emedinews
Head Office: E–219, Greater Kailash, Part 1, New Delhi–110 048, India. e–mail: emedinews@gmail.com, Website: www.ijcpgroup.com
FIRST NATIONAL DAILY eMEDICAL NEWSPAPER OF INDIA
eMedinewS is now available online on www.emedinews.in or www.emedinews.org
  From the Desk of Editor–in–Chief
Dr KK Aggarwal

Padma Shri and Dr B C Roy National Awardee
Dr KK Aggarwal
President, Heart Care Foundation of India; Sr Consultant Physician, Cardiologist and Dean Medical Education Moolchand Medcity; Chairman Ethical Committee Delhi Medical Council; Chairman (Delhi Chapter) International Medical Sciences Academy; Hony Director IMA AKN Sinha Institute (08–09); Hony Finance Secretary National IMA (07–08); Chairman IMA Academy of Medical Specialties (06–07); President Delhi Medical Association (05–06), President IMA New Delhi Branch (94–95, 02–04); Editor in Chief IJCP Group of Publications & Hony. Visiting Professor (Clinical Research) DIPSAR

 

Live Web Cast of 3rd eMedinewS – Revisiting 2011, on January 22, 2012

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eMedinewS Presents Audio News of the Day

Photos and Videos of 2nd eMedinewS – Revisiting 2010

 
  Editorial …

2nd January 2012, Monday

Anna Admitted in Hospital with Flu Complications

Why was Anna admitted in the hospital on 31st night? Medically it looks he has developed pneumonia? Let us revise the subject.

  1. If has no pneumonia what is Anna’s risk to life: Residents of nursing homes and other chronic care facilities; adults ≥65 years of age; pregnancy; asthmatics; heart patients ( except isolated hypertension), underlying cancer/liver/kidney disease, diabetics, sickle cell disease, immunosuppression, HIV positive, cognitive dysfunction, spinal cord injuries, seizure disorders, neuromuscular disorders and obesity with BMI ≥40. Looking at the above he is at low risk with low morbidity and mortality as the only risk factor he has in age.
  2. If he has pneumonia than what is the risk now: We calculate the risk using the CURB-65 score? As per British Thoracic Society in patients above 65 there is 21-fold increase in mortality in patients who had two or more of the following findings: blood urea nitrogen greater than 20 mg/dL; diastolic blood pressure less than 60 mmHg and respiratory rate above 30 per minute. Again the only risk factor is his age and therefore even if he develops or has developed pneumonia he is at low risk of complications.
  3. What are Anna’s chances of developing pneumonia: Pneumonia is the most common complication of influenza, but other complications, especially involving muscle and the central nervous system, also occur. The types of pneumonia that are encountered are categorized as primary viral pneumonia, secondary bacterial pneumonia, or a mixture of both. Primary flu pneumonia occurs when flu virus directly involves the lung, typically producing a severe pneumonia. One should suspect when symptoms persist and increase instead of resolving. Secondary bacterial pneumonia contributes to 25% of all flu deaths. Patients present with exacerbation of fever and respiratory symptoms after initial improvement.

For More editorials…

Dr KK Aggarwal
Group Editor in Chief

 
  eMedinewS Audio PostCard

Stay Tuned with Padma Shri and Dr BC Roy National Awardee Dr KK Aggarwal

Top Cardiology News of 2011

Audio PostCard
 
    Photo Feature (from the HCFI Photo Gallery)

18th MTNL Perfect Health Mela 2011

Harmony – An Inter School Health Festival at Perfect Health Mela Competitions like debate, model display, slogan writing, role play, dance, yoga etc was organized on the spot and students were awarded

 
Dr K K Aggarwal
 
    National News

Infant mortality rate shows slight decline

The infant mortality rate (IMR) has shown a 3 point decline, dropping from 50 deaths per 1,000 live births to 47 and moving a step closer to achieving the Millennium Development Goals (MDG) target of 30. However, IMR increased by one point in Kerala, Mizoram and Dadra and Nagar Haveli. According to the latest Sample Registration System (SRS), conducted by the Registrar–General of India, the two worst performing States — Madhya Pradesh and Himachal Pradesh — have shown an impressive 5 point decline. In the former, the figure dropped from 67 in 2009 to 62 in 2010 and in the latter, it was from 45 to 40. While the IMR national average is 47, it stands at 51 in the rural areas and 31 in the urban regions. However, neo–natal deaths continue to be a challenge where 34 babies are still dying for every 1,000 born. (Source: http://www.thehindu.com/news/national/article2755207.ece, December 28, 2011)

For comments and archives

Certificate courses in 2D and 3D Echocardiography/Fellowship Diploma in non invasive cardiology: Contact Dr KK Aggarwal, Moolchand Medcity, email: emedinews@gmail.com

 
    International News

Two–drug combo appears best for refractory epilepsy

For patients with refractory epilepsy, a combination of lamotrigine and valproate may be the best option for preventing seizures, a retrospective analysis showed. (Source: Medpage Today)

For comments and archives

Silent strokes may scatter memory

Subclinical, or silent, strokes seen on brain imaging may predict memory loss in older age, researchers found. (Source: Medpage Today)

For Comments and archives

Transfusion guidelines in children reviewed

Thresholds for transfusing children vary from those in adults, according to a 2–part review study published in the January 2012 issue of Anaesthesia & Intensive Care Medicine. The first part of the review describes normal hematological ranges in infants and children, lower levels of hemoglobin that can be tolerated without undue risks, and how to evaluate blood loss to ensure that blood products are not transfused unnecessarily. The second part of the review describes strategies to avoid transfusion of blood products, and which fluids to use instead, as well as recommendations regarding how much and which blood products to use when indicated to reduce adverse effects. Normal hemoglobin values are highest at birth (14 – 24 g/dL), decreasing to 8 to 14 g/dL at 3 months, and then gradually increasing to 10 to 14 g/dL at age 6 months to 6 years, 11 to 16 g/dL at age 7 to 12 years, and 11.5 to 18 g/dL in adulthood. (Source: Medscape Medical News)

For comments and archives

 
  Cardiology eMedinewS

(Dr KK Aggarwal, Group Editor in Chief, IJCP Group of Publications and eMedinews)

People with Risk Factors Should Visit Cardiologist

Read More

FDA Approves New Combination for Hypertension

Read More

BP and Sugar Control In Diabetes - What Are The Targets

Read More

 
  Twitter of the Day

@DrKKAggarwal: Padma Shri Awardee Dr KK Aggarwal on Top health happenings in 2011 in In… http://www.youtube.com/watch?v=dM3B6JOxyVE&feature=share via @youtube

@DrKKAggarwal: The universe is a mirror of consciousness. The events in your life reflect who you are.

 
    Spiritual Update

(Dr KK Aggarwal, Group Editor in Chief, IJCP Group of Publications and eMedinews)

Understanding Anna as A Leader

There are only two types of people in the community: leaders or followers. Most of us are followers with only a few amongst us with leadership qualities. A leader is the symbolic soul of a group who acts as a catalyst for change and transformation. The group may be a family, business, political party, community, nation, civilization or any other organization. The actions of the leaders are shaped by the memory and experience, propelled by desires.

For comments and archives

 
    Infertility Update

(Dr Kaberi Banerjee, IVF expert, New Delhi)

Why is infertility evaluated?

Infertility is usually diagnosed if you don’t conceive after one year of unprotected intercourse. If you are concerned about fertility or have an obvious medical problem affecting your ability to conceive, such as amenorrhea, sexual dysfunction, a history of pelvic disease, or prior surgery, you should begin the infertility evaluation immediately. You will undergo various tests, which may include ovulation detection and evaluation of your fallopian tubes, cervix, and uterus. Your partner will have a semen analysis. Most testing can be completed within three months, and appropriate treatment can be started immediately after the evaluation is completed. Preconception counseling is often beneficial as well. Because children born to women over 35 have a higher risk of chromosomal problems, you may wish to discuss these risks with your physician or a genetic counselor prior to attempting pregnancy. Prenatal testing may be performed after conception. Amniocentesis and chorionic villus sampling are two methods of prenatal testing. Blood testing and ultrasound may also be used as screening tests for certain birth defects.

For comments and archives

 
    An Inspirational Story

(Ms Ritu Sinha)

Acres of Diamonds

One of the most interesting Americans who lived in the 19th century was a man by the name of Russell Herman Conwell. He was born in 1843 and lived until 1925. He was a lawyer for about 15 years until he became a clergyman.

One day, a young man went to him and told him he wanted a college education but couldn’t swing it financially. Dr. Conwell decided, at that moment, what his aim in life was, besides being a man of cloth – that is. He decided to build a university for unfortunate, but deserving, students. He did have a challenge, however. He would need a few million dollars to build the university. For Dr. Conwell, and anyone with real purpose in life, nothing could stand in the way of his goal.

Several years before this incident, Dr. Conwell was tremendously intrigued by a true story – with its ageless moral. The story was about a farmer who lived in Africa and through a visitor became tremendously excited about looking for diamonds. Diamonds were already discovered in abundance on the African continent and this farmer got so excited about the idea of millions of dollars worth of diamonds that he sold his farm to head out to the diamond line. He wandered all over the continent, as the years slipped by, constantly searching for diamonds, wealth, which he never found. Eventually he went completely broke and threw himself into a river and drowned.

Meanwhile, the new owner of his farm picked up an unusual looking rock about the size of a country egg and put it on his mantle as a sort of curiosity. A visitor stopped by and in viewing the rock practically went into terminal convulsions. He told the new owner of the farm that the funny looking rock on his mantle was about the biggest diamond that had ever been found. The new owner of the farm said, "Heck, the whole farm is covered with them" – and sure enough it was.

The farm turned out to be the Kimberly Diamond Mine…the richest the world has ever known. The original farmer was literally standing on "Acres of Diamonds" until he sold his farm.

Dr. Conwell learned from the story of the farmer and continued to teach it’s moral. Each of us is right in the middle of our own "Acre of Diamonds", if only we would realize it and develop the ground we are standing on before charging off in search of greener pastures. Dr. Conwell told this story many times and attracted enormous audiences. He told the story long enough to have raised the money to start the college for underprivileged deserving students. In fact, he raised nearly six million dollars and the university he founded, Temple University in Philadelphia, has at least 10 degree–granting colleges and six other schools.

When Doctor Russell H. Conwell talked about each of us being right on our own "Acre of Diamonds", he meant it. This story does not get old…it will be true forever…

Opportunity does not just come along – it is there all the time – we just have to see it.

For comments and archives

 
  Fitness Update

(Contributed by Rajat Bhatnagar, International Sports & Fitness Distribution, LLC, http://www.isfdistribution.com)

Running protects against weight gain, regardless of diet

Exercise physiologists and researchers alike have always questioned the role of diet and nutrition against the role of exercise in weight loss and weight maintenance. Most often, experts agree that both are important factors in weight loss and in living a healthy lifestyle. Now, a new study shows evidence that exercise plays a significant part of the equation. Researchers from the Lawrence Berkeley National Laboratory in Berkeley, California found that exercise (specifically running) protects against weight gain, regardless of diet. The study is published in the most recent issue of the journal Medicine & Science in Sports & Exercise.

For the study, a total of 106,737 participants completed a comprehensive survey. The two–page survey was sent to subscribers of a running magazine and to participants of running events. It asked for demographic characteristics, running history, current average weekly mileage, current weight and height as well as history, and dietary habits, including average weekly consumption of meat, fruits and vegetables. Runners were divided into groups based on the frequency and duration of their runs, and various analyses were performed. The survey data clearly showed that running prevented weight gain, regardless of dietary habits. Although most avid runners were more likely to eat a healthier diet, some ate a significantly higher amount of meat, fat and carbohydrates. Avid runners who ate this unhealthy diet were not affected by weight gain, whereas those who did not run as frequently were much more likely to have an increased weight and/or BMI.

For comments and archives

 
    Legal Question of the Day

(Dr MC Gupta, Advocate & Medico–legal Consultant)

Q. Can an MBBS legally perform surgery for hernia, piles, fistula, removal of uterus or appendix and cesarean section etc.?

Ans.

  1. An MBBS is a graduate in surgery and hence he cannot be legally denied the right to perform surgery. However, law operates not in vacuum but in a real situation with respect to time, place and person. All the surgeries mentioned by you could be validly performed in a remote place where there is no surgeon available to alleviate the suffering of people, especially in emergency. None of these would be expected to be done by an MBBS where qualified surgeons are easily available.
  2. No hard and fast rule can be made applicable in all situations. However, I suggest the following guidelines would seem appropriate:
    1. An MBBS doctor can undertake those surgeries about which he has been taught/trained in his MBBS course and in which he is experienced.
    2. He should preferably not undertake surgery involving general anesthesia.
    3. He should not routinely hold out as a surgeon, especially when a qualified surgeon is available in the area.
    4. Relaxation in the above norms may be permissible in emergencies where it is a question of saving life.
  3. Attention is drawn to the following guidelines issued by the AP Medical Council regarding surgery that may be performed by MBBS doctors.

    "What Can an MBBS Doctor do:–
    1. He can do all the Minor Surgical Procedures for which he is trained in MBBS Course and Houseman Ship.
    2. He can do Deliveries and its related procedures as trained.
    3. He can do National Programmes like Tubectomies & Vasectomies.
    4. In emergencies if a qualified surgeon is not available in the near vicinity, as a life savings measure he can do first aid and a Surgical Procedure based on his experience.
    5. He should not do Elective Major Surgical procedures and the care should be taken to refer to a nearby Hospital where a Surgeon/Gynecologist available."

For comments and archives

 
    Healthy Driving

(Conceptualized by Heart Care Foundation of India and Supported by Transport Department; Govt. of NCT of Delhi)

Driving and epilepsy

An epileptic should avoid driving when sick or tired as these can precipitate seizures.

 
    Medicine Update

(Dr. Neelam Mohan, Director Pediatric Gastroenterology, Hepatology and Liver Transplantation, Medanta)

How do you monitor cystic fibrosis liver disease?

Given the challenges in diagnosing cystic fibrosis (CF) liver disease, periodic monitoring for hepatobiliary disease is recommended for all patients with CF. Annual monitoring should include physical examination for liver span, texture, and spleen size, as well as laboratory studies such as complete blood count, liver tests, and fat–soluble vitamin status. Further, because hepatobiliary disease may be a presenting feature in a small percentage of patients, sweat test or mutational analysis should be performed in any patient with undefined liver or biliary disease, even those without overt symptoms of CF.

For comments and archives

 
    IJCP Special

Dr Good Dr Bad

Situation: An elderly type 2 diabetic patient with lung cancer came with A1c of 7.5%.
Dr Bad: This is high. You need insulin therapy.
Dr Good: This result is ok.
Lesson: As per the 2007 American College of Physicians (ACP) guidelines, A1c goal is > 7% for type 2 diabetic patients who are elderly or frail or have a limited lifespan due to comorbid condition.

For comments and archives

Make Sure

Situation: A patient with diabetes shows deteriorating kidney function.
Reaction: Oh my God! His HbA1c is very high!
Lesson: Make sure that strict glycemic control is maintained in patients with type 2 diabetes in order to delay vascular complications.

For comments and archives

 
  Quote of the Day

(Dr GM Singh)

One can never speak enough of the virtues, the dangers, the power of shared laughter.

 
    Lab Update

(Dr Arpan Gandhi and Dr Navin Dang)

Serum calcium

As part of a routine metabolic, electrolyte panel, in persons with kidney, bone, or nerve disease, or when symptoms of significantly increased or decreased calcium concentrations are present.

 
    Mind Teaser

Read this…………………

getting
it all

Yesterday’s Mind Teaser:  Fairy, Wolf and Duckling

Answer for Yesterday’s  Mind Teaser: The good, the bad, and the ugly

Correct answers received from: Dr. T. Samraj, Raju Kuppusamy, Dr. Mrs. S. Das, Dr. P. C. Das, Dr Ajay Gandhi, Dr. Thakor Hitendrasinh G, Dr.NeelamNath.

Answer for 31st December Mind Teaser: d. XDR TB has not been reported in HIV–positive patients.
Correct answers received from: Dr Anupam, Dr Chandra, Dr Krishna, Dr Sudhir, Priyanshu, shipra, Daman, KP Singh

Send your answer to ijcp12@gmail.com

 
    Laugh a While

(Dr GM Singh)

Too drunk 374

A police officer pulls over this guy who had been weaving in and out of the lanes. He goes up to the guy’s window and says "Sir, I need you to blow into this breathalyzer tube." The man says, "Sorry officer I can’t do that. I am an asthmatic. If I do that I’ll have a really bad asthma attack."

"Okay, fine. I need you to come down to the station to give a blood sample." "I can’t do that either, I am a hemophiliac. If I do that, I’ll bleed to death."

"Well, then we need a urine sample." "I’m sorry officer I can’t do that either. I am also a diabetic. If I do that I’ll get really low blood sugar."

"Alright then I need you to come out here and walk this white line." "I can’t do that, officer." "Why not?"

"Because I’m too drunk to do that.

 
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    Medicolegal Update

(Dr Sudhir Gupta, Additional Prof, Forensic Medicine & Toxicology, AIIMS)

Post mortem in surgical death due to alleged negligence

  • Information is required before beginning the medicolegal autopsy. The patient’s notes are essential along with some other relevant information. Equally important is the attendance of clinicians at the autopsy, more indeed, in deaths associated with anesthesia.
  • Discussion among autopsy surgeon and the anesthetist may arrive at an amicable conclusion of opinion to offer the investigating authority.
  • The hospital lab may be requested to retain any ante mortem blood or fluid samples sent to them so that they remain available for analytical checks, such as blood grouping in transfusion mishaps, or creative phosphokinase activity in malignant hyperthermia.
  • If death is due to a disease or disability, other than that for which the operation was performed, a distinction has to be drawn between those conditions that were known before the operation was performed and those which were unexpected. Naturally, operative and anesthetic techniques may have to be modified to take account of the known adverse conditions.
  • Death may occur due to failure of a surgical technique. This may be inadvertent, from a true ‘accident’ sometimes caused by unusually difficult operative circumstances, to anatomical abnormalities or even failure of equipment.
  • When it is a result of error of incompetence, then a legal action for negligence may ensue and the autopsy surgeon must be even more meticulous than usual in producing a detailed and impartial report.
  • When a failure of equipment may be responsible, then expert examination and advice is required. Anesthetic machines, gas supply, compatibility of connections and all the sophisticated hardware of Operation Theater must be subjected to the most rigorous inspection if a malfunction is suspected. This becomes an important concern to the autopsy surgeon, because he is responsible for the eventual decision about the cause of death.
  • The risk of death from all causes cardiac arrest was the most common single mode of death, being seen on average once or twice a year in most busy operating suites even under the most careful surgical and anesthetic regimens.
  • Most cardiac arrest occurs at either the start or finish of the surgical procedure.

For comments and archives

 
    Public Forum

(Press Release for use by the newspapers)

Get your Press release online http://hcfi.emedinews.in (English/Hindi/Audio/Video/Photo)

Greet your friends with the traditional Namaste on the New Year

Heart Care Foundation of India Wishes Everyone a Very Happy and Healthy New Year. Padma Shri & Dr. B.C. Roy National Awardee, Dr. KK Aggarwal, President, Heart Care Foundation of India., said that the New Year should bring physical, mental, social, spiritual, environmental and financial well being amongst the public at large.

He also said that we must all greet our friends and colleagues with our traditional greeting, Namaste, instead of shaking hands on this New Year because you can spread viruses and bacteria or you may also catch these germs.

Many diseases can be transmitted through contaminated hands. Most common are flu and the common cold Respiratory infections like the cold and flu are common in the winter months. Although the cold and flu viruses spread through air by coughing or sneezing, they can also spread by direct contact with contaminated surfaces such as a door knob or by shaking hands with someone who has the infection. If someone has a cold or flu and coughs into his hand, and then they touch a surface like a door knob, he or she transmits the virus on to that surface. The flu virus stays in the air longer when air is cold and dry as in the winter season.

The length of time that cold or flu germs can survive outside the body on an environmental surface, such as a doorknob, differs to a great extent. But the suspected range is from a few seconds to 48 hours depending on the specific virus and the type of surface.

Flu viruses tend to live longer on surfaces than cold viruses do. The cold and flu viruses live longer on nonporous surfaces such as plastic, metal or wood than they do on porous surfaces like fabrics, skin or paper.

Many other gastrointestinal diseases such as salmonellosis, shigellosis, hepatitis A, giardiasis, amebiasis can also spread through contaminated hands.

Keeping hands clean is the single most important way to prevent the spread of infectious diseases like cold or flu. Hands should be frequently washed with soap and water or with an alcohol–based hand sanitizer.

For comments and archives

 
    Readers Response
  1. Happy New Year 2012 to all the mentors of eMedinews family !– Dr.Malika Minocha Bharadwaj
  2. Dear Dr Aggarwal, I am a regular reader of your e medical newsletter and I really appreciate your dedication in bringing the newsletter out with a focus on relevant topics for all. We at Guwahati, Assam are organizing a National Assembly on Pediatric Emergency Medicine (NAPEM) in Mar 2012. This is for all Pediatricians and other doctors (physicians and surgeons) who see children at some time of their practice. Can I request your esteemed newsletter to please put up a small advertisement of our conference in the forthcoming issues for wider desimmination of information via your newsletter. I would be grateful to you for the same.Thanking you:Yours sincerely:Dr Rashna Dass, M.D. Head, Pediatrics, NEIGRIHMS:Shillong, Meghalaya:& Organizing Secretary, NAPEM 2012
 
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eMedinewS Events: Register at emedinews@gmail.com

3rd eMedinewS Revisiting 2011

The 3rd eMedinewS – revisiting 2011 conference will be held at Maulana Azad Medical College, New Delhi on Sunday January 22nd 2012.

The one–day conference will revisit and cover all the new advances in the year 2011. There will also be a webcast of the event. An eminent faculty is being invited to speak.

There will be no registration fee. All delegates to get registration kit, Attractive gifts, Conference Newsletter, certificates, Morning Snacks, lunch will be provided. The event will end with a live cultural evening, Doctor of the Year award, cocktails and dinner. Kindly register at www.emedinews.in/ rekhapapola@gmail.com/drpawangupta2006@yahoo.com

3rd eMedinewS Doctor of the Year Award

Dear Colleague, The Third eMedinews "Doctor of the Year Award" function will be held on 22nd January, 2012 at Maulana Azad Medical College at 5 pm. It will be a part of the entertainment programme being organized at the venue. If you know of any medical doctor who you feel has made significance achievement in the year 2011, send his/her biodata: emedinews@gmail.com

3rd eMedinewS Revisiting 2011

Dr K K Aggarwal – Revisiting the Year 2011, M K Doogar – Health Insurance, What’s New, Central Bank of India – Financial Health Update, LIC – Schemes, Dr N K Bhatia – What ís New in Transfusion Medicine, Dr Praveen Chandra – Antiplatelets in Cardiology, Dr Ambrish Mithal – Obesity as a Precursor for Diabetes, Dr Ajay Kriplani – Surgery in Diabetes, Dr Kaberi Banerjee – Infertility Update, Dr Kailash Singla – Gastro Update, Dr Surjit Jha – Diabetes Update, Dr Sheh Rawat – What’s New in Radiation Oncology, Dr Amit Bhargava – Cancer Update, Dr Sanjay Chaudhary – Automation in Cataract Surgery with Femto–second laser, Dr Neelam Mohan – Liver Transplant Update, Dr Vikram Sanghi – Imaging Update, Dr Surender Kumar – Diabetes in 2012, Dr S K Khanna – Cardiac Surgery in 2012

For Complete Details Click

IMSOCN2012

The Annual conference of Indian Menopause Society is to be held from 17 to 19th Feb 2012 in Hotel The Claridges, Surajkund Faridabad. It is multidisciplinary approach to the problems of midlife onwards in women. This conference has participation of British Menopause Society and South Asian Federation Of Menopause Societies and opportunity to hear from international faculties.

For information Contact Dr. Maninder Ahuja (Organizing Chairperson) 9810881048 down load forms from web sit http://indianwoman35plus.com/ or Indianmenopausesociety.org or http://fogsi.org/

Contact at ahuja.maninder@gmail.com
Call for free papers and posters on theme topics of conference.

Early Registration till 30th Dec 2011

 
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    Our Contributors

Dr Veena Aggarwal, Dr Arpan Gandhi, Dr Aru Handa, Dr Ashish Verma, Dr A K Gupta, Dr Brahm Vasudev, Dr GM Singh, Dr Jitendra Ingole, Dr Kaberi Banerjee (banerjee.kaberi@gmail.com), Dr Monica Vasudev, Dr MC Gupta, Dr Neelam Mohan (drneelam@yahoo.com), Dr Navin Dang, Dr Pawan Gupta(drpawangupta2006@yahoo.com), Dr Parveen Bhatia, (bhatiaglobal@gmail.com), Dr Prabha Sanghi, Dr Prachi Garg, Rajat Bhatnagar (http://www.isfdistribution.com), Dr. Rajiv Parakh, Dr Sudhir Gupta