanuts into the diet of high-risk infants lowered their likelihood of being allergic to them.
  • Ocrelizumab, a second-generation monoclonal antibody targeting B-cells has been a major advance in multiple sclerosis. Although not available for marketing, it has shown encouraging results in clinical trials (OPERA I and II, ORATORIO) for both relapsing-remitting and primary progressive multiple sclerosis.
  • Many other guidelines have been released: pediatric pulmonary HT (AHA/ATS), pediatric perioperative anesthesia (AAP), thyroid nodule diagnosis & management (ATA), polymyalgia rheumatic (EULAR/ACR), rheumatoid arthritis (ACR)

ACP calls upon physicians to combat health problems associated with climate change

ACP calls upon physicians to combat health problems associated with climate change

The changing climate is one of the most important environmental concerns today. Climate change directly affects five components of the environment: water, air, weather, oceans, and ecosystems And, through changes in the environment such as heat waves, droughts, storms, worsening air quality, floods etc. it also adversely affects human health.

With rise in temperatures, vector-borne diseases such as dengue are increasing in number making them more difficult and challenging to control. What is more, climate change may potentially spread the disease to areas that are currently not endemic for the disease.

The relationship between climate and human health has for long been a much studied topic. A report published in April 2010 by National Institute of Environmental Health Science, USA “A Human Health Perspective on Climate Change a Report Outlining the Research Needs on the Human Health Effects of Climate Change” categorized health consequences of climate change into:

·           Asthma, respiratory allergies, and airway diseases
·           Cancer
·           Cardiovascular disease and Stroke
·           Foodborne diseases and nutrition
·           Heat-related morbidity and mortality
·           Human developmental effects
·           Mental health and stress-related disorders
·           Neurological diseases and disorders
·           Vectorborne and zoonotic diseases
·           Waterborne diseases
·           Weather-related morbidity and mortality

In a position paper published online April 19 in the Annals of Internal Medicine, the American College of Physicians (ACP) has focused on the consequences of climate change on human health including more respiratory and heat-related illness, vector-borne diseases, waterborne diseases, food and water insecurity, malnutrition, behavioral health problems.

ACP has called for urgent "aggressive, concerted" action to fight climate change to counter the “devastating” health consequences.

The position paper emphasizes the crucial role that physicians can play in tackling them by educating themselves, their patients, community, policy makers about the adverse health effects of climate change and also support efforts to alleviate them. The ACP also recommends that medical schools and continuing medical education (CME) providers include climate change-related coursework in their syllabus.

Thursday 21 April 2016

Indian Medical Association asks its members to welcome the girl child

Indian Medical Association asks its members to welcome the girl child

Given the skewed sex ratio in our country and the high rate of female feticide and infanticide, the Indian Medical Association has launched a flagship program called Welcome the Girl Child and also asked its 2.5 lakh members across 1700 branches to come out and support it.

Speaking about the same, Dr SS Agarwal – National President IMA & Padma Shri Awardee Dr KK Aggarwal said, “All men and women have an equal right to life and health. It is disheartening to see that the age-old discrimination against women continues to exist in our country. It is for this reason; that we have launched this flagship campaign aimed at educating our members on how to counsel parents, help support girl children and in-turn save lives.”

According to the circular issued by IMA, a few ways in which its members can help girl children include: 
•    Support a Girl Child (0-18 years) by announcing a scholarship of Rs.500/- per month for her educational / skill development activities.
•    Support her with a fixed deposit of Rs. 1.5 lakhs in a bank and deposit its interest to the Girl Child’s bank account till she becomes 18. After that you can get your money back.
•    Organize a skill development programme for her, which should help her in income generation in future. You can choose any of the 64 arts, which every women should learn.
•    Support a Girl Child for free heart surgery, if the parents cannot afford. You can refer to headquarters for help.
•    Adopt a Girl’s Schools and give health lectures and conduct health check-up camps.
•    Distribute Iron Frolic Supplement to the Girl Child in schools.
•    Create awareness about the Child Sexual Abuse Sutras to Girl Child. “Sexual violence against children, a crime, is common, preventable, whether evident or suspected, is a punishable acute medicolegal emergency
•    Waive off your consultancy fee on birth of Girl Child.
•    Identify a Girl Child who is sick and cannot afford treatment and help her in getting the treatment.
•    Participate in Campaign 950: to bring the child sex ratio of 950 girls to 1000 boys
•    Kindly expose black sheep in the medical fraternity who are indulging in female feticide.
•    The Slogan of IMA is that ‘No Girl Child should die in the country’.

Wednesday 20 April 2016

Welcome the girl child

Welcome the Girl Child

Dear Colleague,

Welcome the Girl Child is a Flagship Programme of IMA.  Kindly promote it as much as possible by any of the followings. The girl is defined till the age of 18.

·         Support a Girl Child (0-18 years) by announcing a scholarship of Rs.500/- per month for her educational / skill development activities.
·          Support her with a fixed deposit of Rs. 1.5 lakhs in a bank and deposit its interest to the Girl Child’s bank account till she becomes 18. After that you can get your money back.
·          Organize a skill development programme for her which should help her in income generation in future. You can choose any of the 64 arts which every women should learn.
·          Support a Girl Child for free heart surgery, if the parents cannot afford. You can refer to headquarters for help.
·          Adopt a Girl’s Schools and give health lectures and conduct health check-up camps.
·          Distribute Iron Frolic Supplement to the Girl Child in schools.
·          Create awareness about the Child Sexual Abuse Sutras to Girl Child. “Sexual      violence against children, a crime, is common, preventable, whether evident or suspected, is punishable acute medico legal emergency
·          Waive off your consultancy fee on birth of Girl Child.
·          Identify a Girl Child who is sick and cannot afford treatment and help her in getting the treatment.
·          Participate in campaign 950: to bring the child sex ration of 950 girls to 1000 boys
·          Kindly expose black sheep in the medical fraternity who are indulging in female foeticide.
·          The Slogan of IMA is that no Girl Child should die in the country.


Dr SS Agarwal and Dr KK Aggarwal

Arm Pit test

Arm Pit test With the temperature rising, cases of heat cramp, heat exhaustion and heat stroke are expected. This trend will continue in coming months with the rise in heat index, though the overall temperature of the environment may be low but the humidity will be high. It is the heat index, which decides occurrence of heat exhaustion and heat stroke. With high humidity, the heat index may be much higher in the presence of relatively low environmental temperature. One should differentiate between heat cramps, heat exhaustion and heat stroke. In heat stroke, the internal temperature may be very high and may not respond to injectable or oral paracetamol. In such cases, the temperature of the body needs to be lowered over minutes and not hours. Clinically, both heat exhaustion and heat stoke may have fever, dehydration and similar symptoms. The main difference will be abnormal “arm pit test”. Normally, axillae will always be wet even if a person has severe dehydration. If the axillae are dry and the person has high fever, this invariably means that the person has progressed from heat exhaustion to heat stroke. Such a situation should be treated as a medical emergency.

Tuesday 19 April 2016

Preventing Fatty Liver Disease

A World Liver Day awareness initiative

Preventing Fatty Liver Disease

Fatty liver, or steatosis, is a term that describes the buildup of fat in the liver. While it’s normal to have some fat in your liver, more than 5 to 10 percent of fat in one’s liver indicates fatty liver disease. Fatty liver disease is found in up to 30% of population, up to 60% in patients who are at risk for heart disease and in up to 90% of obese persons. Fatty liver is a reversible condition that can be resolved with changed behaviors. It often has no symptoms and typically does not cause permanent damage.

The liver is the second largest organ in the body. The liver’s function is to process everything we eat or drink and filter any harmful substances from the blood. This process is interrupted if too much fat is in the liver. The liver commonly repairs itself by rebuilding new liver cells when the old ones are damaged. When there’s repeated damage to the liver, permanent scarring takes place. This is called cirrhosis.
The most common cause of fatty liver is alcoholism and heavy drinking. Besides alcoholism, other common causes of fatty liver include obesity, hyperlipidemia, or high levels of fats in the blood of diabetes, genetic inheritance, rapid weight loss and side effect of certain medications, including aspirin, steroids, tamoxifen, and tetracycline.

There are different types of fatty liver disease, non-alcoholic fatty liver disease (NAFDL) caused when the liver has difficulty breaking down fats, which causes a buildup in the liver tissue. Alcoholic fatty liver is the earliest stage of alcohol-related liver disease.  NAFLD is subdivided into: Nonalcoholic fatty liver (NAFL) or simple fatty liver with no liver inflammation and Nonalcoholic steatohepatitis (NASH) or fatty liver with liver inflammation. A rare but life-threarning condition, fatty liver disease can also develop as a complication of pregnancy in a few women.
Speaking about the same, Dr SS Agarwal – National President IMA & Padma Shri Awardee Dr KK Aggarwal – Honorary Secretary General IMA in a joint statement said, “Fatty liver can develop within hours after a single large binge. Binge alcohol means consuming 150 ml in one hour or more than 160 ml inn one day. Many drugs, NSAIDs, paracetamol, anti-diabetics, anti-epileptic drugs, Anti TB drugs can also raise liver enzymes and so can several herbs. Preventive health awareness must be raised to avoid future complications. Lifestyle modifications are key.”

If your liver is inflamed, your doctor can detect it by examining your abdomen. Ultrasounds, blood tests and a liver biopsy are other tests which are often required to diagnose the condition.

There aren’t any specific medications or surgery to treat fatty liver. Instead, lifestyle modifications are recommended in most cases including limiting or avoiding the consumption of alcoholic beverages, managing one’s cholesterol, weight management and controlling diabetes.

Liver Messages for use on World Liver Day

Today is world liver day: Liver Messages for use

Dr K K Aggarwal


  1. Many drugs, NSAIDs, paracetamol, anti-diabetics, anti-epileptic drugs, Anti TB drugs can raise liver enzymes.
  2. Many herbs can also raise liver enzymes.
  3. SGOT/SGPT > 2 suggests alcoholic liver disease [[Cohen, JA, Kaplan, MM. The SGOT/SGPT ratio — an indicator of alcoholic liver disease. Dig Dis Sci 1979; 24:835.]
  4.  SGOT can be more than SGPT in NASH, hepatitis C Cirrhosis, Dengue, acute muscle injury, H1N1 flu, Wilson’s disease.
  5. 2 fold rise of Gama GT with SGOT/SGPT 2:1 unless proved otherwise is alcoholic liver disease. [Moussavian, SN, Becker, RC, Piepmeyer, JL, et al. Serum gamma-glutamyl transpeptidase and chronic alcoholism. Influence of alcohol ingestion and liver disease. Dig Dis Sci 1985; 30:211.]
  6. In Alcoholic Hepatitis SGOT is never more than 8 fold elevated. {uptodate: http://www.uptodate.com/online/content/topic.do?topicKey=hep_dis/14684&selectedTitle=3%7E150&source=search_result} “It is rare for the SGOT/ AST to be greater than eightfold elevated and even less common for the SGPT /ALT to be greater than fivefold elevated. The ALT may even be normal even in patients with severe alcoholic liver disease.”

  7. Positive HBsAg and core antibody means chronic infection. Go for e-antigen, e-antibody, and Hepatitis B DNA test.
  8. Positive HBsAg & surface antibodies means immunity to Hepatitis B.
  9. Positive HBV DNA & positive e antigen indicates viral replication.
  10. Positive HBsAg & negative HBV DNA & negative e-antigen suggests carrier state.
  11. Serum Fe /TIBC > 45%, ferritin of > 400 mg/ml in man (300 in women) suggest hereditary hemochorotosis.
  12. Immediately after muscle injury, SGOT, SGPT may rise with SGOT/SGPT ratio of more than 3.  
  13. In muscle injury CPK & LDH rises in proportion with rise in SGOT and SGPT.
  14. SGOT & SGPT may be high in thyroid disorders.
  15. Auto-immune Hepatitis will always have hyper gama globulimia.
  16. Persistently high SGOT & SGPT more than two times normal require liver biopsy. http://www.uptodate.com/online/content/topic.do?topicKey=hep_dis/14684&selectedTitle=3%7E150&source=search_result

  17. Over 2-fold polyclonal elevation of immunuglobin suggest auto-immune Hepatitis.
  18. An elevated Gama GT with otherwise normal liver test should not warrant further liver workup.  [http://www.uptodate.com/online/content/topic.do?topicKey=hep_dis/14684&selectedTitle=3%7E150&source=search_result
  19.  Gama GT may be high in patients taking anti-epileptic drugs.
  20. Approximately 70 to 80 percent of patients with hepatic encephalopathy improve after correction of precipitating factors.
  21. Minimal hepatic encephalopathy can alone be treated with lactulose.
  22. Zinc deficiency is common in patients with cirrhosis and in those with hepatic encephalopathy
  23. hypokalemia increases renal ammonia production
  24. Cleansing of the colon is a rapid and effective method to remove ammoniagenic substrates.
  25. There is no good clinical evidence supporting protein restriction in patients with acute hepatic encephalopathy.
  26. Ammonia is the best characterized neurotoxin that precipitates hepatic encephalopathy.
  27. Only 50 percent of patients with variceal hemorrhage stop bleeding spontaneously.
  28. There is more than 90% spontaneous bleeding cessation rate in patients with other forms of upper gastrointestinal hemorrhage.
  29. In variceal bleed, after active bleeding stops, there is a high risk of recurrent bleed for the next 6 weeks.
  30. The greatest risk or variceal re-bleed is within the first 48 to 72 hours
  31. Over 50 percent of all early variceal re-bleeding episodes occur within the first 10 days.
  32.  Bacterial infections are present in up to 20 percent of patients with cirrhosis who are hospitalized with gastrointestinal bleeding; up to an additional 50 percent develop an infection while hospitalized.
  33. Short-term (maximum 7 days) antibiotic prophylaxis should be instituted in any patient with cirrhosis and GI hemorrhage.
  34. Elective surgery is contraindicated in patients with histologic evidence of alcoholic hepatitis.
  35.  The MELD score is a statistical model predicting survival in patients with cirrhosis.
  36. Anesthesia mortality in cirrhosis at 30 days range from 6 percent (MELD score, <8) to more than 50 percent (MELD score, >20).
  37. Patients with mild to moderate chronic liver disease without cirrhosis usually tolerate surgery well
  38. Patients with NASH do not appear to have excessive mortality following elective surgery.
  39. Moderate to severe steatosis means more than 30 percent of hepatocytes contain fat.
  40. Following any surgery, patients with liver disease should be observed closely for hepatic decompensation.
  41. Asymptomatic patients with mild chronic hepatitis are at low risk for complications during any surgery
  42. Infection with the hepatitis C virus (HCV) can result in both acute and chronic hepatitis.
  43. HCV accounts for approximately one-third of HCC cases
  44. Most patients with chronic infection are asymptomatic or have only mild nonspecific symptoms.
  45. Alcohol promotes the progression of chronic HCV even in patients with a relatively low alcohol intake.
  46. High risk patients testing should include HBsAg and anti-HBs. Patients who are negative for these markers should be vaccinated.
  47.  Type 1 classic autoimmune hepatitis: + ve antibodies to nuclei (ANA) and/or smooth muscle (ASMA) and antiactin antibodies (AAA).
  48.  Type 2 autoimmune hepatitis: + ve antibodies to liver/kidney microsomes (ALKM-1), and/or antibodies to a liver cytosol antigen (ALC-1 or LC1).
  49. Fulminant E hepatitis is more likely in those who are pregnant and in those who are malnourished or have preexisting liver disease.
  50. An effective vaccine against HEV has been developed but is not yet commercially available.
  51.  The degree of liver enzymes can help in differentiating between hepatocellular and cholestatic processes.
  52. SGOT, SGPT values less than eight times normal may be seen in either hepatocellular or cholestatic liver disease.
  53. SGOT, SGPT values 25 times normal or higher are seen primarily in hepatocellular diseases.
  54. The SGOT rarely exceeds 300 U/L in alcoholic hepatitis.
  55. Patients with acute hepatitis C are usually asymptomatic.
  56.  While SGOT, SGPT values less than eight times normal may be seen in either hepatocellular or cholestatic liver disease, values 25 times normal or higher are seen primarily in hepatocellular diseases. Patients with jaundice from cirrhosis may have normal or only slight elevations of the liver enzymes.
  57. Wilson disease (Serum aminotransferases typically less than 2,000 IU/L (AST often greater than ALT) Roberts, EA, Schilsky, ML. A practice guideline on Wilson disease. Hepatology 2003; 37:1475.
  58. Muscle disorders — Elevated serum aminotransferases may be caused by disorders that affect organs other than the liver, most commonly striated muscle. Serum AST and ALT may both be elevated with muscle injury. Their ratio depends in part upon when they are assessed relative to the muscle injury. Immediately after muscle injury, the AST/ALT ratio is generally greater than three, but approaches one within a few days because of a faster decline in the serum AST. Peak AST and ALT levels are variable. In one series, peak AST levels range from as low as 235 IU to as high as 10,000 IU while peak ALT ratios range from as low as 115 IU/L to as high as 850 IU/L [Nathwani, RA, Pais, S, Reynolds, TB, Kaplowitz, N. Serum alanine aminotransferase in skeletal muscle diseases. Hepatology 2005; 41:380.]
  59. NASH: Hepatic steatosis and an associated condition, non-alcoholic steatohepatitis (NASH), may present solely with mild elevations of the serum aminotransferases, which are usually less than fourfold elevated. NASH is a condition more common in women and associated with obesity and type 2 diabetes mellitus. (See "Nonalcoholic steatohepatitis".) In contrast to alcohol related liver disease, the ratio of AST to ALT is usually less than one.
  60. Dengue SGOT > SGPT [J Clin Virol. 2007 Mar;38(3):265-8. Epub 2007 Feb 15.] [January 2008, Vol. 37 No. 1 http://www.annals.edu.sg/PDF/37VolNo1Jan2008/V37N1p82.pdf]