Head To Head
Head to Head
Would judicial consent for assisted dying protect vulnerable people?
BMJ 2015; 351 doi: http://dx.doi.org/10.1136/bmj.h4437 (Published 19 August 2015)
Cite this as: BMJ 2015;351:h4437
Rapid response

Re: Would judicial consent for assisted dying protect vulnerable people?
Judicial Consent is a Must in Assisted Dying.
To avoid the misuse of assisted dying it is must get judicial authorities' consent. This will be helpful to avoid treatment neglect for patients in a critical condition. This may also be helpful in preventing organ trading.
So to assist and regulate sensitive issues such as assisted dying, judicial authorities' consent along with medical personal consent can also be helpful in giving legal cover to make a concrete decision in this matter.
Competing interests: No competing interests
27 August 2015
M A Aleem
Neurologist
ABC Hospital
Trichy 620018 Tamilnadu India
Friday, August 28, 2015
Tuesday, August 25, 2015
More than World Health Organization ' s Expectation Tamilnadu Chief Minister Jayalalithaa Today announced Role Modal Heath scheme for Rural and Urban People Of All Section in Tamilnadu (India)
More than World Health Organization ' s Expectation Tamilnadu Chief Minister Jayalalithaa Today announced Role Modal Heath scheme for Rural and Urban People Of All Section in Tamilnadu (India)
TamilNadu chief minister J Jayalalithaa on Tuesday(25.8.2015) announced in the assembly several new medical schemes, including four schemes under the Amma brand -- Amma Master Health Check Up, Amma Woman Special Master Health Check-up, Amma Arogya Scheme and Amma Pregnancy Sanjeevi.
Reading out a four-page statement, Jayalalithaa said, "Amma Master Health Check-up will be launched to facilitate people to go in for master health check-up. Under the scheme, people can undergo various tests to check for diabetes, blood pressure, hepatitis B, abdomen, heart etc at the Government General Hospital in Chennai at a nominal cost."
She said under the Amma Woman Special Master Health Check-up scheme, specific tests like digital mammogram, pap test smear, vitamin D test and thyroid test will be done, apart from other tests. "The government will allocate Rs 10 crore to Government General Hospital towards purchase of equipment," she said.
Under the Amma Arogya Scheme, people can approach 385 primary health centres for conducting tests for diabetes, blood pressure, echo cardiogram (ECG), cholesterol and eye-related ailments. Tests will be done free of cost.
Under Amma Pregnancy Sanjeevi, women will be given pomegranate and curry leave powder during the first three months of pregnancy to prevent nausea. In the next three months, pregnant women will get natural medicines like gooseberry powder etc to improve the iron content.
During the last stage of pregnancy and post-pregnancy, women will be given medicinal powders to ease delivery and increase lactation. "Eleven types of medicinal powders will be given to pregnant women and based on siddha doctors' advice, these will be given. It will cost Rs 10 crore annually to the government," said Jayalalithaa.
She said the Centre had accorded sanction to convert the Adyar Cancer Institute in Chennai into a state-level institution and centre for excellence at a cost of Rs 120 crore. "This follows a letter to Prime Minister seeking the institute's upgradation as it was functioning in an excellent manner".
Pudukottai will get a new medical college, and a new dental college will also be established in a southern district. "At present there is only one dental college in Tamil Nadu and that is in Chennai. This college has been made into a centre of excellence and the number of seats has been increased from 35 to 58. Another dental college will be established in the southern district at a cost Rs 50 crore," she said. The chief minister did not name the district where the new college will be set up.
The government will start 10 more primary health centres in the state in the current year at a cost of Rs 6 crore. "Apart from this, 10 primary health centres will be upgraded into 30-bed centres at a cost of Rs 12 crore. Nurses of 60 PHCs will get residential quarters at a cost of Rs 6 crore," she said.
In addition to 281 blood banks and 415 blood storage centres functioning in the state, the government will open 12 new blood banks, 10 storage centres and 10 blood collection centres at a cost of Rs 12 crore. Infant intensive care centres will be opened at Tambaram, Tiruttani, Gudiyatham, Rajapalayam and Virudhunagar government hospitals at a cost of Rs 3.25 crore.
"To save infants and children from various life-threatening diseases and poison, the government will set up a 20-bed infant intensive care centre at Rajapalayam hospital. A post-operative ward with five beds will also opened in the hospital at a cost of Rs 1.10 crore," she said.
Other announcements include purchase of 20 vehicles to transport women after delivery from hospitals to their houses. This will cost Rs 1.60 crore.
As many as fifty old 108 ambulances would be replaced with new ones at a cost of Rs 5 crore. Eight district government hospitals would be provided with ventilators at a cost of Rs 10.08 crore, she added.
TamilNadu chief minister J Jayalalithaa on Tuesday(25.8.2015) announced in the assembly several new medical schemes, including four schemes under the Amma brand -- Amma Master Health Check Up, Amma Woman Special Master Health Check-up, Amma Arogya Scheme and Amma Pregnancy Sanjeevi.
Reading out a four-page statement, Jayalalithaa said, "Amma Master Health Check-up will be launched to facilitate people to go in for master health check-up. Under the scheme, people can undergo various tests to check for diabetes, blood pressure, hepatitis B, abdomen, heart etc at the Government General Hospital in Chennai at a nominal cost."
She said under the Amma Woman Special Master Health Check-up scheme, specific tests like digital mammogram, pap test smear, vitamin D test and thyroid test will be done, apart from other tests. "The government will allocate Rs 10 crore to Government General Hospital towards purchase of equipment," she said.
Under the Amma Arogya Scheme, people can approach 385 primary health centres for conducting tests for diabetes, blood pressure, echo cardiogram (ECG), cholesterol and eye-related ailments. Tests will be done free of cost.
Under Amma Pregnancy Sanjeevi, women will be given pomegranate and curry leave powder during the first three months of pregnancy to prevent nausea. In the next three months, pregnant women will get natural medicines like gooseberry powder etc to improve the iron content.
During the last stage of pregnancy and post-pregnancy, women will be given medicinal powders to ease delivery and increase lactation. "Eleven types of medicinal powders will be given to pregnant women and based on siddha doctors' advice, these will be given. It will cost Rs 10 crore annually to the government," said Jayalalithaa.
She said the Centre had accorded sanction to convert the Adyar Cancer Institute in Chennai into a state-level institution and centre for excellence at a cost of Rs 120 crore. "This follows a letter to Prime Minister seeking the institute's upgradation as it was functioning in an excellent manner".
Pudukottai will get a new medical college, and a new dental college will also be established in a southern district. "At present there is only one dental college in Tamil Nadu and that is in Chennai. This college has been made into a centre of excellence and the number of seats has been increased from 35 to 58. Another dental college will be established in the southern district at a cost Rs 50 crore," she said. The chief minister did not name the district where the new college will be set up.
The government will start 10 more primary health centres in the state in the current year at a cost of Rs 6 crore. "Apart from this, 10 primary health centres will be upgraded into 30-bed centres at a cost of Rs 12 crore. Nurses of 60 PHCs will get residential quarters at a cost of Rs 6 crore," she said.
In addition to 281 blood banks and 415 blood storage centres functioning in the state, the government will open 12 new blood banks, 10 storage centres and 10 blood collection centres at a cost of Rs 12 crore. Infant intensive care centres will be opened at Tambaram, Tiruttani, Gudiyatham, Rajapalayam and Virudhunagar government hospitals at a cost of Rs 3.25 crore.
"To save infants and children from various life-threatening diseases and poison, the government will set up a 20-bed infant intensive care centre at Rajapalayam hospital. A post-operative ward with five beds will also opened in the hospital at a cost of Rs 1.10 crore," she said.
Other announcements include purchase of 20 vehicles to transport women after delivery from hospitals to their houses. This will cost Rs 1.60 crore.
As many as fifty old 108 ambulances would be replaced with new ones at a cost of Rs 5 crore. Eight district government hospitals would be provided with ventilators at a cost of Rs 10.08 crore, she added.
Friday, August 14, 2015
Aleem M A. Digital Technology should Not Be Misused Inside Premises Providing Health Care BMJ 2015;351:h4098
Head To Head
Should all NHS premises provide free access to wi-fi?
BMJ 2015; 351 doi: http://dx.doi.org/10.1136/bmj.h4098 (Published 12 August 2015)
Cite this as: BMJ 2015;351:h4098
Rapid responses

Re: Should all NHS premises provide free access to wi-fi?
Digital Technology should Not Be Misused Inside Premises Providing Health Care
If digital technology units are used in the right sense for the right reason, these facilities may be useful for the best health care of patients in premises providing health care. These facilities should not be misused for sharing patients' photos videos and their investigations details to the public through live or other means of transmission. This type of attitude by users of digital technology units may lead to many medico-legal problems.
Competing interests: No competing interests
14 August 2015
M A Aleem
Neurologist
ABC Hospital
Annamalainagar Trichy 620018 Tamilnadu India
Should all NHS premises provide free access to wi-fi?
BMJ 2015; 351 doi: http://dx.doi.org/10.1136/bmj.h4098 (Published 12 August 2015)
Cite this as: BMJ 2015;351:h4098
Rapid responses

Re: Should all NHS premises provide free access to wi-fi?
Digital Technology should Not Be Misused Inside Premises Providing Health Care
If digital technology units are used in the right sense for the right reason, these facilities may be useful for the best health care of patients in premises providing health care. These facilities should not be misused for sharing patients' photos videos and their investigations details to the public through live or other means of transmission. This type of attitude by users of digital technology units may lead to many medico-legal problems.
Competing interests: No competing interests
14 August 2015
M A Aleem
Neurologist
ABC Hospital
Annamalainagar Trichy 620018 Tamilnadu India
Wednesday, August 12, 2015
International Youth Day: 12 AUGUST 2015:Youth Civic Engagement.
International Youth Day: 12 AUGUST 2015
The 2015 International Youth Day theme is Youth Civic Engagement.
Youth Civic Engagement, a main goal of the United Nations System-Wide Action Plan on Youth (Youth-SWAP), seeks to promote young people’s effective inclusive civic engagement at all levels. There has been recent increasing attention and policy and programming focus on youth civic engagement by governments, UN entities, regional and multilateral organizations, CSOs, youth and researchers.
The engagement and participation of youth is essential to achieve sustainable human development. Yet often the opportunities for youth to engage politically, economically and socially are low or non-existent.
More efforts are needed to raise awareness about the importance of youth civic engagement and its benefits to the individual and to society, including for sustainable development as well as resilience and wellbeing.
The International Youth Day 2015 campaign aims at promoting civic engagement and participation of youth in politics and public life, so that young people can be empowered and bring a full contribution to society, development and peace. You can be part of these effort
The 2015 International Youth Day theme is Youth Civic Engagement.
Youth Civic Engagement, a main goal of the United Nations System-Wide Action Plan on Youth (Youth-SWAP), seeks to promote young people’s effective inclusive civic engagement at all levels. There has been recent increasing attention and policy and programming focus on youth civic engagement by governments, UN entities, regional and multilateral organizations, CSOs, youth and researchers.
The engagement and participation of youth is essential to achieve sustainable human development. Yet often the opportunities for youth to engage politically, economically and socially are low or non-existent.
More efforts are needed to raise awareness about the importance of youth civic engagement and its benefits to the individual and to society, including for sustainable development as well as resilience and wellbeing.
The International Youth Day 2015 campaign aims at promoting civic engagement and participation of youth in politics and public life, so that young people can be empowered and bring a full contribution to society, development and peace. You can be part of these effort
International Youth Day: 12 AUGUST 2015:Youth Civic Engagement.
International Youth Day: 12 AUGUST 2015
The 2015 International Youth Day theme is Youth Civic Engagement.
Youth Civic Engagement, a main goal of the United Nations System-Wide Action Plan on Youth (Youth-SWAP), seeks to promote young people’s effective inclusive civic engagement at all levels. There has been recent increasing attention and policy and programming focus on youth civic engagement by governments, UN entities, regional and multilateral organizations, CSOs, youth and researchers.
The engagement and participation of youth is essential to achieve sustainable human development. Yet often the opportunities for youth to engage politically, economically and socially are low or non-existent.
More efforts are needed to raise awareness about the importance of youth civic engagement and its benefits to the individual and to society, including for sustainable development as well as resilience and wellbeing.
The International Youth Day 2015 campaign aims at promoting civic engagement and participation of youth in politics and public life, so that young people can be empowered and bring a full contribution to society, development and peace. You can be part of these effort
The 2015 International Youth Day theme is Youth Civic Engagement.
Youth Civic Engagement, a main goal of the United Nations System-Wide Action Plan on Youth (Youth-SWAP), seeks to promote young people’s effective inclusive civic engagement at all levels. There has been recent increasing attention and policy and programming focus on youth civic engagement by governments, UN entities, regional and multilateral organizations, CSOs, youth and researchers.
The engagement and participation of youth is essential to achieve sustainable human development. Yet often the opportunities for youth to engage politically, economically and socially are low or non-existent.
More efforts are needed to raise awareness about the importance of youth civic engagement and its benefits to the individual and to society, including for sustainable development as well as resilience and wellbeing.
The International Youth Day 2015 campaign aims at promoting civic engagement and participation of youth in politics and public life, so that young people can be empowered and bring a full contribution to society, development and peace. You can be part of these effort
Indian Organ Donation Day 2015 August 13 : Brain Death And Organ Donation
Indian Organ Donation Day 2015 August 13
Brain Death And Organ Donation
Dr.M.A.Aleem M.D.D.M. (Neuro)
Former of Vice Principal HOD & Professor of Neurology
KAPV Government Medical College & MGM Government Hospital
Consultant neurologist and Epileptologist (Trained at Institution of Neurology Queen,s Square. London.UK.)
ABC Hospital,
Trichy - 620018
President
Trichy Neuro Association
drmaaleem@hotmail.com
Brain Death
The concept of Brain death has been with serious inconsistencies and contradictions. The first serious systematic study was undertaken by the Adhoc committee of the Harvard Medical Scholl to examine the definition of brain Death, Which Published its report in 1968.
It can be determined in several ways:
I. No electrical activity in the brain (determined by EEG)
II. No blood flow to the brain (determined by blood flow studies)
III. Absence of function of all parts of the brain – as determined by clinical assessment (no movement, no response to stimulation, no breathing, no brain reflexes)
Causes of brain death
I. Anoxia
II. Ischemia
III. Intracranial hematoma
IV. A gunshot wound to the head
V. Intracranial Aneurysm
VI. Brain tumors
When any of these occur, they cause swelling of the brain. Because the brain is enclosed in the skull, it doesn’t have room to swell, thus intracranial pressure increases. This can stop blood flow to the brain, killing brain cells and causing herniation of the brain (pushing the brain outside its normal space). When brain cells die, they don’t grow back, thus any damage caused in permanent and irreversible.
Nowadays, modern resuscitative devices and techniques can maintain the function of heart, lungs and visceral organs for a period of time (hours or days) after the life maintaining centers of the brain stem tissue have stopped function which results in a medical dilemma of a dead brain in a otherwise living body.
On the other hand development of transplant surgery and the need of viable organs have focused ethical and legal attention on the desirability of agreeing on medical criteria of brain death.
Brain death is essential in current practice of organ retrieval because it legitimates organ removal from bodies that continue to have circulation and respiration, thereby avoiding ischemic injury to organs.
Preconditions
Reversible causes (must be excluded)
Intoxication
Depressant drugs
Muscle relaxant
Primary hypothermia
Hypovolemic shock
Metabolic and endocrinal disturbances
Criteria for Diagnosis of brain death
In 1981 – the president’s Commission for the study of Ethical Problems in Medicine and Biomedical and Behavioral Research (USA) developed standards for the determination of brain death which with some modifications are accepted world wide.
Some steps are important to be followed:
Unresponsiveness
Visual
Auditory
Tactile stimuli
No communication in any manner
Absence of cerebral and brain stem function
(-)Absent:
Pupillary response
Vestibuloocular reflex (cold caloric test)
Oculo – cephalic reflex (Doll’s eye movement)
Corneal reflex
Gag reflex
Spontaneous movements of limbs & postural responses (Spinal and tendon reflexes may be present)
Some peculiar movements of upper limbs have been noted to occur in the confirmed brain death patient & collectively are termed ‘Lazarus sign’
This could be confused with postural response (Hypotension and mechanical stimulation play a role )
Apnea test
No spontaneous respiration present at PCO2 level of 60 mm Hg
100% oxygenation maintained by a cannula inserted into endotracheal tube.
This is consistent with medullary failure.
Nature of coma must be known
Some reversible causes must be ruled out
Hypothermia (body temperature >32oC)
Drug intoxication or neuromuscular blockade
Shock etc.
Persistence of brain dysfunction
Six hours with a confirmatory isoelectric EEG i.e, “Electro – cerebral silence”
Twelve hours without a confirmatory EEG.
Twenty fours for anxic brain injury without a confirmatory isoelectric EEG.
Confirmatory test (are not necessary to diagnose brain death )
EEG with physiological brain activity. (False(+ve) and Flase (-ve) results may occur)
No cerebral circulation present on angiographic examination (Principal legal sign) “Electro cerebral silence + Non – visualization of cerebral arteries’ = Brain death confirmed.
Brain stem – evoked responses with absent function in vital brain stem structures
Xenon Computed tomography (CT) scan
Digital subtraction angiography
Atropine bolus test
Transcranial Doppler sonogrraphy which records arterial blood flow at the base of brain (TCD)
99 mTc HMPAO test (Most premising confirmatory test)
Single positron emission tomography (PET scan) Best teat
Medico – legal implications
Medically and legally the patients is death. The same time appears on death certificate.
Brain death needs to be certified by board of doctor’s consisting of:
I. Registered Medical Practioner (RMP) in charge of hospital where brain death has occurred.
II. An independent RMP – a specialist.
III. A Neurologist/Neurosurgeon nominated by panel.
IV. RMP treating the patient.
The patient must be examined by team of doctor’s at least trice with a reasonable gab of time in between (at least 6b hours )
None of the doctor’s who participate in diagnosis of brain death should have any interest in transplantation or organ removal from cadaver.
i. Organ donation
unless damaged by injury or disease, the organ from a brain dead body may be used by another individual through an organ transplant.
Incase the family wishes to donate the organs / tissue, medications are usually continued until the time the patient is declared brain dead. These medications help to keep the blood pressure and heart rate under control and some reduces swelling in brain.
Organ / tissue transplant offers life or a better quality of life to another person. It gives the donor family the opportunity to help others at this time tragedy and loss.
Organs or tissues that can be donated
Heart
Liver
Lungs
Pancreas
Kidney
Heart valves
Cornea
Tissue
Skin, tendons, ligaments, bones
Organ Donation
It offers to donor an opportunity to help and to recipient’s life or better quality of life.
Transplantation of human organ Act 1994 came in to force in 1995 in India.
Highlights of this act are:
1. Statuary sanction to the brain drain death concept.
2. Regulation of removal storage and transplantation of human organs for therapeutic purposes.
3. Commercial dealings in human organs prevented
Level of awareness about transplantation, brain death & cadaver organ donation:
It is extremely low. Only a small number of individuals are aware that brain death is legal in India. Awareness about brain death is especially low among villagers.
Education about various aspects, its immense importance for organ donation and legality of brain death in India needs to be highlighted.
II. Removal of life supporting system
There is a line of demarcation i.e. when the artificial aide should be stopped so that the docter may not get involved in the offence of culpable homicide not amounting to murder or one of rash and negligent act, if he has removed the aids indiscriminately. Thus he should first consult with other doctors.
Clinician should make it clear to the relatives that ventilation is not being withdrawn to let the patient die but because continued ventilation is immaterial for a patient who is already dead except in case of organ transplant.
III. Other applications:
Akabayashi & Morioka reviewed the feasible uses of brain dead bodies, especially of dead fetus and anencephalics. They are following:
Donor for organ transplantation including marrow.
For storage and preservation of organs for transplant
Factory to produce hormones and antibodies.
For experimentation
a) In basic medicine to help determine physiologic functions in human in place of animal experimentation.
b) Inclinical medicine I. To serve as disease models II. For use in technological development III. For use in preliminary test of new drugs
c) For education purpose in practical raining and anatomic dissection
Parkinson’s disease (>1 million sufferers in USA)
They may get potential benefit from tissue (Foetal brain tissue) transplantation.
Relevant facts:
All over world, Brain death is viewed in difference ways in different countries and different laws have been framed likewise.
In Canada two physicians who are not associated with a transplant team to certify death.
Reluctance to accept brain death
Lack of understanding the concept.
Special emotional attachment to the dead person
Loss of confidence in medical practice
Ethical questions related to earlier organ transplant procedure
Perceived insufficient participation of government and medical associations.
Conclusion
Today much greater attention must be given to understanding the public and professional perceptions of brain death and to educate both groups, to assist in the development of improved and appropriate medical criteria.
Proper laws should be framed perhaps to assure legal and ethical exemption for those who by reason of conscience cannot accept the concept of brain death.
Brain Death And Organ Donation
Dr.M.A.Aleem M.D.D.M. (Neuro)
Former of Vice Principal HOD & Professor of Neurology
KAPV Government Medical College & MGM Government Hospital
Consultant neurologist and Epileptologist (Trained at Institution of Neurology Queen,s Square. London.UK.)
ABC Hospital,
Trichy - 620018
President
Trichy Neuro Association
drmaaleem@hotmail.com
Brain Death
The concept of Brain death has been with serious inconsistencies and contradictions. The first serious systematic study was undertaken by the Adhoc committee of the Harvard Medical Scholl to examine the definition of brain Death, Which Published its report in 1968.
It can be determined in several ways:
I. No electrical activity in the brain (determined by EEG)
II. No blood flow to the brain (determined by blood flow studies)
III. Absence of function of all parts of the brain – as determined by clinical assessment (no movement, no response to stimulation, no breathing, no brain reflexes)
Causes of brain death
I. Anoxia
II. Ischemia
III. Intracranial hematoma
IV. A gunshot wound to the head
V. Intracranial Aneurysm
VI. Brain tumors
When any of these occur, they cause swelling of the brain. Because the brain is enclosed in the skull, it doesn’t have room to swell, thus intracranial pressure increases. This can stop blood flow to the brain, killing brain cells and causing herniation of the brain (pushing the brain outside its normal space). When brain cells die, they don’t grow back, thus any damage caused in permanent and irreversible.
Nowadays, modern resuscitative devices and techniques can maintain the function of heart, lungs and visceral organs for a period of time (hours or days) after the life maintaining centers of the brain stem tissue have stopped function which results in a medical dilemma of a dead brain in a otherwise living body.
On the other hand development of transplant surgery and the need of viable organs have focused ethical and legal attention on the desirability of agreeing on medical criteria of brain death.
Brain death is essential in current practice of organ retrieval because it legitimates organ removal from bodies that continue to have circulation and respiration, thereby avoiding ischemic injury to organs.
Preconditions
Reversible causes (must be excluded)
Intoxication
Depressant drugs
Muscle relaxant
Primary hypothermia
Hypovolemic shock
Metabolic and endocrinal disturbances
Criteria for Diagnosis of brain death
In 1981 – the president’s Commission for the study of Ethical Problems in Medicine and Biomedical and Behavioral Research (USA) developed standards for the determination of brain death which with some modifications are accepted world wide.
Some steps are important to be followed:
Unresponsiveness
Visual
Auditory
Tactile stimuli
No communication in any manner
Absence of cerebral and brain stem function
(-)Absent:
Pupillary response
Vestibuloocular reflex (cold caloric test)
Oculo – cephalic reflex (Doll’s eye movement)
Corneal reflex
Gag reflex
Spontaneous movements of limbs & postural responses (Spinal and tendon reflexes may be present)
Some peculiar movements of upper limbs have been noted to occur in the confirmed brain death patient & collectively are termed ‘Lazarus sign’
This could be confused with postural response (Hypotension and mechanical stimulation play a role )
Apnea test
No spontaneous respiration present at PCO2 level of 60 mm Hg
100% oxygenation maintained by a cannula inserted into endotracheal tube.
This is consistent with medullary failure.
Nature of coma must be known
Some reversible causes must be ruled out
Hypothermia (body temperature >32oC)
Drug intoxication or neuromuscular blockade
Shock etc.
Persistence of brain dysfunction
Six hours with a confirmatory isoelectric EEG i.e, “Electro – cerebral silence”
Twelve hours without a confirmatory EEG.
Twenty fours for anxic brain injury without a confirmatory isoelectric EEG.
Confirmatory test (are not necessary to diagnose brain death )
EEG with physiological brain activity. (False(+ve) and Flase (-ve) results may occur)
No cerebral circulation present on angiographic examination (Principal legal sign) “Electro cerebral silence + Non – visualization of cerebral arteries’ = Brain death confirmed.
Brain stem – evoked responses with absent function in vital brain stem structures
Xenon Computed tomography (CT) scan
Digital subtraction angiography
Atropine bolus test
Transcranial Doppler sonogrraphy which records arterial blood flow at the base of brain (TCD)
99 mTc HMPAO test (Most premising confirmatory test)
Single positron emission tomography (PET scan) Best teat
Medico – legal implications
Medically and legally the patients is death. The same time appears on death certificate.
Brain death needs to be certified by board of doctor’s consisting of:
I. Registered Medical Practioner (RMP) in charge of hospital where brain death has occurred.
II. An independent RMP – a specialist.
III. A Neurologist/Neurosurgeon nominated by panel.
IV. RMP treating the patient.
The patient must be examined by team of doctor’s at least trice with a reasonable gab of time in between (at least 6b hours )
None of the doctor’s who participate in diagnosis of brain death should have any interest in transplantation or organ removal from cadaver.
i. Organ donation
unless damaged by injury or disease, the organ from a brain dead body may be used by another individual through an organ transplant.
Incase the family wishes to donate the organs / tissue, medications are usually continued until the time the patient is declared brain dead. These medications help to keep the blood pressure and heart rate under control and some reduces swelling in brain.
Organ / tissue transplant offers life or a better quality of life to another person. It gives the donor family the opportunity to help others at this time tragedy and loss.
Organs or tissues that can be donated
Heart
Liver
Lungs
Pancreas
Kidney
Heart valves
Cornea
Tissue
Skin, tendons, ligaments, bones
Organ Donation
It offers to donor an opportunity to help and to recipient’s life or better quality of life.
Transplantation of human organ Act 1994 came in to force in 1995 in India.
Highlights of this act are:
1. Statuary sanction to the brain drain death concept.
2. Regulation of removal storage and transplantation of human organs for therapeutic purposes.
3. Commercial dealings in human organs prevented
Level of awareness about transplantation, brain death & cadaver organ donation:
It is extremely low. Only a small number of individuals are aware that brain death is legal in India. Awareness about brain death is especially low among villagers.
Education about various aspects, its immense importance for organ donation and legality of brain death in India needs to be highlighted.
II. Removal of life supporting system
There is a line of demarcation i.e. when the artificial aide should be stopped so that the docter may not get involved in the offence of culpable homicide not amounting to murder or one of rash and negligent act, if he has removed the aids indiscriminately. Thus he should first consult with other doctors.
Clinician should make it clear to the relatives that ventilation is not being withdrawn to let the patient die but because continued ventilation is immaterial for a patient who is already dead except in case of organ transplant.
III. Other applications:
Akabayashi & Morioka reviewed the feasible uses of brain dead bodies, especially of dead fetus and anencephalics. They are following:
Donor for organ transplantation including marrow.
For storage and preservation of organs for transplant
Factory to produce hormones and antibodies.
For experimentation
a) In basic medicine to help determine physiologic functions in human in place of animal experimentation.
b) Inclinical medicine I. To serve as disease models II. For use in technological development III. For use in preliminary test of new drugs
c) For education purpose in practical raining and anatomic dissection
Parkinson’s disease (>1 million sufferers in USA)
They may get potential benefit from tissue (Foetal brain tissue) transplantation.
Relevant facts:
All over world, Brain death is viewed in difference ways in different countries and different laws have been framed likewise.
In Canada two physicians who are not associated with a transplant team to certify death.
Reluctance to accept brain death
Lack of understanding the concept.
Special emotional attachment to the dead person
Loss of confidence in medical practice
Ethical questions related to earlier organ transplant procedure
Perceived insufficient participation of government and medical associations.
Conclusion
Today much greater attention must be given to understanding the public and professional perceptions of brain death and to educate both groups, to assist in the development of improved and appropriate medical criteria.
Proper laws should be framed perhaps to assure legal and ethical exemption for those who by reason of conscience cannot accept the concept of brain death.
Friday, August 7, 2015
Healthy Food Healthy Life . Aleem M A BMJ 2015;351:h4249
Editor's Choice
Food for thought
BMJ 2015; 351 doi: http://dx.doi.org/10.1136/bmj.h4249 (Published 06 August 2015)
Cite this as: BMJ 2015;351:h4249
Rapid responses
Re: Food for thought
Healthy Food Healthy Life
Types of food with their ingredients, preparation and storage, along with the individual's time and frequency of intake of food, can determine the overall outcome of health. Along with the above, environmental and genetic factors can also play an important role. Individuals' co-morbid health conditions, drug intake and habits such as use of tobacco and alcohol, as well as other abusive behavior and their sleep habit and work pattern, can also determine overall health together along with food habit.
Competing interests: No competing interests
06 August 2015
M A Aleem
Neurologist
ABC Hospital
Annamalainagar Trichy 620018 Tamilnadu India
Food for thought
BMJ 2015; 351 doi: http://dx.doi.org/10.1136/bmj.h4249 (Published 06 August 2015)
Cite this as: BMJ 2015;351:h4249
Rapid responses
Re: Food for thought
Healthy Food Healthy Life
Types of food with their ingredients, preparation and storage, along with the individual's time and frequency of intake of food, can determine the overall outcome of health. Along with the above, environmental and genetic factors can also play an important role. Individuals' co-morbid health conditions, drug intake and habits such as use of tobacco and alcohol, as well as other abusive behavior and their sleep habit and work pattern, can also determine overall health together along with food habit.
Competing interests: No competing interests
06 August 2015
M A Aleem
Neurologist
ABC Hospital
Annamalainagar Trichy 620018 Tamilnadu India
Healthy Food Healthy Life . Aleem M A
Editor's Choice
Food for thought
BMJ 2015; 351 doi: http://dx.doi.org/10.1136/bmj.h4249 (Published 06 August 2015)
Cite this as: BMJ 2015;351:h4249
Rapid responses
Re: Food for thought
Healthy Food Healthy Life
Types of food with their ingredients, preparation and storage, along with the individual's time and frequency of intake of food, can determine the overall outcome of health. Along with the above, environmental and genetic factors can also play an important role. Individuals' co-morbid health conditions, drug intake and habits such as use of tobacco and alcohol, as well as other abusive behavior and their sleep habit and work pattern, can also determine overall health together along with food habit.
Competing interests: No competing interests
06 August 2015
M A Aleem
Neurologist
ABC Hospital
Annamalainagar Trichy 620018 Tamilnadu India
Food for thought
BMJ 2015; 351 doi: http://dx.doi.org/10.1136/bmj.h4249 (Published 06 August 2015)
Cite this as: BMJ 2015;351:h4249
Rapid responses
Re: Food for thought
Healthy Food Healthy Life
Types of food with their ingredients, preparation and storage, along with the individual's time and frequency of intake of food, can determine the overall outcome of health. Along with the above, environmental and genetic factors can also play an important role. Individuals' co-morbid health conditions, drug intake and habits such as use of tobacco and alcohol, as well as other abusive behavior and their sleep habit and work pattern, can also determine overall health together along with food habit.
Competing interests: No competing interests
06 August 2015
M A Aleem
Neurologist
ABC Hospital
Annamalainagar Trichy 620018 Tamilnadu India
Food: Gives Health Or Takes Health .Aleem M A BMJ 2015;351:h4034
Editorials
Where the latest US dietary guidelines are heading
BMJ 2015; 351 doi: http://dx.doi.org/10.1136/bmj.h4034 (Published 24 July 2015)
Cite this as: BMJ 2015;351:h4034
Rapid responses
Re: Where the latest US dietary guidelines are heading
Food: Gives Health Or Takes Health
In each individual, his or her food habit can give good health or it can lead to many diseases. This may be based on the type of food or it can be determined by the individual's genetic composition. Goats eat only plants but their meat gives much fat.
So our type of food intake can give health, and diseases may also be based on our genetic factors.
Competing interests: No competing interests
06 August 2015
M A Aleem
Neurologist
ABC Hospital
Annamalainagar Trichy 620018 Tamilnadu India
Where the latest US dietary guidelines are heading
BMJ 2015; 351 doi: http://dx.doi.org/10.1136/bmj.h4034 (Published 24 July 2015)
Cite this as: BMJ 2015;351:h4034
Rapid responses
Re: Where the latest US dietary guidelines are heading
Food: Gives Health Or Takes Health
In each individual, his or her food habit can give good health or it can lead to many diseases. This may be based on the type of food or it can be determined by the individual's genetic composition. Goats eat only plants but their meat gives much fat.
So our type of food intake can give health, and diseases may also be based on our genetic factors.
Competing interests: No competing interests
06 August 2015
M A Aleem
Neurologist
ABC Hospital
Annamalainagar Trichy 620018 Tamilnadu India
Wednesday, August 5, 2015
Should doctors recommend homeopathy? BMJ 2015;351:h3735
Head To Head
Should doctors recommend homeopathy?
BMJ 2015; 351 doi: http://dx.doi.org/10.1136/bmj.h3735 (Published 14 July 2015)
Cite this as: BMJ 2015;351:h3735

Sys review of AEs of homeopathy
The systematic review I and M A Aleem cited reviews a number of papers on the adverse effects of homeopathy and all are fully referenced. JK Anand requested:
"to let us have references to any reports of adverse reactions of any kind, to homoeopathic medicines, in the medical journals published in Germany and the UK"
It seems clear to me that this review fulfils that request, so I am puzzled by the response: the review is only eleven pages long so I'm unsure why Dr Anand equates the task to looking for 'a needle in that haystack of a review'. However, the whole point of a review is to summarise the current state of evidence and I'm certainly grateful to Prof Ernst et al. for doing so.
Competing interests: Director of the Nightingale Collaboration, which challenges misleading healthcare claims.
30 July 2015
Alan Henness
Director
The Nightingale Collaboration
BM The Nightingale Collaboration, London WC1N 3XX

Re: Should doctors recommend homeopathy?
Dear Dr Aleem
I am obliged to you - as I am to Mr Henness - for the RRs.
Both you and Mr Henness have offered me a lot of material thst I never asked for.
Both of you have referred to the review paper, by three authors (the seniormost being Prof Ernst), in the International Journal of Clinical Practice. Kindly see my comments to Mr Henness on the subject, so that I do not repeat myself.
Clearly Prof Ernst is the last port of call for me - and I hope to have his response in due course.
Sincerely
Dr JK Anand
Retired.
( not a homoeopathic practitioner)
Competing interests: A desire for facts requested by me.
30 July 2015
JK Anand
Retired doctor
Free spirit
Peterborough

Re: Should doctors recommend homeopathy?
Mr Henness has kindly replied (please see his RR today, 30 July).
Alas, his reference to the article in the International Journal of Clinical Practice is a review - it does not give me the information I specifically requested. Difficult to look for a needle in that haystack of a review.
I assume Mr Henness is unable to help any more.
As Prof Ernst is one of the three authors of the review mentioned above, perhaps he will, in due course, oblige me?
Now I await the replies from Dr Aleem and Prof Ernst.
Thank you
Competing interests: Impatiently waiting for precise answer to my original question.
30 July 2015
JK Anand
Retired doctor
Free spirit
Peterborough


Re: Should doctors recommend homeopathy?
This has reference to JK Anand
With homeopathy remedies there are so many direct and indirect adverse effects. The direct adverse effects included abdominal pain, flatulence, acute erythroderma, acute pancreatitis, severe allergic reactions, atopic dermatitis, burning lips, nausea, emesis, apnoea, cyanosis, regurgitation, anaphylaxis, arsenical keratosis and cancer, bladder cancer, bullous pemphigoid, severe asthenia, cardiac arrest, cognitive-behavioural disorders, coma, death, dermatitis, severe pulmonary involvement, emesis, euphoria, extreme agitation, hyponatraemia and hypoalbuminaemia, erythaema, limb oedema, irritability and albuminuria, melanosis and keratosis, skin lesions, acute gastrointestinal illness, leukopaenia, thrombocytopaenia, diffuse dermal melanosis, metabolic acidosis, weight loss, chronic diarrhoea, morbiliform and pruritic rash with hospital admission, multiple alopecia and hair loss, pain, pancreatitis, problem with balance, somnolence, pruritus, swelling and erythroderma, renal failure with metabolic acidosis, interstitial nephritis and hyperkalaemia, severe acute tubulointerstinal nephritis, severe bradycardia, reversible panconduction defect, hypotension and syncope, severe swelling, bleeding, rashes, sneezing, rhinitis, slight lethargy, symptoms of thall poisoning, tachypnea, high fever, lower limb areflexia, hypotension, pupillary abnormalities, gait ataxia, widespread leukocytosis and widespread maculopapular vesicular rash. The direct side effects of homeopathy occasionally resulted in serious outcomes including cancer, death, dialysis, toxic polyneuropathy and quadriparesis. In several instances, patients presenting adverse effects required hospital admission and pharmacotherapy .
The indirect side effects with homeopathy drugs included deterioration of pulmonary allergy, deterioration of sarcoidosis glomerulonephritis, hypertensive heart failure and encephalopathy, haemophilus influenzae meningitis, septicaemia high fever and seizures, malignant melanoma, multiple organ system failure, oedema, pneumococcal pneumonia with purulent pericarditis and coma, sepsis and death and severe aggravation of atopic dermatitis. Indirect side effects of homeopathy resulted in the following clinical outcomes: death, permanent hypertension, hydrocephalus and the need for neuro-surgical drainage.
Mechanism of Adverse Effects
With homeopathy agents in the majority of cases, the possible mechanism of action involved allergic reactions or ingestion of toxic substances. Preparations of heavy metals, such as arsenic, cadmium, mercury or iron, which are frequently used in homeopathy can be toxic, if not highly diluted. Other poisons regularly employed in homeopathy include aconitum, kerosene or thallium, which also can lead to serious health problems in sufficiently low dilutions.
There are several reports of adverse effects of homeopathy have been published and some of them had serious consequences. Clinicians should be aware of the risks associated with homeopathy.
References
1. Adverse Effects of Homeopathy
http://www.medscape.com/viewarticle/777749_2
2.Posadzki P et al In J Clin Pract.2012;66(12):1178-1188
Competing interests: No competing interests
30 July 2015
M A Aleem
Neurologist
ABC Hospital
Trichy 620018 Tamilnadu India


Re: Should doctors recommend homeopathy?
JK Anand said:
"May I request:
Dr Aleem
Mr Henness
Prof Edzard
to let us have references to any reports of adverse reactions of any kind, to homoeopathic medicines, in the medical journals published in Germany and the UK.
I hope this request is reasonable."
Not really. I was pointing out the disconnect between what M A Aleem said about the specific harms of homeopathic products and what various homeopathy organisations state about their inherent safety - it's up to them to provide good evidence one way or the other. There is evidence of harms, of course, [1] but the onus is on those who proclaim homeopathy to be safe to provide the evidence that is so, and, of course, that the purported benefits outweigh those possible harms.
However, obfuscation between specific and non-specific harms should not be allowed to hinder discussion. It seems unlikely that properly diluted and manufactured homeopathic products - containing as they do, no active ingredients but simply sugar or water - could have any serious harms in themselves. Those would be specific harms, but perhaps the greater issue is that of non-specific harms such as the delay in seeking proper medical attention for potentially serious and life-threatening medical conditions and, frequently, the distrust of science and medicines such as vaccines engendered by some homeopaths. [2, 3]
References
1. Posadzki, P., Alotaibi, A. and Ernst, E. (2012), Adverse effects of homeopathy: a systematic review of published case reports and case series. International Journal of Clinical Practice, 66: 1178–1188. doi: 10.1111/ijcp.12026
2. http://discoverhomeopathy.co.uk/victims-2/
3. http://whatstheharm.net/homeopathy.html
Competing interests: Director of the Nightingale Collaboration, which challenges misleading healthcare claims.
30 July 2015
Alan Henness
Director
The Nightingale Collaboration
BM The Nightingale Collaboration, London WC1N 3XX
Should doctors recommend homeopathy?
BMJ 2015; 351 doi: http://dx.doi.org/10.1136/bmj.h3735 (Published 14 July 2015)
Cite this as: BMJ 2015;351:h3735

Sys review of AEs of homeopathy
The systematic review I and M A Aleem cited reviews a number of papers on the adverse effects of homeopathy and all are fully referenced. JK Anand requested:
"to let us have references to any reports of adverse reactions of any kind, to homoeopathic medicines, in the medical journals published in Germany and the UK"
It seems clear to me that this review fulfils that request, so I am puzzled by the response: the review is only eleven pages long so I'm unsure why Dr Anand equates the task to looking for 'a needle in that haystack of a review'. However, the whole point of a review is to summarise the current state of evidence and I'm certainly grateful to Prof Ernst et al. for doing so.
Competing interests: Director of the Nightingale Collaboration, which challenges misleading healthcare claims.
30 July 2015
Alan Henness
Director
The Nightingale Collaboration
BM The Nightingale Collaboration, London WC1N 3XX

Re: Should doctors recommend homeopathy?
Dear Dr Aleem
I am obliged to you - as I am to Mr Henness - for the RRs.
Both you and Mr Henness have offered me a lot of material thst I never asked for.
Both of you have referred to the review paper, by three authors (the seniormost being Prof Ernst), in the International Journal of Clinical Practice. Kindly see my comments to Mr Henness on the subject, so that I do not repeat myself.
Clearly Prof Ernst is the last port of call for me - and I hope to have his response in due course.
Sincerely
Dr JK Anand
Retired.
( not a homoeopathic practitioner)
Competing interests: A desire for facts requested by me.
30 July 2015
JK Anand
Retired doctor
Free spirit
Peterborough

Re: Should doctors recommend homeopathy?
Mr Henness has kindly replied (please see his RR today, 30 July).
Alas, his reference to the article in the International Journal of Clinical Practice is a review - it does not give me the information I specifically requested. Difficult to look for a needle in that haystack of a review.
I assume Mr Henness is unable to help any more.
As Prof Ernst is one of the three authors of the review mentioned above, perhaps he will, in due course, oblige me?
Now I await the replies from Dr Aleem and Prof Ernst.
Thank you
Competing interests: Impatiently waiting for precise answer to my original question.
30 July 2015
JK Anand
Retired doctor
Free spirit
Peterborough


Re: Should doctors recommend homeopathy?
This has reference to JK Anand
With homeopathy remedies there are so many direct and indirect adverse effects. The direct adverse effects included abdominal pain, flatulence, acute erythroderma, acute pancreatitis, severe allergic reactions, atopic dermatitis, burning lips, nausea, emesis, apnoea, cyanosis, regurgitation, anaphylaxis, arsenical keratosis and cancer, bladder cancer, bullous pemphigoid, severe asthenia, cardiac arrest, cognitive-behavioural disorders, coma, death, dermatitis, severe pulmonary involvement, emesis, euphoria, extreme agitation, hyponatraemia and hypoalbuminaemia, erythaema, limb oedema, irritability and albuminuria, melanosis and keratosis, skin lesions, acute gastrointestinal illness, leukopaenia, thrombocytopaenia, diffuse dermal melanosis, metabolic acidosis, weight loss, chronic diarrhoea, morbiliform and pruritic rash with hospital admission, multiple alopecia and hair loss, pain, pancreatitis, problem with balance, somnolence, pruritus, swelling and erythroderma, renal failure with metabolic acidosis, interstitial nephritis and hyperkalaemia, severe acute tubulointerstinal nephritis, severe bradycardia, reversible panconduction defect, hypotension and syncope, severe swelling, bleeding, rashes, sneezing, rhinitis, slight lethargy, symptoms of thall poisoning, tachypnea, high fever, lower limb areflexia, hypotension, pupillary abnormalities, gait ataxia, widespread leukocytosis and widespread maculopapular vesicular rash. The direct side effects of homeopathy occasionally resulted in serious outcomes including cancer, death, dialysis, toxic polyneuropathy and quadriparesis. In several instances, patients presenting adverse effects required hospital admission and pharmacotherapy .
The indirect side effects with homeopathy drugs included deterioration of pulmonary allergy, deterioration of sarcoidosis glomerulonephritis, hypertensive heart failure and encephalopathy, haemophilus influenzae meningitis, septicaemia high fever and seizures, malignant melanoma, multiple organ system failure, oedema, pneumococcal pneumonia with purulent pericarditis and coma, sepsis and death and severe aggravation of atopic dermatitis. Indirect side effects of homeopathy resulted in the following clinical outcomes: death, permanent hypertension, hydrocephalus and the need for neuro-surgical drainage.
Mechanism of Adverse Effects
With homeopathy agents in the majority of cases, the possible mechanism of action involved allergic reactions or ingestion of toxic substances. Preparations of heavy metals, such as arsenic, cadmium, mercury or iron, which are frequently used in homeopathy can be toxic, if not highly diluted. Other poisons regularly employed in homeopathy include aconitum, kerosene or thallium, which also can lead to serious health problems in sufficiently low dilutions.
There are several reports of adverse effects of homeopathy have been published and some of them had serious consequences. Clinicians should be aware of the risks associated with homeopathy.
References
1. Adverse Effects of Homeopathy
http://www.medscape.com/viewarticle/777749_2
2.Posadzki P et al In J Clin Pract.2012;66(12):1178-1188
Competing interests: No competing interests
30 July 2015
M A Aleem
Neurologist
ABC Hospital
Trichy 620018 Tamilnadu India


Re: Should doctors recommend homeopathy?
JK Anand said:
"May I request:
Dr Aleem
Mr Henness
Prof Edzard
to let us have references to any reports of adverse reactions of any kind, to homoeopathic medicines, in the medical journals published in Germany and the UK.
I hope this request is reasonable."
Not really. I was pointing out the disconnect between what M A Aleem said about the specific harms of homeopathic products and what various homeopathy organisations state about their inherent safety - it's up to them to provide good evidence one way or the other. There is evidence of harms, of course, [1] but the onus is on those who proclaim homeopathy to be safe to provide the evidence that is so, and, of course, that the purported benefits outweigh those possible harms.
However, obfuscation between specific and non-specific harms should not be allowed to hinder discussion. It seems unlikely that properly diluted and manufactured homeopathic products - containing as they do, no active ingredients but simply sugar or water - could have any serious harms in themselves. Those would be specific harms, but perhaps the greater issue is that of non-specific harms such as the delay in seeking proper medical attention for potentially serious and life-threatening medical conditions and, frequently, the distrust of science and medicines such as vaccines engendered by some homeopaths. [2, 3]
References
1. Posadzki, P., Alotaibi, A. and Ernst, E. (2012), Adverse effects of homeopathy: a systematic review of published case reports and case series. International Journal of Clinical Practice, 66: 1178–1188. doi: 10.1111/ijcp.12026
2. http://discoverhomeopathy.co.uk/victims-2/
3. http://whatstheharm.net/homeopathy.html
Competing interests: Director of the Nightingale Collaboration, which challenges misleading healthcare claims.
30 July 2015
Alan Henness
Director
The Nightingale Collaboration
BM The Nightingale Collaboration, London WC1N 3XX
Saturday, August 1, 2015
Combination of Monocloinal Antibodies,β-Secretase inhibitor and a Anti-Tau agent with or without a Cholinesterase inhibitors for Alzheimer 's Disease . Aleem M A . BMJ 2015;351:h4064
Views & Reviews
No Holds Barred
Margaret McCartney: The “breakthrough” drug that’s not been shown to help in Alzheimer’s disease
BMJ 2015; 351 doi: http://dx.doi.org/10.1136/bmj.h4064 (Published 24 July 2015)
Cite this as: BMJ 2015;351:h4064
Rapid responses

Re: Margaret McCartney: The “breakthrough” drug that’s not been shown to help in Alzheimer’s disease
Combination of Monocloinal Antibodies,
β-Secretase inhibitor and a Anti-Tau agent with or without a Cholinesterase inhibitors for Alzheimer 's Disease .
In Alzheimer 's disease amyloid accumulation likely starts many years before the onset of symptoms. There are many pathways involved in amyloid synthesis and deposition cascade in the
Pathogenesis of Alzheimer ' s disease. so using of modified versions of monoclonal antibodies such as Solanezumab may not give a successful outcome. So along with monoclonal antibodies a combination of an another drug that decreases deposits of amyloid, for example, a β-secretase inhibitor, which targets an earlier step on the amyloid pathway, might have superior results. Addition of one more drug that target tau might also provide much more benefit along with above combination.
So a combination of Monocloinal antibodies, a β-secretase inhibitor and a anti-tau agent with or without a Cholinesterase inhibitors is ideal treatment strategy for prevention and progression of Alzhemier' s disease .
As far as Solanezumab is concern it may be well tolerated and without evidence of meningoencephalitis, microhemorrage or vasogenic edema. It can produce physiological changes in the amount of amyloid beta concentrations in the plasma and CSF, but Solanezumab in recent study shows no evidence of cognitive or functional improvement in patients with Alzheimer’s disease
Competing interests: No competing interests
01 August 2015
M A Aleem
Neurologist
ABC Hospital
Annamalainagar Trichy 620015 Tamilnadu India
No Holds Barred
Margaret McCartney: The “breakthrough” drug that’s not been shown to help in Alzheimer’s disease
BMJ 2015; 351 doi: http://dx.doi.org/10.1136/bmj.h4064 (Published 24 July 2015)
Cite this as: BMJ 2015;351:h4064
Rapid responses

Re: Margaret McCartney: The “breakthrough” drug that’s not been shown to help in Alzheimer’s disease
Combination of Monocloinal Antibodies,
β-Secretase inhibitor and a Anti-Tau agent with or without a Cholinesterase inhibitors for Alzheimer 's Disease .
In Alzheimer 's disease amyloid accumulation likely starts many years before the onset of symptoms. There are many pathways involved in amyloid synthesis and deposition cascade in the
Pathogenesis of Alzheimer ' s disease. so using of modified versions of monoclonal antibodies such as Solanezumab may not give a successful outcome. So along with monoclonal antibodies a combination of an another drug that decreases deposits of amyloid, for example, a β-secretase inhibitor, which targets an earlier step on the amyloid pathway, might have superior results. Addition of one more drug that target tau might also provide much more benefit along with above combination.
So a combination of Monocloinal antibodies, a β-secretase inhibitor and a anti-tau agent with or without a Cholinesterase inhibitors is ideal treatment strategy for prevention and progression of Alzhemier' s disease .
As far as Solanezumab is concern it may be well tolerated and without evidence of meningoencephalitis, microhemorrage or vasogenic edema. It can produce physiological changes in the amount of amyloid beta concentrations in the plasma and CSF, but Solanezumab in recent study shows no evidence of cognitive or functional improvement in patients with Alzheimer’s disease
Competing interests: No competing interests
01 August 2015
M A Aleem
Neurologist
ABC Hospital
Annamalainagar Trichy 620015 Tamilnadu India