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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

  Editorial ...

5th November 2010, Friday

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

eMedinewS wishes all its readers a very happy, bright and safe Diwali!

What are the rituals behind pooja?

Pooja means to take care or to serve. As per Vedas, pooja can be Shodasha Upachara Pooja (16 steps), Dasopachara Pooja (10 steps) or Panchopachara Pooja (5 steps).

Most follow the path of 16 steps, which have deep Vedic meaning. As GOD resides within us we should incorporate these 16 basic steps as the foundation of our daily routine or dincharya. These should also form the steps of our behavior with others and how to receive and treat guest at home (atithi devo bhava).

The 1st step is Dhyana and Avahana where the ritual involves sitting before the image or the idol of the deity or the coconut depicting GOD and meditating. Dhyana (focused attention) with prayers (intention) invokes the deity into the idol. The symbolic message behind the ritual is to start the day with meditation and invoking the self within us hidden behind the triad of kama, greed and ego. It also means inviting guests at home.

The 2nd step is Asana and the ritual involves offering the deity a seat by touching the deity idol and asking the GOD to sit. In case of guests, it symbolizes offering warm welcome. In daily routine, it prepares one for the next step of personal hygiene.

The next three steps involve Padya (washing the deity’s feet with water and offering respect), Arghya (offering water to wash hands), and Achamanya and Madhuparka (offering water to clean the mouth and face). Madhuparka (Madhu - Honey) is a beverage made of honey and milk offered for drinking. All the three steps symbolize the sequence of external bath in our daily routine.

The 6th step is Abhishekam or Snanam and involves bathing the deity with different options (water, milk, rose water, sandalwood paste, panchamrit (milk, water, curd, water, honey, water, ghee, water and sugar, water). It provides one the natural ways of bathing by not depending on the soap.

The 7th, 8th, 9th, 10th, 11th and 12th steps involve various offerings. Firstly, Vastra or dress; secondly, Gandha or sandalwood/kumkum (red powder); thirdly, Abarana or gold/silver/stone ornaments; fourthly, Pushpa mala or flowers; fifthly, Archana or flowers of various types and finally Dhoop or an incense stick like an agarbatti or incense stick.

The 13th step is Deepam or offering to the lighted lamp. The 14th step is Naivedya or prasada i.e. offering food which is satvik (fruits) and/or cooked, including kheel and patasha, symbolizing fulfilled desires.  It is followed by Tambol (supari, pan, betel leaves, and clove) symbolizing internal cleansing.

The 15th step is Aarti, which is lighting camphor and reciting mantras. Mantras here symbolize the intentions or the check list of the day to be completed by the end of the day. The aarti ends with Dakshina, a reminder to start the day with some charity.

The last step is the Pradakshina and Namaskara or offering flowers at the feet of GOD symbolizing surrender and then prostrating before the deity and thanking him for giving us another day to live. It also invokes humility within us to live yet another day full of inner happiness. 

Dr KK Aggarwal
Editor in Chief
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  Quote of the Day

"Joy comes from using your potential." ~ Will Schultz

    Photo Feature (from the HCFI Photo Gallery)

 Women Empowerment 2010

A Seminar on Women and Child healthcare issues was organized in the just concluded 17th MTNL Perfect Health Mela by Dr Sadhna International Women’s Rights Protection Trust and Heart Care Foundation of India.

Dr K K Aggarwal
    National News

Certificate courses in 2D and 3D Echocardiography/ Fellowship Diploma in non invasive cardiology

Contact Dr KK Aggarwal, Moolchand Medcity, email: emedinews@gmail.com

Tobacco warning pic may change

Approved by Union Health Minister Ghulam Nabi Azad earlier this year, the newly selected pictorial warning on tobacco products depicting “mouth cancer” is most likely to be replaced. Having notified it in May this year, the Health Ministry was all set to introduce the new picture of mouth cancer on both smoke and smokeless forms from December 1, 2010. It is unlikely that the same picture would now be used on the products. The ministry decided to change the pictorial warning after a survey revealed that it was not serving any purpose. As of now, picture of a scorpion is used on bidi packs and that of a cancer-affected lung on cigarette packs. About 30-odd countries use pictorial warnings on tobacco products. (Source: Indian Express)

World’s smallest cat found in UP

A camera–trapping exercise at Uttar Pradesh’s Pilibhit forests has revealed presence of rare species like the world’s smallest cat and four–horned antelope. "Presence of rusty–spotted cats and four–horned antelopes, locally called as Chausingha, was hardly known in the region and it was only when they were trapped by the cameras that their presence was revealed," said Harish Kumar of World Wide Fund for Nature (WWF). WWF–India had deployed the cameras for the ongoing tiger census in association with the Wildlife Institute of India (WII), the National Tiger Conservation Authority (NTCA), and the State Forest Department. (Source: The Pioneer)

    International News

(Contributed by Rajat Bhatnagar, International Sports & Fitness Distribution, LLC)

Diet and physical activity intervention helps obese adults lose weight and gain health

Researchers conducted a one–year, randomized trial study to examine whether a physical activity program, in addition to diet, would promote greater weight loss than diet alone in severely obese adults. After looking at the effects of a combined physical activity and restricted diet lifestyle intervention, researchers concluded that this type of program "can result in clinically significant and meaningful weight loss and improvements in cardio metabolic risk factors in severely obese patients." The study also noted that the addition of physical activity aided in even greater weight loss.

Physical activity can improve academic achievement

The Centers for Disease Control and Prevention (CDC) conducted a comprehensive literature review evaluating fifty studies that examine the relationship between school–based physical activity and school–based performance. As a result of this review, the CDC team concluded that physical activity was positively related to academic performance and, "increasing or maintaining time dedicated to physical education may help, and does not appear to adversely impact academic performance." In light of these findings, the CDC believes that parents and schools can feel confident that sending kids out to play at recess, increasing access to quality physical education classes, incorporating physical activity into the classroom and supporting extra–curricular physical activity and sports may help academic performance, with no negative affects.

Physical activity may reduce postmenopausal breast cancer risk

After looking at data from the twenty–year Nurses’ Health Study, researchers have found that moderate physical activity, including brisk walking, may reduce the risk of postmenopausal breast cancer, and that increasing activity after menopause may be beneficial. This research confirms the association between physical activity and breast cancer that has been observed in other large perspective studies, most of which have found a ten to thirty percent lower risk, through comparing the most active subjects with the least active subjects. They also found that activity appears to have a proactive effect during the postmenopausal years, suggesting that it is never too late for women to reap the benefits of getting physically active.

Insulin sensitivity may explain link between midlife obesity and memory problems

Psychologists at The University of Texas at Austin conducted research that found that obese individuals demonstrate different brain responses from their normal weight peers while completing challenging cognitive tests. Though both groups performed equally well, obese individuals displayed lower functional brain response in one region of the brain: the inferior parietal lobe. In light of this finding, researchers have concluded that impaired insulin sensitivity, (which generally accompanies obesity), may serve as a mediator between obesity and cognitive activity decline later on. "The good thing about insulin sensitivity is that it’s very modifiable through diet and exercise," says psychology graduate student Mitzi Gonzales, who co–authored the paper published in the journal Obesity.

The way doctors communicate can aid in patient weight loss

According to a recent study, patients whose doctors consistently collaborate with, reflect and listen to them while discussing weight loss, are more likely to be successful in shedding unwanted pounds. In this observational study, patients whose doctors used motivational interviewing techniques when discussing their weight loss, typically lost weight within 3 months of post–appointment. Those patients whose physicians did not use, or did not consistently use, these communication techniques either gained or maintained weight. Lead researcher, Kathryn Pollard, noted that doctors are usually called upon to be experts, not to change behavior. The whole point is to help the patient solve the problem himself. Doctors have to see the difference between behavioral counseling and the rest of their job.

    Infertility Update

Dr. Kaberi Banerjee, Director Precious Baby Foundation

What is IUI? What is the average success rate of IUI? How many cycles of IUI can we try?

IUI or intrauterine insemination is a simple OPD procedure. In this procedure washed capacitated sperms are introduced in the uterus. The ovary is stimulated by giving hormone injections to produce multiple follicles and the procedure is carried out when the eggs are about to be released. We have had a good success rate with this method and recommend it as the first–line of treatment in patients who have patent tubes and a reasonably good semen count. Success rate varies according to the indication but around 15% to 18% can be considered good. Most couples conceive within first three cycles of IUI, in subsequent cycles the positive outcome is less. One can try up to six IUI cycles then probably turn to IVF–ET (In Vitro Fertilization Pre–Embryo Transfer).

For queries contact: banerjee.kaberi@gmail.com.

    Gastro Update

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

What are the other investigations that help to diagnose IBD?

  • Technetium white cell scanning documents areas of inflammation and is undertaken in several centers. It is a safe, noninvasive investigation that may lack specificity but can be helpful to define disease extent. It may give a false-negative result, if the child is taking steroids and also may not show esophageal or pelvic inflammation.
  • Ultrasound, in skilled hands, is a sensitive and noninvasive way of identifying thickened small bowel loops in CD and may identify abscesses or free fluid in the peritoneum.
  • Computed tomography (CT) and, increasingly, magnetic resonance imaging (MRI) of the pelvis, for example, may help clinicians to evaluate activity and complications of disease (e.g., fistula). Due to decreased radiation exposure, small–bowel MRI is replacing small bowel follow–through in some centers.
  • Laparoscopy may be helpful in selected patients, for e.g. if intestinal TB is possible.
  • Capsule endoscopy is not widely used in children at present but may become increasingly valuable in the diagnosis of disease of the small intestine. Capsule endoscopy cannot be used in the presence of strictures because it may be retained.
    Medicolegal Update

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

What is opiate abuse?

Opiates, also called opioids or narcotics, are used to treat pain, cough and diarrhea etc. Examples of opiates are:codeine methadone, dextromethorphan, morphine, dextropropoxyphene, heroin (opium diamorphine), pentazocine, pethidine etc. Opiates are often abused as they make people feel relaxed. Opiate abuse is harmful.

  • Opiates affect the brain so that the patient becomes deeply unconscious; breathing becomes slower and may stop suddenly.
  • When diphenoxylate is taken together with atropine, it may be many hours before the opiate affects breathing. Atropine slows down the absorption of the opiate from the gut into the blood.
  • Opiates in poisonous can cause death within an hour, particularly if taken with alcohol or other substances that slow down the brain.
  • People treated with opiates may become dependent on them. People taking opiates for a long time may need to take larger doses to get the same effects, and may take a fatal dose by mistake.
  • Diphenoxylate with atropine can cause serious poisoning if given to young children to treat diarrhea. Diphenoxylate with atropine is especially dangerous if more than the therapeutic dose is taken, because atropine delays the effect of the opiate for many hours, sometimes up to 30 hours after the dose. If patients with suspected poisoning are sent home too soon, before the opiate has started to take effect, they may stop breathing and die before there is time to get them back to hospital.

The antidote to opiates is naloxone. Naloxone should be given if the patient is taking fewer than 10 breaths per minute. Dose: 1 ml (0.4 mg) by intramuscular injection, for adults and children. If the patient does not wake up and begin to breathe normally after 2–3 minutes, give another injection. Up to four doses can be given if the patient still does not recover.

    Diabetes Update: Question of the Day

What are the barriers to insulin therapy? (Dr Shobhana Ramachandran) 

Some common barriers to initiation of insulin therapy are:

Cost: About 65% of people with diabetes feel insulin is costly. This barrier can be overcome by asking the patient to visualize the cost of treating the complications due to uncontrolled diabetes.

Fear of injections: Patients feel that injections are painful. Today we have sharp needles that slide through the skin with little or no pain. About 5% of people on insulin frequently experience emotional distress and feelings of disgust related to self–injecting.

Social stigma/embarrassment: Reluctance to self–inject may also be associated with the fear of being stigmatized meaning being looked upon by others as sick or an addict. Social stigma can be overcome by excusing oneself from the crowd and finding a private place to self–inject. Pen injectors can be used instead of the regular syringes.

Patients’ attitude and perceptions: For some, insulin therapy indicates that the disease has advanced into a very serious stage. They may try to postpone or evade insulin therapy. Some fear that once insulin is started, they have to continue taking it lifelong. Many fear that they might get addicted to insulin.

Physicians’ attitude, perceptions and practices: Patients are sensitive to their doctors’ attitude and behavior. Unfortunately, insulin therapy is often used as a threat to force people with type 2 diabetes to exercise more and adhere to their diet ("If you go on like this, I am afraid I will have to put you on insulin!"). By labeling insulin therapy negatively, physicians may stimulate people with diabetes to think that they have failed, leading to self–blame and feelings of guilt.

Fear of hypoglycemia: Hypoglycemia has been found to be a worry for many people. Even the so–called ‘mild hypos’ (self–correctible) disrupt normal functioning and cause feelings of embarrassment. Hypoglycemia can be prevented by proper monitoring of blood sugar and adjustment of insulin dose, and by avoiding long intervals in between meals or including intermediary foods.

Weight gain: Some people are afraid of weight gain. But the overall weight gain due to insulin therapy is moderate.

Other common barriers are change in regular routine and the daily concerns of insulin therapy. Though the above barriers deter the patient, these barriers can be overcome through instructive education and psychosocial counseling.

    Lab Update

(Dr Arpan Gandhi and Dr Navin Dang)

Tests for deep and systemic fungal infections

  • To identify the microorganism responsible, and to determine its likely susceptibility to specific antimicrobial agents
  • To detect and identify bacteria that may be causing a concurrent infection.

    Tests include:
  • Microscopic examination of the sample (KOH prep and calcofluor white stain) to determine whether or not the infection is due to a fungus
  • Fungal culture: This is the primary test used to diagnose a fungal infection.
  • Susceptibility testing: A follow–up test to the fungal culture may be done to help guide treatment.
  • Antigen and Antibody testing: Available for a variety of different fungi but only for deep or systemic infections. May be performed on blood or other body fluids, such as CSF.
    Medi Finance Update

Global funds: These funds invest in any country around the globe. Foreign equity funds provide an opportunity to diversify across many markets and reduce the risks associated with the health of any one economy and its stock market. These funds do have risks associated with political and market conditions in other countries. In addition, foreign funds are exposed to currency risk. Different accounting practices and securities regulations around the world may affect the fund managers’ ability to value and trade in some securities. Portfolio managers seek to reduce these risks by investing in different countries and industries

    Drug Update

List of Drugs Prohibited for Manufacture and Sale through Gazette Notifications under Section 26a of Drugs & Cosmetics Act 1940 by the Ministry of Health and Family Welfare

Drugs prohibited from the date of notification

Fixed dose combination of Metoclopramide with systemically absorbed drugs except fixed dose combination of metoclopramide with aspirin/paracetamol

    IMSA Update

International Medical Science Academy (IMSA) Update

Large randomized trials comparing stenting with endarterectomy for carotid disease showed higher rates of periprocedural stroke with stenting

    IJCP Special

Dr Good Dr Bad

Situation: An elderly diabetic patient came with a blood pressure (BP) of 160/80 mmHg.
Dr Bad: You need more intensive treatment.
Dr Good: It is ok to have it at this level.
Lesson: BP is a marker for mortality in elderly type 2 diabetes mellitus patients; but, has an inverse relationship. In a prospective observational cohort study of more than 800 patients aged ≥60 years, a decrease of 10 mmHg in systolic BP, diastolic BP and pulse pressure led to a mortality increase of 22% (95% confidence interval (95% CI): 13–31%), 30% (95% CI: 13–46%) and 22% (95% CI: 11–33%), respectively.

Make Sure

Situation: A foreigner with a single loose stool developed sepsis.
Reaction: Oh my God! Why were antibiotics not started in time.
Lesson: Make sure that all foreigners are diagnosed to be suffering from Travelers diarrhea even if there is one single loose motion.

    Lighter Side of Reading

An Inspirational Story

The Seven Wonders of the World

Junior high school students in Chicago were studying the Seven Wonders of the World. At the end of the lesson, the students were asked to list what they considered to be the Seven Wonders of the World. Though there was some disagreement, the following received the most votes:

  1. Egypt's Great Pyramids
  2. The Taj Mahal in India
  3. The Grand Canyon in Arizona
  4. The Panama Canal
  5. The Empire State Building
  6. St. Peter's Basilica
  7. China's Great Wall

While gathering the votes, the teacher noted that one student, a quiet girl, hadn't turned in her paper yet. So she asked the girl if she was having trouble with her list. The quiet girl replied, "Yes, a little. I couldn't quite make up my mind because there were so many." The teacher said, "Well, tell us what you have, and maybe we can help." The girl hesitated, then read, "I think the Seven Wonders of the World are:

  1. To touch...
  2. To taste...
  3. To see...
  4. To hear... (She hesitated a little, and then added...).
  5. To feel...
  6. To laugh, and...
  7. To love

The room was so quiet, you could have heard a pin drop.
May this story serve as a gentle reminder to all of us that the things we overlook as simple and ordinary are often the most wonderful - and we don't have to travel anywhere special to experience them….Enjoy your gifts!

Humor Section

Joke (Dr G M Singh)

“I hate it, I hate it, I hate it!” Felman wailed, “I can’t stand having a cold.”
“You’ll just have to be patient,” the doctor told him. “People get colds in the winter, and there’s no cure.”
“But it’s making me crazy. You’ve got to do something.”
“Tell you what you can do,” the doctor said. “Take a cold shower, wrap a towel around your waist, and run around outside the house for an hour.”
“But doctor,” said Felman, “then I’ll get pneumonia”.
“Yes, but that we have a cure for!”

Mind Teaser

Read this…………………

gener   ation

Answer for yesterday’s Mind Teaser: "Good intentions"

Correct answers received from: Dr Virender Prakash Gautam, Dr Marak,  Dr Muthumperumal Thirumalpillai, Dr Chandresh Jardosh,  Dr. Rohini. Vaswani, Dr.G.Pademanabhan, Dr.K.Raju, Dr Santanu Guria, Dr. Suman Kumar Sinha, Dr Sudha Nayyar, Dr S. Upadhyaya.  Dr K.P .Rajalakshmi, Dr Rajiv Kohli, Dr Prabha Sanghi, Dr Anupam Sethi Malhotra, Dr Naorem Sharat Kumar, Dr Meera Rekhari

Answer for 3rd November Mind Teaser: "Mixed up child"
Correct answers received from: Dr. Dinesh Kumar S

Send your answer to ijcp12@gmail.com

    Readers Responses
  1. Happy Diwali to Dr.K.K.Aggarwal and the entire team of emedinews. Thanks and Regards: Dr Neelam Nath
    Public Forum

(Press Release for use by the newspapers)

Prophylactic platelet transfusion offer no benefits in adult dengue patients

Thrombocytopenia or low platelet count is common in dengue and there is concern about risk of bleeding. Many studies and our own experience now have shown no benefit from prophylactic platelet transfusion in adult dengue patients, said Padma Shri & Dr. B.C. Roy National Awardee, Dr. KK Aggarwal, President, Heart Care Foundation of India.

Findings from a retrospective paediatric intensive care study presented by Dr Lye D.C and group at the 18th European Congress of Clinical Microbiology and Infectious Diseases at Barcelona, Spain show no benefit in prophylactic platelet transfusion for thrombocytopenia <30,000/uL.

In the study all dengue patients admitted were retrospectively reviewed. Patients without bleeding when their platelet count dropped <20,000/uL were evaluated. Prophylactic platelet transfusion was defined as platelet transfusion without clinical bleeding excluding petechiae (skin bleeding).

Baseline data on admission and clinical data when patients platelet count first dropped <20,000/uL were compared. Outcome measures included: any bleeding after platelet transfusion, median platelet increase the next day, median time to platelet count 50,000/uL, median length of hospital stay, and death.

Of 1973 laboratory–confirmed dengue patients, 256 developed thrombocytopenia <20,000/uL without bleeding, of whom 188 were given prophylactic platelet transfusion. Baseline demographic, clinical and laboratory features at that platelet threshold were similar, except that transfused patients were significantly more likely to be febrile (33% vs. 18%).

Median platelet count on day of platelet transfusion was 15,000/uL in transfused vs. 16,000/uL in non–transfused patients. Bleeding occurred subsequently in 1 of 188 transfused (0.5%) and 2 of 68 non–transfused (3%) (p = 0.17).

Median platelet increase the next day was 6000/uL vs. 13,000/uL, and median time to platelet 50,000/uL was 3 days vs. 2 days, in transfused vs. non–transfused patients respectively. There was no difference in length of stay and death.

    Forthcoming Events
eMedinewS Events: Register at emedinews@gmail.com

November 29, 2010, Monday, 9 AM – 1PM, Moolchand Medcity – “Update on Kidney Transplant”. No Fee. Entry by Invitation.  Contact: emedinews@gmail.com
eMedinewS Revisiting 2010

The 2nd eMedinewS  - revisiting 2010 conference will be held at Maulana Azad Medical College, New Delhi on January 08-09, 2011.

January 08, 2011, Saturday, 6PM – 9PM – Opening Ceremony, Cultural Hungama and eMedinewS Doctor of the Year Awards. For registration contact – emedinews@gmail.com

January 09, 2011, Sunday, 8 AM – 6PM – 2nd eMedinewS revisiting 2010, A Medical Update

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