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Dr KK Aggarwal

From the Desk of Editor in Chief
Dr B C Roy National Awardee,

Dr KK Aggarwal
President, Heart Care Foundation of India; Sr Consultant and Dean Medical Education, Moolchand Medcity; Member, Delhi Medical Council; Past President, Delhi Medical Association; Past President, IMA New Delhi Branch; Past Hony Director. IMA AKN Sinha Institute, Chairman IMA Academy of Medical Specialities & Hony Finance Secretary National IMA; Editor in Chief IJCP Group of Publications & Hony Visiting Professor (Clinical Research) DIPSAR

Dear Colleague,

1st February 2010, Monday

Practice Changing Updates: Methotrexate-induced hepatotoxicity in patients with psoriasis

For monitoring liver toxicity in patients receiving methotrexate for treatment of psoriasis, one should individualize the decision to perform liver biopsy based on a patient's risk factors, liver chemistry results, and cumulative methotrexate dose, in accord with new updated guidelines from the American Academy of Dermatology (AAD).

Previous guidelines advocated performing liver biopsies after every 1 to 1.5 g of cumulative methotrexate.

For patients without risk factors, the AAD recommends close monitoring of liver chemistries, with liver biopsy if five out of nine SGOT levels are elevated over the course of 12 months or if serum albumin levels decline.

Liver biopsy should also be considered, on an individualized basis, after a cumulative dose of 3.5 to 4 g methotrexate. The same should also apply to when using methotrexate for rheumatoid arthritis or for sarcoid disease.

Menter, A, Korman, NJ, Elmets, CA, et al. Guidelines of care for the management of psoriasis and psoriatic arthritis: section 4. Guidelines of care for the management and treatment of psoriasis with traditional systemic agents. J Am Acad Dermatol 2009; 61:451.

Dr KK Aggarwal
Chief Editor

Do not give statins in asthma
3-hydroxy-3-methylglutaryl-coenzyme A reductase inhibitors have significantly improved outcomes in coronary artery disease. They have anti-inflammatory and cholesterol-lowering effects. Statins alter the production of T(H)1 cytokines and thus promote a T(H)2 response. This immune alteration would promote allergic diseases such as asthma.

A preliminary study published in December 2009 issue of Allergy, Asthma, & Immunology has demonstrated that patients with asthma who received statins had a worse clinical course than controls. Given the prevalence of both statin use and asthma, further research is needed.

Treatment-resistant depression
Treatment-resistant depression (TRD) presents major challenges. There is no universally accepted definition of TRD, but results from the US National Institute of Mental Health (NIMH) STARD (Sequenced Treatment Alternatives to Relieve Depression) programme indicate that after the failure of two treatment trials, the chances of remission decrease significantly.

Several pharmacological and nonpharmacological treatments for TRD may be considered when optimized (adequate dose and duration) therapy has not produced a successful outcome and a patient is classified as resistant to treatment.

Nonpharmacological strategies include psychotherapy (often in conjunction with pharmacotherapy), electroconvulsive therapy and vagus nerve stimulation. The US FDA recently approved vagus nerve stimulation as adjunctive therapy (after four prior treatment failures); however, its benefits are seen only after prolonged (up to 1 year) use. Other nonpharmacological options, such as repetitive transcranial stimulation, deep brain stimulation or psychosurgery, remain experimental and are not widely available.

Pharmacological treatments of TRD can be grouped in two main categories: switching or combining. In the first, treatment is switched within and between classes of compounds. The benefits of switching include avoidance of polypharmacy, a narrower range of treatment-emergent adverse events and lower costs. An inherent disadvantage of any switching strategy is that partial treatment responses resulting from the initial treatment might be lost by its discontinuation in favor of another medication trial. Monotherapy switches have also been shown to have limited effectiveness in achieving remission.

The advantage of combination strategies is the potential to build upon achieved improvements; they are generally recommended if partial response was achieved with the current treatment trial. Various non-antidepressant augmenting agents, such as lithium and thyroid hormones, are well studied, although not commonly used. There is also evidence of efficacy and increasing use of atypical antipsychotics in combination with antidepressants, for example, olanzapine in combination with fluoxetine (OFC) or augmentation with aripiprazole. The disadvantages of a combination strategy include multiple medications, a broader range of treatment-emergent adverse events and higher costs. (Source: Drugs 2010; 24(2):131-61)

News and Views (Brahma and Monica Vasudeva)

Why high-dose rosuvastatin did not improve cardiac remodeling in chronic heart failure in the UNIVERSE study

Statins are given for prevention of atherosclerotic outcomes in patients who have chronic heart failure (CHF), if this has an ischemic etiology. These agents may also possess additional properties, independent of effects on blood lipid levels, which may have an effect on cardiac remodeling. However, beneficial effects were not observed in the recent UNIVERSE trial.

A new study prospectively planned a substudy of UNIVERSE to explore relevant mechanistic effects of rosuvastatin, including effects on collagen turnover and plasma coenzyme Q10 (CoQ) levels. Additionally, CoQ levels in CHF patients receiving chronic statin therapy were measured.

CoQ levels were significantly reduced after 26 weeks of rosuvastatin statin therapy, compared to placebo in CHF patients in UNIVERSE trial. Patients with CHF matched for age, gender and severity of disease who had been taking statins for 12 months or longer had CoQ levels of 847 ± 344 nmol/L, significantly lower than 1065.4 ± 394nmol/L in UNIVERSE patients at baseline. Serum types I and III N-terminal procollagen peptide (PINP and PIIINP), measures of collagen turnover which can contribute to cardiac fibrosis were significantly increased in the rosuvastatin group compared to baseline in UNIVERSE patients.

In conclusion, putative beneficial effects of statin therapy on cardiac remodeling in UNIVERSE may have been negated by increases in collagen turnover markers as well as a reduction in plasma CoQ levels in these patients with CHF. (International Journal of Cardiology, January 2010)

Eye care snippets
Spectacle Frames


Efficient vision is largely dependent on an accurate treatment, and on the right type and size of a frame to hold the lenses. The frame must be both good to look at and comfortable to wear.

By 1900, spectacle frames had been made from brass, bronze, silver, wood, bone, horn, and gold. Since then, frame materials included gold, aluminum, other metal alloys, tortoise shell, and plastics. Modern frame materials are metal (gold, stainless steel, aluminum, silver, nickel, titanium, copper/beryllium alloys, and nickel/chrome alloy) and plastic (cellulose nitrate, cellulose acetate, nylon, optyl, cellulose propionate, carbon fiber, polycarbonate, polymide, and Kevlar). Frames are made of either plastic or metal or a combination of plastic and metal.

Plastic frames may be of cellulose nitrate and cellulose acetate materials. While the former type has been widely use in India till recently, the latter is now being widely used. Cellulose acetate frames are lighter in weight, and come in a variety of pleasing colors. Plastic powder frames are cheaper in price, but inferior in quality. Carbon frames get broken on impact usually at the nose-bridge. Polymide frames can be adjusted cold, and burn easily.

Metal frames are usually made of nickel, or a combination of metals or alloys. Color of the frame is dependent on the combination of alloy or paint. These frames can easily be bent. Upon impact the metal frame results in a distorted shape, which can usually be re-adjusted. Soldering can also be done to repair a frame. Metal frames are, however, not suitable for protective eyewear due to their lacerating ability.

Gold is measured by karats (pure gold is 24K). '1/20 14K GF’ means 1/20 percent of the frame's weight is gold alloy of 14K. Combination frames are made of metal, plastic materials and nylon threads, e.g., keymount, rimless etc.

Half-eye are special frames to be used as single vision reading prescription glasses. These provide freedom to the patient to look up and see in the distance without disturbance. These frames are placed lower on the nose, and not on the bridge. A spectacle frame is made of three parts: front, temples (or sides) and hinges. The front holds the lenses in position, and the sides (temples) attach to the front by way of hinges and rest over ears to keep spectacles in place. The part of the front which holds the lens is called the rim (or eyewire). Rims are connected by the bridge (which may be with or without nose pads), which rests on the nose. Metal frames usually have nose pads attached by a metal connecting piece (or pad arm).

One half of a hinge is mounted on the front and the other half, on the side of the frame. Hinges have an odd number of interlaced barrels held together by a screw. These may be attached to the front by a shield or may be embedded into the frame (hidden hinge) without a shield. Hinges may be of regular or spring types. One end of the side holds the hinge and the other end bends over the ear (earpiece). Because of variations in front styles, frames may be of half-eyes, rimless, and nylon rimless (or supra) types. Adjustable nose pads come in a variety of sizes and shapes; and their size, angle, and the distance between the two pads are critical in exact fitting of the frame as per the contour of the face of an individual. Temples may be with regular or hockey-end earpieces, or other variations.

Special purpose frames include those worn in industrial settings to protect the wearer from eye injury. Around 15% of all work-related injuries involve eyes, and the possible hazards may be classified into mechanical, chemical and radiation categories. Usually these are frames (in cellulose acetate material) fitted with lenses (polycarbonate having high impact safely, being light in weight and strong, and having inherent quality to absorb UV radiation well). These may be goggles, welding goggles, or masks. These may or may not be with side-shields. Sports eyewear, available for specific sports, commonly has elastic headbands, comfort cable temples (hockey-end sides), better eye coverage, and high impact materials.

Frame measurement and markings are done based on the Datum System (mid-lens width) to provide reference points so as to correctly position lenses in the frame with respect to optical centers and segment height for bifocals. DBL or bridge size (distance between the lenses) and DBC or frame PD (distance between the geometrical centers) are important points in frame measurement. Segment height needs to be specified in multi-focal lenses. Temple length is the measurement required for spectacles to sit on the ears correctly and comfortably.

Frames are usually marked with eye-size and bridge size. Marking of temple length is useful; it is obligatory in the US, but is not the practice in India. 52/18 denotes eye-size to be 52 and DBL (or bridge size) to be 18. Gold frames are also marked with the amount of gold present in the frame.

To conclude, the combination of accurate treatment, the best form of lens, and a proper sized frame (that is comfortable, good-looking and of good quality) provide for the best vision care needs of the patient. [Dr. Narendra Kumar (OptometryToday@gmail.com)]

Conference Update
In the first clinical trial in locally advanced esophageal cancer, gene therapy, administered concurrent with chemotherapy and radiotherapy, led to high pathologic complete response (pCR) rates and a doubling in survival over historic controls. (Kenneth Chang, University of California Irvine Medical Center, Orange; 2010 Gastrointestinal Cancers Symposium (GICS): Abstract 45)

 Question of the Day
What is relapse and recrudescence of malaria?

Relapse of disease after it has been apparently cured: In malaria, true relapses are caused by reactivation of dormant liver stage parasites (hypnozoites) found in P. vivax and P. ovale. This can occur any time after 30-180 days of the primary attack. The relapses have the characteristic symptoms of malaria. Splenomegaly may be a prominent feature in these patients.Such long-term relapses commonly occur in patients who have either not taken primaquine or taken incomplete treatment.

Recrudescence or repeated attacks of malaria (short term relapse or delayed): occur due to the survival of malaria parasites in red blood cells. In P. falciparum and P. malariae infections, the parasites can remain in the blood for months or even years and cause recurrent symptoms from time to time. In falciparum malaria, such recrudescence can occur within 28 days of the primary attack and may indicate partial resistance to chloroquine. However, treating every case of recurrent P. falciparum as resistant malaria is unjustified. One should consider the possibility of re-infection in most of these cases. It is a common observation that in a household, only some members get recurrent attacks of malaria while the others escape the infection. In such cases, it is important to find the cause for this phenomenon. The person may be getting bitten by the mosquitoes elsewhere, may be at his/her workplace. The resting and sleeping habits of such individual may be facilitating mosquito bites.

 Readers responses

 1. Congratulations Dr. Aggarwal on this honour. May God bless you.  Dr. R. K. Sharma.

2. Congratulations Dr. For your award, Satyen


4. Dear Dr Aggarwal,I would like to congratulate you for receiving the very well deserved Padma Shri award and best wishes for many more to come your way. Thanking you, With Kind regards, Dr. P. Kar, Director Professor of Medicine & Gastroenterologist, Department of Medicine, Maulana Azad Medical College,

 5. Dear Dr Aggarwal, Congratulations. Dr Surinder H.Singh

What people have to spaek about Dr KK Aggarwal

1. Dear Dr. Aggarwal, My family joins me in extending hearty congratulations and felicitations to you on your being conferred the prestigious Padmashri. Please accept our warmest greetings and good wishes on behalf of the entire Apollo Family.

This recongnition is indeed very well deserved: the credibility and respect that you have brought to the healthcare sector, specially your invaluable and passionate contribution in the field of cardiac sciences are indeed amazing. I write on behalf of the entire medical fraternity of the Apollo Hospital Group: You have made all of us proud. With warm wishes: Dr. Prathap C. Reddy

2. Dr Krishan Aggarwal is great scholar and Medical scientist. I know Krishan since last 30 years as a Bright student and Dedicated medical person and great human being. It is a great joy and satisfaction that he has been honoured with Padma Award by President of India. I am proud  to be his one of the Teacher. Congratulation Krishan.
Dr. (Prof) Suresh. C. Tiwari, Director  Fortis Institute of Renal Sciences

3. Hi KK, Heartiest Congratulations on your receiving Padma Shri award. We are very happy and proud of you. You deserve it. Kanta and Dr Navin C Nanda (Director echo lab USA UAB)

Dr Good Dr Bad

Situation: A 34-year-old-woman with PCOS on metformin got pregnant.
Dr Good: Continue metformin.
Dr Bad: Stop metformin.
Lesson: In women with PCOS, continuous use of metformin during pregnancy significantly reduces the rate of miscarriage, gestational diabetes requiring insulin treatment and fetal growth restriction. No congenital anomaly, intrauterine death or stillbirth is reported. (J Obstet Gynaecol Res 2008;34(5):832-7)

 ENT Facts
Acute otitis media in children is marked by rapid onset of signs and symptoms such as otalgia (ear pain or pulling of the ear in an infant), irritability in an infant or toddler, ear discharge (otorrhea) and/or fever.

Make Sure
Situation: A patient on contact lens with keratitis developed severe infection
Reaction: Oh my God! Why was he not treated intensively.
Make sure that all patients with suspected bacterial keratitis who use contact lens are promptly and empirically treated with a fourth-generation fluoroquinolone (gatifloxacin or moxifloxacin) with a combination fortified aminoglycoside/fortified cephalosporin eye drops instilled hourly.

Formulae in Imaging
Pleural effusions became visible as a meniscus on the lateral chest radiograph at a volume of approximately 50 ml; at a volume of 200 ml, the meniscus could be identified on the posteroanterior radiograph. At a volume of about 500 ml, the meniscus obscured the hemidiaphragm. (Source: Acad Radiol 1996;3(2):103-9)

Mistakes in Critical Care
Include allergies and age and weight of patient on prescriptions when possible.

Emedinews Try this It Works
Insulin safety net
When diabetic patients who need insulin at home are hospitalized, it is common practice to have them follow a regimen of regular insulin on a sliding scale alone, and insulin is taken only when the blood glucose level is high. This is a common mistake and we allow the patient develop hyperglycemia.

It is much more 'physiologic' to have patients take regular insulin plus a reduced dose of NPH insulin (once or twice a day) so that blood glucose levels don't reach high readings in the first place. With this regimen, the sliding scale is used only as a ‘safety net,’ in case additional insulin is required.

Milestones in Neurology
Joseph Jules François Félix Babinski (1857 –1932) was a Polish neurologist. He is best known for his 1896 description of the Babinski sign, a pathological plantar reflex indicative of corticospinal tract damage.

Laughter the Best Medicine (Sent by Ms Kamleshwari)
Patient: My hair keeps falling out. What can you give me to keep it in?
Gynecologist: A shoebox.

SMS Anemia
Iron deficiency Anemia (IDA) is classically described as a microcytic anemia.

Quote (Sent by Swapna C K )
Certain thoughts are prayers. There are moments when, whatever be the attitude of the body, the soul is on its knees. (Victor Hugo)

Public Forum
Press Release

Sudden cardiac death is an instant unexpected death, which occurs within one hour of the onset of cardiac symptoms.

Over 24-lakh people die in the country of sudden cardiac deaths and 17 lakh of them die suddenly before reaching the hospitals; 12 lakh of them can be revived if the general public is taught basic cardio brain pulmonary chest resuscitation, said Dr K. K. Aggarwal, President, Heart Care Foundation of India and Editor eMedinewS.

The main cause of death in such situations is generally an irregularity of the heart rhythm called ventricular tachyarrhythmia. The underlying pathology is usually coronary heart blockages in middle aged and elderly persons, but can also be one of the familial well defined heart enlargement (hypertrophic cardiomyopathy, dilated cardiomyopathy, arrhythmogenic right ventricular dysplasia).

In children and young athletes, two main causes of sudden death are long QT syndrome (abnormal ECG) and hypertrophic cardiomyopathy (commonest cause of deaths during sports). Such patients are advised to avoid competitive sports.

Family history of sudden cardiac death should encourage the physician to examine the patient's relatives.

About half of all deaths from coronary heart disease are sudden and unexpected, regardless of the underlying disease.

The term "massive heart attack" is often mistakenly used in the media to describe sudden death. The term "heart attack" or myocardial infarction refers to death of heart muscle tissue due to loss of blood supply, not necessarily resulting in the death of the heart attack victim. While a heart attack may cause cardiac arrest and sudden cardiac death, the terms are not synonymous.

In people without organic heart disease, recreational drug abuse is an important cause of sudden cardiac death.

There are numerous contributors to cardiac arrest, but most important ones are:
1. A previous heart attack: 75% of the people who die of SCD show signs of a previous heart attack.
2. Coronary artery disease: 80% of sudden cardiac death victims have signs of coronary artery disease. This is a condition in which the arteries that supply blood to the heart are narrowed or blocked.
3. Other parameters are low heart functions and high resting heart rate.

4. Very high blood pressure

Hypertensive urgency must be distinguished from emergency. Urgency is defined as severely elevated blood pressure (i.e. upper systolic >220 mm Hg or lower diastolic >120 mm Hg) with no evidence of target organ damage.
Hypertensive emergency on the other hand requires immediate therapy to decrease blood pressure within minutes to hours. A hypertensive emergency is a condition in which elevated blood pressure results in target organ damage.
No evidence suggests a benefit from rapidly reducing blood pressure in patients with hypertensive urgency. In fact, such aggressive therapy may harm the patient, resulting in cardiac, renal, or cerebral hypo perfusion.

(Advertorial section)


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Advertising in emedinews
emedinews is the first daily emedical newspaper of the country. One can advertise with a singe insertion or 30 insertions in a month. Contact: drkk@ijcp.com. emedinews@gmail.com  

eMedinewS-PadmaCon 2010: 

Will be organised at MAMC on 3rd July Sunday to commomorate Doctors day. The speakers, chairpersons and panelists will be various past and present padma awardees of NCR.

eMedinewS-revisiting 2010 

The second eMedinewS-revisiting 2010 conference will be held at Maulana Azad Medical College, New Delhi on 2nd January 2011. The event will have a day-long CME, doctor of the year awards, cultural hangama and live webcast.  Suggestions are invited.

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Punjab & Sind Bank
Central Bank of India