Straight from the Heart: Medical Uptodate Year Roundup 2017

• Elvitegravir-cobicistat use during pregnancy: For HIV-infected women who become pregnant while on an elvitegravir-cobicistat-containing regimen switch to a different regimen (1,2).
• Acetylcysteine IV or oral does not prevent contrast nephropathy(3).
• Frequency for dosing of oral iron for individuals with iron deficiency should be every other day rather than every day (4).
• Patients ≥60 years of age with new onset dyspepsia should undergo an upper endoscopy (5).
• Patients <60 years with new onset dyspepsia upper GI endoscopy is reserved for those with clinically significant weight loss, overt gastrointestinal bleeding, more than one alarm feature, or rapidly progressive alarm features. These patients should be tested and treated for H. pylori infection (5).
• For patients with suspected multiple myeloma do cross-sectional imaging (low-dose CT, PET/CT, or MRI scan), rather than a skeletal survey, as the imaging modality to detect bone involvement (6).
• For patients age ≤60 years with an embolic-appearing cryptogenic ischemic stroke who have a patent foramen ovale with a right-to-left shunt detected by saline contrast bubble study go for percutaneous PFO closure in addition to antiplatelet therapy, rather than antiplatelet therapy alone (8,9).
• For patients with RAS/BRAF wild-type (wt) metastatic colorectal cancer (mCRC) and a left-sided primary tumor, treat with an antibody targeting the epidermal growth factor receptor (EGFR), rather than bevacizumab, when a biologic agent is chosen as a component of first-line therapy (10).
• For most patients with RAS/BRAF wt mCRC and a right-sided primary tumor treat with bevacizumab rather than an anti-EGFR antibody in conjunction with first-line chemotherapy (10).
• In mild to moderate treatment resistant major depression augment the initial antidepressant with a second drug and/or psychotherapy, rather than other strategies such as switching antidepressants or switching from pharmacotherapy to psychotherapy (11).
• For patients with chronic HCV genotype 1 infection who have not been previously treated with sofosbuvir or an NS5A inhibitor give ledipasvir-sofosbuvir, sofosbuvir-velpatasvir, or glecaprevir-pibrentasvir (12-16).
• For patients with advanced systemic mastocytosis give midostaurin for initial systemic therapy rather than imatinib or other cytoreductive therapies (17, 18).
• In patients with a presumptive diagnosis of acquired TTP administer rituximab as a component of initial therapy (19).
• For patients with cutaneous melanoma and a positive sentinel lymph node biopsy go for clinical observation and ultrasound surveillance of the positive nodal basin rather than immediate completion lymph node dissection [20].
• For patients with newly diagnosed ALK-positive NSCLC go for alectinib as first-line treatment.For those without access to alectinib, appropriate alternatives include crizotinib or ceritinib. For patients with advanced anaplastic lymphoma kinase (ALK)-positive non-small cell lung cancer (NSCLC), crizotinib has been administered as frontline therapy. However, newer agents have shown promising efficacy in advanced ALK-positive NSCLC (22,23).
• For patients with an asymptomatic solid or subsolid (pure ground glass or part-solid) solitary pulmonary nodule (SPN) <6 mm, no routine follow-up is required. For patients with solid SPNs that have been stable on serial CT over a two-year period, or with subsolid SPNs that have been stable over a five-year period, we suggest no further diagnostic testing (24).
• For women with postpartum hemorrhage diagnosed within three hours of delivery administer tranexamic acid as a component of overall treatment (25).
• For patients with ALS who have a disease duration of two years or less, are living independently, and have an FVC ≥80 percent treat with edaravone and edaravone for patients with more advanced ALS (26,27).
• For adults with acquired severe aplastic anemia who are not candidates for allogeneic hematopoietic cell transplantation treat with eltrombopag plus standard immunosuppressive therapy (IST) rather than IST alone (28).
• For patients with primary progressive multiple sclerosis treat with ocrelizumab (29).
• Scalp hypothermia can prevent chemotherapy-induced alopecia in women with breast cancer (30,31).
• Do not give venom immunotherapy (VIT) to patients with reactions to stinging insects limited to cutaneous systemic symptoms and not involving other organ systems. However, VIT is effective in reducing the severity of future reactions and may still be offered in selected situations (32).
• For most patients with chronic HBV infection who initiate therapy with tenofovir give tenofovir alafenamide rather than tenofovir disoproxil fumarate (tenofovir DF). Those initially started on tenofovir DF switch to tenofovir alafenamide (33-35).

References

1. http://aidsinfo.nih.gov/guidelines/html/3/perinatal-guidelines/0/(Accessed on October 19, 2017).
2. 7th International Workshop on HIV and Women. Seattle, WA. February 11-12, 2017.
3. N Engl J Med 2017.
4. Lancet Haematol 2017; 4:e524.
5. Am J Gastroenterol 2017; 112:988.
6. Blood Cancer J 2017; 7:e599.
7. N Engl J Med 2017; 377:1022.
8. N Engl J Med 2017; 377:1033.
9. N Engl J Med 2017; 377:1011.
10. Eur J Cancer 2017; 70:87.
11. JAMA 2017; 318:132.
12. 52nd Annual Meeting of the European Association for the Study of the Liver (EASL), Amsterdam, The Netherlands, April 19-23, 2017.
13. Lancet Infect Dis 2017; 17:1062.
14. American Association for the Study of Liver Diseases Liver Meeting, Boston, MA, November 11-15, 2016.
15. N Engl J Med 2017; 377:1448.
16. N Engl J Med 2017; 376:2134.
17. Leukemia 2017.
18. N Engl J Med 2016; 374:2605.
19. Blood Advances 2017; 1:1159.
20. N Engl J Med 2017; 376:2211.
21. N Engl J Med 2017; 377:829.
22. Lancet 2017; 390:29.
23. WCLC 2016; PL03.07.
24. Radiology 2017; 284:228.
25. Lancet 2017.
26. Lancet Neurol 2017; 16:505.
27. www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm557102.htm(Accessed on May 09, 2017).
28. N Engl J Med 2017; 376:1540.
29. N Engl J Med 2017; 376:209.
30. JAMA 2017; 317:596.
31. JAMA 2017; 317:606.
32. Ann Allergy Asthma Immunol 2017; 118:28.
33. www.gilead.com/news/press-releases/2016/11/us-food-and-drug-administration-approves-gileads-vemlidy-tenofovir-alafenamide-for-the-treatment-of-chronic-hepatitis-b-virus-infection
34. Lancet Gastroenterol Hepatol 2016; 1:185.
35. Lancet Gastroenterol Hepatol 2016; 1:196.

Annual HCFI Awards 2017 presented under various categories for noteworthy contribution in the field of healthcare

Annual HCFI Awards 2017 presented under various categories for noteworthy contribution in the field of healthcare

·         Schools who took part in the Perfect Health Mela were also recognized

·         All present at the event trained in first aid and hands-only CPR 10

New Delhi, 09 November 2017: The Heart Care Foundation of India (HCFI), a leading National NGO committed to making India a healthier and disease-free nation, organized the annual HCFI Awards 2017 on 9^th November 2017. These awards are given to eminent personalities for their selfless contribution in promoting healthcare in the country. The award ceremony was followed by a felicitation of the schools that participated in the recently concluded Perfect Health Mela 2017.

The event also featured the launch of a video on the HCFI - ONGC Swacch Bharat Abhiyaan. ONGC has taken its Swacch Bharat Abhiyan to many parts of the country already. The public health awareness video prepared in collaboration with HCFI highlighted the intrinsic relationship between a clean environment and a healthy nation. Padma Shri Awardee Dr KK Aggarwal, National President IMA and President HCFI chaired the event in the presence of other distinguished guests. Those present were also trained in the life-saving technique of hands-only CPR 10 and first aid.

Delivering the welcome address, Padma Shri Awardee Dr K K Aggarwal, National President Indian Medical Association (IMA) and President Heart Care Foundation of India (HCFI), said, “It was heartening to see the immense participation by schools at the Perfect Health Mela this year. We are happy to felicitate them for doing their bit towards healthcare and ensuring that they participate in the larger good of the community by creating awareness. I congratulate those who are receiving the awards today for their outstanding and selfless contribution to healthcare in the country. These awards will set an example for others in the field to work better and ensure that they create relevant awareness through their activities. Each one of us has a responsibility towards the environment, which will further translate into good health. Every citizen of the country must be ‘health aware’ and make efforts to be disease free and promote best practices. Preventive measures towards health must start right at a young age.”

More than 20 schools participated this year in various competitions and events in the Perfect Health Mela. This is a one-of-its-kind event organized by the HCFI every year to create awareness on health through competitions, campaigns, health check camps, and workshops. IMA is the knowledge partner for this event.

Accepting the HCFI awards for their contribution, Shri Rajesh Mittal and Ms Kamaleshwari, said, “We are very happy to receive this award today. However, we are happier to see a body like HCFI recognizing our contribution to healthcare. This award is not only an encouragement for us to work more in this direction but will also serve as an example for many others to follow suit and work towards improving healthcare outcomes in the country, in their own way.”

The workshop on first aid and hands-only CPR 10 aimed at educating people on the need to be aware of these basic techniques. First aid is a priority at any cost. By learning the technique of CPR 10, one can revive victims of sudden death within 10 minutes. Sudden death may include heart attack, electrocution deaths, hypothermia deaths, deaths due to choking, drowning deaths and other deaths, which occur suddenly without notice. Dr Aggarwal added that it is unfortunate that in our country, medical personnel cannot reach the victim early. It is, therefore, imperative for every citizen of the country to be trained in basic first aid including cardiac first aid to victims.

Giving the vote of thanks, Dr RN Tandon – Honorary Secretary General IMA, said, “The IMA has always supported any effort aimed at ensuring universal access to healthcare and creating awareness on health issues. This event is no different and I congratulate all the winners. I also thank all those present here for having attended the event and helping us take the agenda of ensuring health for all, a step further.”

HCFI awards were presented under the following categories to the following people.

• HCFI K L Chopra Media Award for the best health news reporting for the year
  Shri Durgesh Nandan and Ms Payal Banerjee

• HCFI K L Chopra Lifetime Achievement Media award
  Shri Rajesh Mittal, Shri Mukesh Aggarwal, Shri Alok Mohan Nayak

• HCFI Dr Rakesh Gupta Excellence Award for the best philanthropic contribution in the field of a community health project 

Dr Mridula Pandey, Dr Arun Gupta (Sacchi Saheli), Dr Swati Bhave

• HCFI Abheeta Khanna Lifetime Achievement Award for exemplary contribution in the field of PR and Journalism 

Shri Veerendra Verma and Ms Ratan Kaul

• HCFI Anil Jaju Excellence Award for the best project in the field of health awareness during the last one year by an NGO

Indian Medical Association

• HCFI Qimat Rai Aggarwal Excellence Award for contribution in the field of preventive health and environment preservation in the last one year

Shri P K Bajaj and Dr Akshat Wahal

• HCFI Dr Vijay Aggarwal Excellence Award for contributionto the society

Ms Kamaleshwari

• HCFI Dr K K Aggarwal Running Trophy for contribution to the field of health in the last one year

Ms Paavani Gupta and Ms Santosh Kumari

• HCFI Performer of the Year Award will be presented to the best performer from the HCFI Family

Shri Ram Singh

• HCFI Lifetime Achievement Award

Shri D K Gupta, Dr U Kakroo and Shri K. Sareen

• HCFI Perfect Health Mela Special Award

Ms Geeta Anand, Ms Aruna Tyagi, Shri Yogesh Jaju, Shri Yogesh Pant, and Dr Prachi Garg

National Health Policy 2017 approved by Cabinet

National Health Policy 2017 approved by Cabinet Focus on Preventive and Promotive Health Care & Universal access to good quality health care services The Health Ministry has formulated the National Health Policy 2017, after a gap of 14 years, to address the current and emerging challenges necessitated by the changing socio-economic and epidemiological landscapes since the last National Health Policy was framed in 2002. The Cabinet has approved the National Health Policy 2017. The policy informs and prioritizes the role of the Government in shaping health systems in all its dimensions investment in health, organization and financing of healthcare services, prevention of diseases and promotion of good health through cross-sectoral action, access to technologies, developing human resources, encouraging medical pluralism, building the knowledge base required for better health, financial protection strategies and regulation and progressive assurance for health. The roadmap of this new Policy is predicated on public spending and provisioning of a public healthcare system that is comprehensive, integrated and accessible to all. The Policy seeks to reach everyone in a comprehensive integrated way to move towards wellness. It aims at achieving universal health coverage and delivering quality health care services to all at affordable cost. The policy is patient centric and empowers the patient for resolution of all their problems. The policy, has at its centre, the person, who seeks and needs medical care. The policy also looks at reforms in the existing regulatory systems both for easing manufacturing of drugs and devices, to promote Make in India, as also for reforming medical education. The policy envisages a time-bound Implementation Framework with clear deliverables and milestones to achieve the policy goals. It also seeks to ensure improved access and affordability of quality secondary and tertiary care services through a combination of public hospitals and strategic purchasing in healthcare deficit areas from accredited non-governmental healthcare providers, achieve significant reduction in out of pocket expenditure due to healthcare costs, reinforce trust in public healthcare system and influence operation and growth of private healthcare industry as well as medical technologies in alignment with public health goals. The policy emphasizes reorienting and strengthening the Public Health Institutions across the country, so as to provide universal access to free drugs, diagnostics and other essential healthcare. • The broad principles of the Policy are centered on professionalism, integrity and ethics, equity, affordability, universality, patient-centered and quality of care, accountability and pluralism. • The main objective of the National Health Policy 2017 is to achieve the highest possible level of good health and well-being, through a preventive and promotive health care orientation in all developmental policies, and to achieve universal access to good quality health care services without anyone having to face financial hardship as a consequence. • The policy seeks to move away from Sick- Care to Wellness, with thrust on prevention and health promotion. • It envisages providing larger package of assured comprehensive primary health care through the ‘Health and Wellness Centers’ and denotes important change from very selective to comprehensive primary health care package which includes care for major NCDs, mental health, geriatric health care, palliative care and rehabilitative care services. • It advocates allocating major proportion (two-thirds or more) of resources to primary care followed by secondary and tertiary care. • It also aspires to provide at the district level most of the secondary care which is currently provided at a medical college hospital. • In order to provide access and financial protection at secondary and tertiary care levels, NHP 2017 proposes free drugs, free diagnostics and free emergency care services in all public hospitals. • National Health Policy 2017 affirms commitment to pre-emptive care (aimed at pre-empting the occurrence of diseases) to achieve optimum levels of child and adolescent health. It envisages school health programmes as a major focus area as also health and hygiene being made a part of the school curriculum. • The policy looks at stronger partnership with the private sector and advocates a positive and proactive engagement with the private sector for critical gap filling towards achieving national goals. It envisages private sector collaboration for strategic purchasing, capacity building, skill development programmes, awareness generation, developing sustainable networks for community to strengthen mental health services, and disaster management. The policy also advocates financial and non-incentives for encouraging the private sector participation. • The policy proposes raising public health expenditure to 2.5% of the GDP in a time bound manner. • It aims to ensure availability of 2 beds per 1000 population distributed in a manner to enable access within golden hour. • The Policy advocates a progressively incremental assurance-based approach. • The policy envisages a three dimensional integration of AYUSH systems encompassing cross referrals, co-location and integrative practices across systems of medicines. This has a huge potential for effective prevention and therapy that is safe and cost-effective. • Yoga would be introduced much more widely in school and work places as part of promotion of good health. • It seeks to strengthen the health surveillance system and establish registries for diseases of public health importance, by 2020. • It also seeks to align other policies for medical devices and equipment with public health goals. • Under a ‘giving back to society’ initiative, the new Health Policy supports voluntary service in rural and under-served areas on pro-bono basis by recognized healthcare professionals. • It also advocates extensive deployment of digital tools for improving the efficiency and outcome of the healthcare system and proposes establishment of National Digital Health Authority (NDHA) to regulate, develop and deploy digital health across the continuum of care. • The Policy has also assigned specific quantitative targets aimed at reduction of disease prevalence/incidence under 3 broad components viz. a) Health status and programme impact, b) Health system performance and c) Health systems strengthening, aligned to the policy objectives. Some key targets that the policy seeks to achieve are - • Life Expectancy and healthy life a. Increase Life Expectancy at birth from 67.5 to 70 by 2025. b. Establish regular tracking of Disability Adjusted Life Years (DALY) Index as a measure of burden of disease and its trends by major categories by 2022. c. Reduction of TFR to 2.1 at national and sub-national level by 2025. • Mortality by Age and/ or cause a. Reduce Under-Five Mortality to 23 by 2025 and MMR from current levels to 100 by 2020. b. Reduce infant mortality rate to 28 by 2019. c. Reduce neo-natal mortality to 16 and still birth rate to “single digit” by 2025. • Reduction of disease prevalence/ incidence a. Achieve global target of 2020 which is also termed as target of 90:90:90, for HIV/AIDS i. e,- 90% of all people living with HIV know their HIV status, - 90% of all people diagnosed with HIV infection receive sustained antiretroviral therapy and 90% of all people receiving antiretroviral therapy will have viral suppression. b. Achieve and maintain elimination status of Leprosy by 2018, Kala-Azar by 2017 and Lymphatic Filariasis in endemic pockets by 2017. c. To achieve and maintain a cure rate of >85% in new sputum positive patients for TB and reduce incidence of new cases, to reach elimination status by 2025. d. To reduce the prevalence of blindness to 0.25/ 1000 by 2025 and disease burden by one third from current levels. e. To reduce premature mortality from cardiovascular diseases, cancer, diabetes or chronic respiratory diseases by 25% by 2025. (Source: Press Information Bureau, 16th March, 2017) Dr KK Aggarwal National President IMA and HCFI

ADA 2017 Standards of Medical Care in Diabetes

Dr K K Aggarwal, National President IMA

The American Diabetes Association (ADA) has released its new Standards of Medical Care in Diabetes for the year 2017. The guidelines have especially focused on psychological health, access to care, expanded and personalized treatment options, and the tracking of hypoglycemia in people with diabetes.

Some salient features of the new Standards of care include:

·         Guidelines on screening adults and youth with diabetes for diabetes distress, depression, anxiety and eating disorders; a list of situations that warrant a referral to a mental health specialist is also included.

·         An expanded list of diabetes comorbidities now includes autoimmune disease, HIV, anxiety disorders, depression, disordered eating behavior and serious mental illness.

·         New lifestyle management guidelines include a physical activity recommendation to interrupt prolonged sedentary behavior every 30 minutes.

·         Sleep patterns should be assessed as part of overall diabetes care because sleep quality may be associated with blood glucose management.

·         The indications for metabolic surgery have been expanded to include patients with inadequately controlled type 2 diabetes who have a BMI as low as 30 kg/m2 (27.5 kg/m2 in Asian Americans).

·         Any of the four classes of blood pressure medications that have shown beneficial cardiovascular outcomes in people with diabetes - ACE inhibitors, angiotensin receptor blockers, thiazide-like diuretics or dihydropyridine calcium channel blockers - may now be used as first-line treatment for hypertension.

·         Anew insulin algorithm included in the guidelines offers more glucose management options for people with type 2 diabetes.

·         The Standards include a new recommendation to consider the GLP-1 receptor agonist liraglutide and the SGLT-2 inhibitor empagliflozin in patients with diabetes and CV disease (history of stroke or heart attack, acute coronary syndromes, angina or peripheral arterial disease) to reduce risk of death.

·         A level of less than 54mg/dl is now defined as denoting serious clinically important hypoglycemia.

·         To help reduce health disparities, the Standards now recommend people with diabetes receive self-management support from lay health coaches, navigators and community health workers.

The Standards are available online on Dec. 15, 2016, and will be published as a supplement to the January 2017 issue of Diabetes Care.

(Source: ADA Press Release, December 15, 2016)