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Dr KK Aggarwal

From the Desk of Editor in Chief
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

  Editorial ...

4th September, 2010, Saturday

For regular emedinews updates follow at www.twitter.com/DrKKAggarwal

ACR/EULAR Panel releases new Rheumatoid Arthritis Criteria

Earlier initiation of disease–modifying therapy should be the goal for diagnosing rheumatoid arthritis.

The new diagnostic criteria show that the early initiation of sometimes aggressive therapy can prevent erosions and may occasionally induce remission. The new rules replace what had been the prevailing RA classification criteria, which were framed by the American Academy of Rheumatology in 1987 (Arthritis Rheum 1988;31:315–24).

The new criteria rate patients on a scale of 0–10 points, with points assigned in four separate domains of signs and symptoms: joint involvement, serology, duration of symptoms, and acute phase reactants.

The New RA Criteria

Patients are definitively diagnosed with RA, if they score 6 or more points according to the following criteria.

Domain: Joint involvement

  • 1 medium–large joint (0 points)
  • 2–10 medium–large joints (1 point)
  • 1–3 small joints (2 points)
  • 4–10 small joints (3 points)
  • More than 10 small joints (5 points)

Domain: Serology

  • Not positive for either rheumatoid factor or anti–citrullinated protein antibody (0 points)
  • At least one of these two tests are positive at low titer, defined as more than the upper limit of normal but not higher than three times the upper limit of normal (2 points)
  • At least one test is positive at high titer, defined as more than three times the upper limit of normal (3 points)

Domain: Duration of synovitis

  • Less than 6 weeks (0 points)
  • 6 weeks or longer (1 point)

Domain: Acute phase reactants

  • Neither C–reactive protein nor erythrocyte sedimentation rate is abnormal (0 points)
  • Abnormal CRP or abnormal ESR (1 point)

Note: Patients receive the highest point level they fulfill within each domain. For example, a patient with five small joints involved and four large joints involved scores 3 points.

eMedinewS editorial

Tree algorithm for classifying definite rheumatoid arthritis (RA) (green circles) or for excluding its current presence (red circles) among those who are eligible to be assessed by the new criteria.
APR = acute–phase response. Serology: += low–positive for rheumatoid factor (RF) or anti–citrullinated protein antibody (ACPA); serology: ++= high-positive for RF or ACPA; serology: +/++ = serology either + or ++.

Dr KK Aggarwal
Editor in Chief
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  Photo Feature (From HCFI Gallery)

MTNL perfect Health Mela 2009

The dates of the MTNL perfect Health Mela 2009 held from Oct 3rd–12th were anounced along with a press briefing. Presence and performance of Ms Shibani Kashyap, the famous pop singer was the star attraction of the event.
In the photo: Dr K S Bagotia, CMO, Dr Ramesh Kumar NDMC, Ms Shibani Kashyap singer, Padma Shri and Dr B C Roy National Awardee Dr K K Aggarwal, President HCFI, Mr S Bhatnagar, MTNL


Dr K K Aggarwal
  IMSA Update

International Medical Science Academy (IMSA) Update

Peginterferon alfa–2A for chronic hepatitis C infection

Use treatment with peginterferon alfa–2a in patients with chronic HCV rather than treatment with peginterferon alfa–2b. (Hepatology 2010;51:1176)

  National News

3-yr 'hands-on' syllabus for rural medicos (TNN : Shobha John & Rema Nagarajan)

It syllabus for the three-year course for rural medical practitioners is ready. It promises to do away with what's "unnecessary" in the four-and-a-half-year MBBS course and prepare "hands-on" doctors at the primary level.  The course is called the Bachelor of Rural Health Care (BRHC). The Medical Council of India (MCI), which has prepared the syllabus, has differentiated between BRHC and MBBS doctors by not allowing the former to use the prefix 'Dr' to their name. Instead, they will have BRHC suffixed to their name.
This, according to Dr Ranjit Roy Chaudhury, member, board of governors of MCI, will assuage the fears of the Indian Medical Association which has been up in arms, fearing this move will trample on the toes of MBBS doctors. "This new category will be drawn from 10+2 students from rural areas/districts and 25 will be chosen district-wise after an exam. They will be trained at community colleges by practicing or retired doctors from nearby district hospitals. Their practice will be confined to that area and registration will be for one year only," he said. The course will include 10 things: Community medicine, internal medicine, pediatrics, surgery, orthopedics, obstetrics and gynecology, ophthalmology, ENT, radio-diagnosis and dentistry. It will be divided into three phases.  In the first, students will study the health problems of the community, basic principles of diagnosis and prevention of common rural aliments such as malaria, anemia, hookworm, kala-azar, TB and diarrhoea. Phase II will involve taking patient history, basic clinical examination and management of diseases. They will be tied up with national health programmes. Phase III will deal with training to prevent basic health problems. The curriculum will do away with many unnecessary aspects in the MBBS course such as in pharmacy and anatomy.

Doctors will now have to register in all states they practice (DNA News)

Medical Council of India (MCI) is planning to introduce a new registration system for doctors. As per the proposal, a doctor practicing in multiple states will have to register in all those states simultaneously, unlike now when a single registration is enough to practice anywhere in the country. “This means doctors practicing in Maharashtra, Karnataka and Uttar Pradesh will have to be registered in all three states simultaneously, irrespective of the place they got their degrees from. This will give us a better idea about availability of doctors in a state,” Sita Naik, a member of MCI’s board of governors, said.
Similarly, all doctors will have to keep state medical councils updated about the higher degrees, such as post-graduation, they acquire.

National exit exam

The health ministry is considering another MCI proposal to introduce a national exit examination for medical professionals to ascertain if they are suitable to practice as doctors. It will be a qualifying examination in each discipline of health for those who want to practice in more than one state. It will evaluate the outcome of training and proficiency attained after the completion of graduate or postgraduate medical courses.

  International News

(Contributed by Dr. Monica & Brahm Vasudev)

Diet rich in green leafy vegetables may reduce risk of developing type 2 diabetes

A meta–analysis published online in the British Medical Journal states that a diet rich in green leafy vegetables may reduce the risk of developing diabetes. In an analysis of six studies evaluating fruit and vegetable intake, only food that included spinach and cabbage was found to have a significant positive effect, with researchers finding that a portion and a half a day…reduced the risk of type 2 diabetes by 14%. Green leafy vegetables are useful, because they are high in antioxidants and magnesium. A trend suggesting a benefit for consuming greater quantities of fruits and vegetables overall was also observed.

Binge drinking dangerous for patients with hypertension

High blood pressure and binge drinking may be a lethal combination. In the study, men with high BP who even occasionally consumed more than six drinks in one sitting nearly double their risk of dying from a stroke or heart attack vs teetotalers with normal BP. Intake of ≥12 drinks at a time increased this risk almost 13–fold in the presence of severe hypertension. The study is published in the journal Stroke.

NSAIDs may slightly increase risk of stroke

A study published online in the journal Stroke has found that NSAIDs may increase chances of stroke among 38,000 Taiwanese adults who suffered strokes during a 12–month period. Earlier studies have demonstrated an association of COX–2 inhibitorswith increased risk of heart attacks and other cardiovascular issues. This led to two of those drugs, rofecoxib and valdecoxib being taken off the market.

Football players may face increased risk of heat–related illness

A study from the CDC has reiterated that football players are at much higher risk of heat–related illness compared to athletes in other sports. Football players suffer heat–related illnesses at 10 times the rate of athletes in other high school sports.

  Liver Update

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

A new blood test marker may help to rule out Acute Appendicitis

A rapid blood test for the inflammatory marker S100A8/A9 shows potential as an aid in diagnosing acute appendicitis.  S100A8/A9 is a large protein that plays a pivotal role in the acute inflammatory cascade. Diagnosis of acute appendicitis is one of the most difficult challenges for emergency physician. The assay demonstrated greater sensitivity for acute appendicitis than did either abdominal CT or white blood cell count, the most widely utilized blood test for this purpose. The assay displayed mediocre specificity, but when used in conjunction with either a WBC count or abdominal CT, the assay had a 700 negative predictive value.

  Infertility Update

Dr. Kaberi Banerjee, Infertility and IVF Specialist Max Hospital; Director Precious Baby Foundation

Q: What if IVF fails the first time? How many times will one have to undergo it?

A. You can go through IVF as many times as you wish, but we advise upto five cycles at the most.

  Gyne Update: Question of the day

Is there an association between PCOS and Social anxiety Disorder?
(Dr Reshma Aggarwal)

Yes, there is an association between PCOS & Anxiety. 

Psychological Basis of Anxiety:
PCOS affects many areas of a woman’s life, its symptoms can be embarrassing (like weight gain, acne, hair loss or unwanted hair growth) and affect the way she sees herself, and can lead to low self esteem & frustration which further cause anxiety. These women may feel unattractive & masculine, and often have anxiety attacks when they have to go out in public & prefer to stay at home because of fear of ridicule and rejection. Also a series of miscarriages can make a woman more likely to experience anxiety. The same holds true for a woman who is trying to conceive, but is unsuccessful.

Biological Basis of Anxiety:
Elevated androgens affect a woman’s mood, and make her more anxious and/or more depressed. The insulin resistance & diabetes that many women with PCOS develop can also become a possible cause of anxiety. However, more research is needed, and studies on this have not been entirely conclusive.

As far as Social Anxiety Disorder is concerned, it is a specific diagnosis with very well-defined criteria and should be differentiated from generalized or social anxiety symptoms as described above which are commonly seen in women with PCOS.

  Medicolegal Update

Dr Sudhir Gupta, Associate Professor, Forensic Medicine & Toxicology, AIIMS

What is the appearance of the firearm wounds ranging up to about 15 cm and beyond?

A doctor attending the patient of fire arm injury may be required to give opinion about the range of firing.

When a firearm is discharged at a range of 15 cm, the lacerating and burning effects of the gases are usually lost due to dispersion and cooling of the gases before they reach the skin. The bullet entrance wound is circular in shape and is surrounded by a narrow zone of skin abrasion. Blackening of the skin is sometimes seen, while tattooing is invariably found at this range. The appearance of a homicidal close–range bullet entrance wound, particularly the eccentric entrance wound indicates the direction of fire.

Beyond a range of 15 cm, all traces of blackening usually disappear, while the opening of the bullet entry remains circular in shape. Powder grain deposits may still be present, and are usually seen up to ranges of about 40–60 cm, but the limit within which powder grain deposits can occur varies with different weapons and different cartridges. This is outside the domain of surgeon/physician and is instead evaluated by the ballistic expert.

  Medi Finance Update

Q. Is it required to file a return of loss?

Ans. Yes. Filing the return of loss within the prescribed time is required, if it is desired to carry forward and set off such losses.

  Drug Update

List of Approved drugs from 01.01.2010 TO 30.4.2010

Drug Name


DCI Approval Date

Citicholine 500mg + Piracetam 400mg Tablets

For the treatment of acute stroke


  Lab Update

Blood indices

Mean corpuscular volume (MCV)

MCV (fL) = 10 × Hematocrit (in %) / RBC count (in millions/μL)

MCV measures the average volume of the red blood cells.
Normal Adult Range: 80 – 100 fl (femtoliters)

Interpretation: If <80, RBCs are microcytic; if >100, RBCs are macrocytic. Anemia can be of microcytic or macrocytic type based on whether MCV is above or below the expected normal range.

  IJCP Special

Dr Good Dr Bad

Situation: A 20–year–old male smoker wanted to know whether he should go for a cholesterol check.
Dr. Bad: It is not required.
Dr. Good: Go ahead.
Lesson: Screening is recommended at an age of 20–35 in men and 20–45 in women for people with cholesterol risk factors.

Make Sure

Situation: An ICU patient with pH below 7.2 developed cardiac arrest.
Reaction: Oh my God. Why was acidosis not managed in time?
Lesson: Make sure that all patients with pH less than 7.2 are treated on an emergency basis.

Mnemonic of the Day (Dr Varesh Nagrath)

Drugs causing hypokalemia

Beta 2 agonists/Biphosphonates (pamidronate)
Amphoterecin B /Acetazolamide (Carbonic anhydrase inhibitor)
Triamcinolone /Thiazides

Quote of the Day

Martin Luther King Jr…"The ultimate measure of a man is not where he stands in moments of comfort and convenience, but where he stands at times of challenge and controversy."
(Contributed by Dr Prachi Garg)

Hypertension Alert

A 5 mm reduction in diastolic lower blood pressure can reduce heart disease by 21%.

If the community blood pressure is kept lower than 120/80 mm Hg one can potentially prevent about 47 % of all heart attacks.

  Mind Teaser

Read this………………

GR 12" AVE

(Contributed by Dr. GM Singh)

The answer for yesterday’s Mind Teaser: "Repeat after me"

Correct answers received from: Dr Jayashree B Keshav, In Charge - Scientific Publications, The Himalaya Drug Company, Dr. Susheela Gupta, Dr Gagan Shrivastava, Dr Vijay Kansal, Dr K Mohan

Send your answer to ijcp12@gmail.com

  Humor Section

As the doctor approached the school boy to give him an injection, the boy yelled out loud with pain.

"What’s the matter?" said the doctor crossly. "I haven’t touched you yet."

"You’re standing on my foot!" answered the boy.

Funny One Liner
Dictionary: A place where success comes before work.

  An Inspirational Story

A Little Boy asks the Meaning of Life

An 8–year–old boy approached an old man in front of a wishing well, looked up into his eyes, and asked: "I understand you're a very wise man. I'd like to know the secret of life."
The old man looked down at the youngster and replied: "I’ve thought a lot in my lifetime, and the secret can be summed up in four words.
The first is ‘think.’ Think about the values you wish to live your life by.
The second is ‘believe.’ Believe in yourself based on the thinking you’ve done about the values you’re going to live your life by.
The third is ‘dream.’ Dream about the things that can be, based on your belief in yourself and the values you're going to live by.
The last is ‘dare.’ Dare to make your dreams become reality, based on your belief in yourself and your values."
And with that, Walter E. Disney said to the little boy, "Think, Believe, Dream, and Dare."

  Readers Responses
  1. Schedule for Td vaccine. In response to this query I shall like to point out that primary series of vaccines must include DPT, ie full dose of Tetanus & Pertussis along with Diphtheria at least till 5 years of age , except in cases of progressive neurological illness,  where pertussis is contraindicated & TD, not Td  is  advised. One basic fact: upper case means full dose, lower case is half dose. With the availability of Tdap (ap is half dose of acellular pertussis) role of Td is further reduced. Any child beyond  5 years should get a dose of Tdap. TT in pregnant ladies should be replaced by Tdap. This ensures better passive immunity in newborns for Diphtheria & Pertussis also. After Tdap, minor injuries need no TT till  10 years & major injuries till 5 years. Practice of Inj TT after each injury if no TT was given in last 6 months, may cause serum sickness or hyporesponsiveness to vaccine. Regards Sunil Bhatnagar, MD (sunilbhatnagar@hotmail.com )
  2. Short-cut Morning walk is supposedly the best exercise that doesn’t cost a penny and helps you out with the effective mobility of all your body joints, better blood circulation and increased vitality. Prior to visiting the religious shrines Badrinath and Kedarnath, I had consistently tried to increase the duration of my walk to be able to cope up better with the otherwise well-laid path of the hilly terrain!  When we go, say, to a nearby park for a morning walk, the idea is to walk as much as we can. But we seem to have become so used to taking short-cuts in almost every walk of life that while covering the inner boundary of the park, we turn to extreme right while taking a right turn forgetting that we in India traditionally follow the `keep to the left’ rule. This type of short-cut (that reduces our walking distance) is not only against the goal of walking `as much as you can’ but also puts the person coming from the opposite direction in trouble. So, the next time while embarking on our voyage to morning walk let us ask ourselves, “Do I really need to take a short-cut?” Dr. Narendra Kumar, kumars@vsnl.com
  3. Dear KK,  It was a treat to read your 'Krishna- Analysis'. Very thought  provoking. Thanks for initiating my journey. May Krishna always be with you and may you live up to your name.Warm Regards Guruji, Dr Ashish Sabharwal
  Public Forum

(Press Release for use by the newspapers)

Dengue is preventable and manageable

The Dengue situation in the city has created an unnecessary panic, said Padma Shri and Dr B C Roy National Awardee Dr K K Aggarwal, President Heart Care Foundation of India, BSNL Dil Ka Darbar & MTNL Perfect Health Mela. Dengue is both preventable and manageable. The risk of complications is in less than 1% of dengue cases and, if warning signals are known to the public, all deaths from dengue can be avoided.

  1. A platelet transfusion is not needed if the platelet counts are more than 10,000. Unnecessary platelet transfusion can cause more harm.
  2. Most complications of dengue occur after the fever is over. The 2 days after the last episode of the fever are crucial and during this period, a patient should be encouraged to take plenty of oral fluids mixed with salt and sugar. The main complication is leakage of capillaries and collection of blood outside the blood channels leading to intravascular dehydration. Giving fluids orally or by intravenous routes, if given at a proper time, can save fatal complications.
  3. Physicians should remember the ‘Formula of 20’ i.e. rise in pulse by more than 20; fall of BP by more than 20; difference between lower and upper BP less than 20 and presence of more than 20 hemorrhagic spots on the arm after a tourniquet test suggest a high risk situation and the person needs immediate medical attention.
  4. The onus of preventing dengue lies with the public and not with the Government authorities. The dengue mosquitoes are found only in fresh water collected outside the house and not in dirty water in the drains or ‘nallas’, flowing all over the country.
  5. In dengue, one should NOT use aspirin for fever as aspirin also has anti platelet effects.
  Conference Calendar

23rd International Conference of the International Trauma Care Organization

Date: September 6–8, 2010
Venue: India Habitat Centre Conference
Website: http://www.traumacare2010.com

  Forthcoming Events

eMedinewS Events: Register at emedinews@gmail.com

26th September: Sunday– BSNL Dil ka Darbar A daylong interaction with top cardiologists of the city. 8 AM  5 PM at MAMC Auditorium, Delhi Gate.

17th MTNL Perfect Health Mela 2010 Events: Venue: NDMC Ground Laxmi Bai Nagar, New Delhi

24th October, Sunday: Perfect Health Darbar, Interaction with top Medical experts of the city from 8 AM to 5 PM
30th October, Saturday: eMedinewS Update from 8 AM to 5 PM
29th October, Friday: Divya Jyoti Inter Nursing College/ School Competitions/ Culture Hungama
30th October, Saturday: Medico Masti Inter Medical College Cultural festival from 4 PM to
10 PM
31st October, 2010, Sunday: Perfect Health Darbar, An interaction with top Cardiologists

eMedinews Revisiting 2010

The 2nd eMedinewS – revisiting 2010 conference will be held at Maulana Azad Medical College, New Delhi on January 2, 2011. The event will have a day–long CME, Doctor of the Year awards, Cultural Hungama and Live Webcast. Suggestions are invited.

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