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  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


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eMedinewS Presents Audio News of the Day

Photos and Videos of 3rd eMedinewS – RevisitinG 2011 on 22nd January 2012

Photos of Workshop on Stress Management and How to be Happy and Healthy

  Editorial …

2nd June 2012, Saturday

Red flag arthritis

Arthritis is not a disease but a symptom indicating pain in joints. Skeletal muscular disorders which mean disorders of joints, muscles, bones and soft tissues account for about 20% of the problems encountered by the general practitioners in their clinical practice.

Arthritis clinically can be divided into two types: Mechanical structural damage, which constitutes 90% of arthritis. This is called green flag arthritis, wear and tear arthritis or mechanical structural arthritis. In clinical terms, it is called osteoarthritis. In 10% of cases, arthritis is red flag dangerous arthritis involving defense system impairment and autoimmune system. It is a systemic disease and not arthritis alone and the commonest form is rheumatoid arthritis.

Following are the points and excerpts of a panel discussion held between Dr. AN Malviya, Dr. Jatinder Maheshwari and Dr. KK Aggarwal.

  • Osteoarthritis of the knee is the commonest arthritis in the body. It is wear and tear arthritis usually seen in patients with obesity, not exercising or in patients who have past injury or in patients who are suffering from rheumatoid arthritis.
  • Extra weight of one Kg extra weight leads to 9 kg extra weight on the knee joint.
  • The causes linked with osteoarthritis are obesity, squatting, sitting cross legged, climbing stairs which are more than 4 inches in height and genetic in origin. Genetics is an important aspect in arthritis.
  • Smoking is not directly linked with arthritis but linked with rheumatoid arthritis. Alcohol and diet are linked with osteoarthritis through obesity.
  • The best exercises for osteoarthritis are – brisk walking, aerobics, cycling and swimming. To prevent arthritis, the best exercise is walking and once arthritis develops, the best exercise is cycling.
  • One should not give painkillers in osteoarthritis for more than three months. It is always better to try methods which can omit painkillers. It is a myth that glucosamine helps. In acute arthritis, one can try cold fomentation and in chronic cases, hot fomentation.
  • Acupuncture may be helpful as it secrets endorphins.
  • Surgery may be required in both early and late stages. In late stages, surgery corrects deformities and in the early stages, surgery corrects the correctable causes of bone disorders which can lead to osteoarthritis.
  • One can also try knee support, braces etc. to pull on the pain of arthritis for some time.
  • In osteoarthritis, one can experience pain in climbing the stairs or climbing down the stairs, especially if the patella joint is involved.
  • Osteoarthritis is common in elderly specifically aged 50 plus.
  • Red flag arthritis involves 1% of population with rheumatoid arthritis with female: male ratio of 4:1. Up to 60–70 lakh people in India may be suffering from deforming rheumatoid arthritis. 70% of them may be in bad shape because of deformity.
  • Rheumatoid arthritis should be diagnosed as early as possible but definitely within 6 months.
  • For diagnosis: 85% history helps, 10% examination helps and only in 5% cases do diagnostic lab tests help. Lab tests involve ESR, rheumatoid factor, ACPA (high specificity).
  • The second type of red flag arthritis is spondyloarthritis (SPA).
  • SPA can be axial involving the spine or peripheral involving the below trunk joints. The peripheral form is usually missed. It is seen in young people with male: female ratio of 2:1. Patients often present with low backache, which is worse in the morning. They have bad nights but as they get up in the morning, they feel better. Immobility is bad for them and mobility is good for them. The age group affected is usually less than 17 years and the disease involves below waist joints which are hip, knee, ankle and feet. It is asymmetric. Early morning stiffness is present. Smoking worsens the situation.
  • Axial arthritis is called ankylosing spondylitis and has similar features but it involves spines.
  • Inflammatory arthritis is a systemic arthritis, which involves lungs, ear, heart liver and legs. Most people die 20 years prematurely. It impairs the range of motion in spine. It is a systemic illness.
  • Rheumatoid arthritis is treated with methotrexate 20–25 mg every week. The maintenance dose is 12.5 mg. Hydroxychloroquine is a must as it improves lipids and reduces heart attack and improves patient’s symptoms. Leflunomide is to be used if above two combinations fails but it is a toxic drug. Sulfasalazine should be used if other two drugs fail but it is mildly acting drug. TNF blockers are to be used if the patients are refractory and the drugs available are infliximab and etanercept.
  • Three other drugs, which are available for rheumatoid arthritis are abatacept, Abatacept, tocilizumab and rituximab. The last one is broad-spectrum and can be used in many conditions. In SPA, NSAIDs are disease modifying drugs and they should be given continuously and not on demand for a period of two continuous years. Etoricoxib is a good choice but naproxen and indomethacin can also be given. IV pamidronate 60 mg + IV 250 mg methyl prednisolone can be given for three days; repeated monthly for six months. Stiffness can be measured clinically or by CRP and ESR. In 66 % cases, the NSAIDs will work and they will fail in 33% requiring lifetime TNF inhibitors. They are to be given every second month (infliximab and etanercept).

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

Red flag arthritis

Audio PostCard
    Photo Feature (from the HCFI Photo Gallery)

Quitting Tobacco Poster released by
Hon’ble Chief Minister Smt Sheila Dixit

A poster depicting 10 benefits of quitting tobacco was released by Hon’ble Chief Minister of Delhi Smt Sheila Dixit on the occasion of World No Tobacco Day. Padma Shri and Dr BC Roy National Awardee Dr KK Aggarwal and DMA Members were presented on the occassion

Dr K K Aggarwal
    National News

ICMR to study health impacts of Grass pea

Fifty years after khesari dal (Lathyrus sativus) was banned for sale, the Central government will conduct an epidemiological study of the high–protein legume that can be grown in extreme weather conditions. Khesari dal, also known as Grass pea, was banned for consumption in 1961 as it was believed that Beta–N–Oxalyl–aminoalanine, a neurotoxic amino–acid in the legume, caused neurolathyrim or a paralysis of the lower limbs. It is cultivated extensively in central and western India for cattle fodder. Chhattisgarh, Maharashtra and West Bengal are the only States where the sale for human consumption was not banned. Khesari dal is also cheaper than other pulses, whose prices have gone up manifold in the past few years. The withdrawal of the ban will help to solve the shortage of pulses, as it is believed that the harmful effects of khesari dal depends on the amount consumed, its toxin content, the method of cooking and the nutritional status of individuals. Furthermore, the amount of neurotoxin varies from variety to variety and is inversely proportional to the moisture content in the soil, with the toxin content increasing in drought conditions. The Planning Commission has asked the Indian Council of Medical Research (ICMR) to conduct an epidemiological study in Chhattisgarh, where the cultivation of khesari dal is the highest. The study will be co–ordinated by the Centre for Promotion of Nutrition Research and Training with Special Focus on North East, Tribal and Inaccessible Population of the ICMR, along with the India Gandhi Krishi Vishwavidyalaya, Raipur; Pt. Jawaharlal Nehru Memorial Medical College, Raipur; the All–India Institute of Medical Sciences, New Delhi; and the National Institute of Nutrition, Hyderabad. (Source: The Hindu, May 27, 2012)

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

(Contributed by Dr Monica and Brahm Vasudev)

Ten–day course of doxycycline effective for erythema migrans

A 10–day course of doxycycline controls erythema migrans as effectively as a 15–day course, according to researchers from Slovenia. "For adult patients with solitary erythema migrans who have no clinical signs of disseminated disease and are not immunocompromised, pregnant, or lactating, we employ 10–day treatment with doxycycline 100 mg twice daily," Dr. Franc Strle from University Medical Center Ljubljana told Reuters Health. (Source: Medscape)

For comments and archives

Peyronie disease responds to new medical treatment

Collagenase Clostridium histolyticum (CCh) alleviates many symptoms of Peyronie disease, according to the findings of a phase 2b randomized, double–blind, placebo–controlled trial. Martin Gelbard, MD, from Urology Associates Medical Group in Burbank, California, and colleagues published their findings in the June 2012 issue of the Journal of Urology. (Source: Medscape)

For comments and archives

FDA Oks cip–isotretinoin for severe recalcitrant nodular acne

The US Food and Drug Administration (FDA) has approved cip–isotretinoin, a novel, patented brand formulation of the currently available acne medication isotretinoin, Cipher Pharmaceuticals announced this week. Cip–isotretinoin is indicated for the treatment of severe recalcitrant nodular acne. It is expected to be available in the United States in the fourth quarter of 2012 under the brand name Absorica. (Source: Medscape)

For comments and archives

VEGF levels may indicate brain bleed

A signaling factor that promotes blood vessel growth may play a role in the cerebral microbleeds that often follow an ischemic stroke, researchers reported.

For comments and archives

Prophylaxis, early treatment of HIV show promise

Although treating people exposed to HIV soon after exposure is crucial, offering treatment to some especially high–risk people before potential exposure is an even newer approach that is showing promise, according to a review article focusing on strategies for preventing HIV infections in nonoccupational settings, published in the June issue of Canadian Medical Association Journal. (Source: Medscape)

For comments and archives

    Prayer Meeting

Dr. Vidya Prakash Sood (13/04/1936 – 03/03/2012)

A prayer meeting will be held to pay homage to the departed soul of Dr VP Sood (Issue Editor – Asian Journal of Ear, Nose and Throat) who passed away peacefully on March 3, 2012 in USA.

Date: Sunday 10th June 2012
Venue: Chinmaya Mission (Auditorium), 89, Lodhi Road, New Delhi.
Time: 11 A.M – 12 Noon

(IJCP and eMedinews)

For comments and archives

  Twitter of the Day

@DrKKAggarwal: DMA and Heart Care Foundation of India Demands complete ban on Gutka, Tobacco & Tobacco Products DMA and Heart… http://fb.me/1tL7nxS08

@DeepakChopra: Language creates reality. Words have power. Speak always to create joy.

    Spiritual Update

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

Science behind Ganga Dussehera

Ganga dussehera is the day when one can wash away all their sins. Ganga is most sacred Divine River of the world. Its water never gets spoiled even when heavily polluted. It is worshipped like a Goddess sitting on white lotus (detached attachment) and wearing white clothes (purity).

For comments and archives

    Infertility Update

(Dr Kaberi Banerjee, IVF expert, New Delhi)

What are the psychological effects of the multiples on a family?

Many women with a multiple pregnancy do well; their families may experience significant stress. Even if medical problems are overcome and the infants survive without disability, the effect of multiple births on family life is profound and life–altering. The impact of a multiple birth clearly affects the parents, but also the babies, other siblings, and the extended family. Financial stresses may be overwhelming. Obvious additional costs include feeding, clothing, housing, and caring for multiple children.

For comments and archives

    Tat Tvam Asi………and the Life Continues……

(Dr N K Bhatia, Medical Director, Mission Jan Jagriti Blood Bank)

Advantages of leukodepleted blood

  • Closed System Preparation ensuring complete sterility and minimizing the risk of bacterial contamination
  • Reduced incidence of non–hemolytic febrile transfusion reactions
  • Better patient response to transfusion, less investigations, less number of transfusions

For comments and archives

    An Inspirational Story

(Ms Ritu Sinha)


People are unreasonable, illogical and self–centered. Love them anyway.

If you do good, people will accuse you of selfish ulterior motives. Do good anyway.

If you are successful, you win false friends and true enemies. Succeed anyway.

The good you do today will be forgotten tomorrow. Do good anyway.

Honesty and frankness make you vulnerable. Be honest and frank anyway.

What you spend years building may be destroyed overnight. Build anyway.

People really need help but may attack you if you help them. Help people anyway.

Give the world the best you have and you’ll get kicked in the teeth. Give the world the best you’ve got anyway.

For comments and archives

  Cardiology eMedinewS

EU okays combination type 2 diabetes pill Read More

Exposed to passive smoking, infants develop infections Read More

Risk score shows likely long–term ICD benefit Read More

  Pediatric eMedinewS

Parenteral MTX in children with JIA questioned Read More

Soy formula has no effect on baby’s cognition Read More

Vitamin D deficiency linked with eardrum perforation risk Read More

    IJCP Special

Dr Good Dr Bad

Situation: A diabetic patient was found to have high ESR and elevated CRP.
Dr Bad: You are suffering from an inflammatory disease.
Dr Good: This may be a part of diabetes.
Lesson: In diabetes, both ESR and CRP can be high at the same time and this can be due to IL–6 secretion by adipose tissue.

For comments and archives

Make Sure

Situation: A patient on dialysis and on oral antacid developed aluminium toxicity.
Reaction: Oh my God! You should have put him on magaldrate preparations?
Lesson: Make sure to remember that magaldrate preparations do not cause aluminium toxicity in patients undergoing dialysis.

For comments and archives

    Legal Question of the day

(Prof. M C Gupta, Advocate & Medico–legal Consultant)

What action can be taken to improve the following situation?

"On 4th October, 2011, S. Naskar, a 53–year–old male of Ramnagar village near Haldia, an industrial town, was bitten by a viper snake. He was taken to the Haldia State General Hospital. No treatment was given there and he was referred to the Tamluk district hospital about 60 km away. There he was given only 5 vials of AVS (anti–viper serum) and was transferred to the NRS Medical College Hospital at Kolkata, where, on 5th Oct (Navami of Durga puja), he was admitted in the Male Medical Ward on Bed No. 8 and had to purchase 10 vials of AVS from outside."

Ans. This is a disappointing and unacceptable situation that should not be quietly and silently accepted without protest if any change has to be brought about. I suggest the following:

  1. Write letters to the three hospitals concerned under the RTI Act to get relevant information.
  2. At the same time, without waiting for RTI replies, send a proper (legally drafted) complaint to the state health authorities under the West Bengal Clinical Establishments Act, 1950.
  3. Send a complaint to the West Bengal Medical Council against doctors of the Haldia State General Hospital who sent away a viper snake bite patient without proper treatment. Even if the hospital did not have the medicine, the hospital should have procured the same urgently and administered it to the patient without loss of time.
  4. Most likely, the Haldia State General Hospital and the NRS hospital would be covered under the CPA, 1986. A consumer complaint seeking compensation can be filed there.
  5. Later, at an appropriate stage, a writ petition or a PIL may be filed in Calcutta High Court.
  6. All the above should be done with legal guidance.

For comments and archives

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  Quote of the Day

(Dr GM Singh)

Men are like steel. When they lose their temper, they lose their worth. Chuck Norris

    Lab Update

(Dr Navin Dang and Dr Arpan Gandhi)

AST (aspartate aminotransferase)

This test is normally done to:

  • Check for liver damage
  • Check for liver disease, especially hepatitis and cirrhosis

High levels of AST may be caused by:

  • Recent or severe liver damage, such as hepatitis caused by a viral infection or drug reaction
  • Decay of a large tumor (necrosis)
  • Shock

Moderately high levels may be caused by:

  • Chronic diseases affecting the liver, such as cirrhosis
  • Heart attack or heart failure
  • Alcohol abuse
  • High doses of vitamin A
  • Kidney or lung damage
  • Mononucleosis
  • Duchenne’s muscular dystrophy
  • Some types of cancer
  • Myositis

Slightly high levels of AST may be caused by:

  • Fatty deposits in the liver
  • Medicines, such as statins, antibiotics, chemotherapy, aspirin, narcotics, and barbiturates
  • Alcohol abuse
    Mind Teaser

Read this…………………

A recent fitness walk left you breathless, and you’ve been having trouble sleeping. You’ve also been dealing with an upset stomach and occasional dizziness. These could be symptoms of:

A. Depression
B. Heart disease
C. Diabetes
D. High blood pressure
E. All of the above.

Yesterday’s Mind Teaser: Nurse Katrina would recognize that the demonstration of crutch walking with tripod gait was understood when the client places weight on the:

a. Palms of the hands and axillary regions
b. Palms of the hand
c. Axillary regions
d. Feet, which are set apart.

Answer for Yesterday’s Mind Teaser: b. Palms of the hand

Correct answers received from: Dr Gopal M Shinde, Yogindra Vasavada, Dr Chandresh Jardosh,
Dr Jainendra Upadhyay, Dr Thakor Hitendrsinh G, Raju Kuppusamy.

Answer for 31st May Mind Teaser: c. It is associated with APC mutation.
Correct answers received from: Y J vasavada.

Send your answer to ijcp12@gmail.com

    Laugh a While

(Dr GM Singh)

When will they meet?

A mathematician, a physicist and an engineer were each given the following problem to solve.

A school dance floor included a straight line down the middle dividing the floor in two equal halves. Boys were lined up against one wall and girls against the opposite wall, each facing the centre line. They were instructed to advance in stages towards the centre line every 10 seconds, where the distance from the person to the centre line at each stage is equal to one–half the distance at the past stage i.e.: If the starting distance from the wall to centre line was D, the progressive series of distances at t = 0, 10 seconds, 20 seconds…10n seconds to the centre line is (D, D/2, D/4, D/8, ……D/2n). The question was when will they meet at the middle?

The mathematician said that they would never meet.

The physicist said they would meet when time equals infinity.

The engineer said that in one minute they would be close enough for all practical purposes.

    Medicolegal Update

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

What is the 8th clause of Section 320 Indian Penal Code for doctors?

The eighth clause of Indian Penal Code 320 defines grievous hurts as "Any hurt which endangers life or which causes the sufferer to be during the space of twenty days in severe bodily pain, or unable to follow his ordinary pursuits."

  • Ordinary pursuits means the patient is unable to visit the toilet, to bathe or brush his teeth, eat himself, walk or carry on such daily pursuits and requires mandatory help of other person for 20 days
  • The length of time during which an injured person is in pain, disease or is not able to pursue his ordinary daily routine work must be meticulously and satisfactorily observed by the doctor himself before certifying the injury as a grievous injury.
  • It is employed not only in cases where violence has been used but also in cases where hurt has been caused without any assault, e.g., by administration of drugs, setting of traps etc. The extent of hurt and the intention of the offender are considered for giving punishment.
  • It is difficult for a doctor to prove that an injured person was in severe bodily pain for 20 days but it is easier to prove that he was unable to follow his ordinary profession/pursuits due to the hurt.
  • A mere stay of 20 days in the hospital doesn’t make injury grievous. The certifying doctor must rule out and document the feigned illness in medicolegal report.

For comments and archives

    Public Forum

Public Forum (Press Release for use by the newspapers)

Can diabetes be warded off?

Adhering to Mediterranean diet, rich in fruits and vegetables and low in animal products may protect from type 2 diabetes said Padma Shri and Dr B C Roy Awardee Dr KK Aggarwal, President Heart Care Foundation of India, quoting a Spanish study. The Mediterranean diet gives emphasis to olive oil, vegetables, fruits, nuts, cereals, legumes and fish, and de–emphasizes meat and dairy products. It is a healthy eating plan that prevents heart disease.

In the study published in the British Medical Journal, researchers tracked the diets of 13,380 Spanish university graduates with no history of diabetes. The study participants filled out a 136–item food questionnaire, which measured their entire diet (including their intake of fats), their cooking methods and their use of dietary supplements. During an average of 4.4 years of follow–up, the researchers found that people who adhered to a Mediterranean diet had a lower risk of developing type 2 diabetes. In fact, those who very closely adhered to the diet reduced their risk by 83 percent.

Moreover, the people who tended to stick closest to the diet were those with factors that put them at the highest risk for developing diabetes, such as being older, having a family history of diabetes and being an ex–smoker. These people were expected to have a higher rate of diabetes, but when they adhered to the Mediterranean diet this was not the case.

Type 2 diabetes is typically brought on by poor eating habits, too much body weight and too little exercise. One key factor that might be responsible for the protective effect of the Mediterranean diet is its emphasis on olive oil for cooking, frying, putting on bread and mixing in salad dressings.

Tips to prevent diabetes

  • Eat less
  • Omit refined carbohydrates (white sugar, white rice and white maida)
  • Use olive oil, vegetables, fruits, nuts, cereals, legumes and fish, and reduce meat and dairy products.
    Readers Response
  1. Great reaction by Dr Atul, very nicely written. It should be circulated to all through IMA. Vivek Kumar, Varanasi.
    Forthcoming Events
Dr K K Aggarwal

4th Asia Pacific Vascular Intervention Course (APVIC–IV)

Date: June 8–10–2012

THE OBEROI, Dr. Zakir Hussain Marg, New Delhi
In association with ‘International Society of Endovascular Specialists’ ‘Vascular Society of India’ ‘Society of Cardiovascular Angiography & Interventions’


All are cordially invited for the 2nd National Conference of IYCF Chapter of IAP. This conference is organized by: IYCF Chapter, MOH&FW GOI, MOWCD GOI, WHO, UNICEF, IMLEA, SDHE Trust.
The theme of the conference is: "Proper Nutrition: Defeat Malnutrition – Investing in the Future"
Venue: India Habitat Centre, Lodhi Road, New Delhi – 110 003.
Date: 5th Aug 2012
For further details contact:
Conference Secretariat: Dr. Balraj Yadav, E–Mail: drbalraj@ymail.com, drvisheshkumar@gmail.com,
Ph: +91.124.2223836, Mobile: +91.9811108230

Dil Ka Darbar

September 23, 2012 at 9:00 AM – 6:00 PM
Tal Katora Indoor Stadium, Connaught Place, New Delhi, 110001

A non stop question answer session between all the top cardiologists of the NCR region and the mass public. Event will be promoted through hoardings, our publications and the press. Public health discussions

    eMedinewS Special

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3. eMedinewS audio lectures (This may take a few minutes to open)

4. eMedinewS ebooks (This may take a few minutes to open)

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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