Address: 39 Daryacha, Hauz Khas Villege, New Delhi, India. e-Mail: drkk@ijcp.com , Website: www.ijcpgroup.com

Dr K K Aggarwal

Dr KK Aggarwal
Dr BC Roy Awardee
Sr Physician and Cardiologist,
Moolchand Medcity
President, Heart Care
Foundation of India
Gp Editor-in-Chief,
IJCP Group
Delhi Medical Council
Director, IMA AKN Sinha Institute (08-09)



emedinews is now available online on www.emedinews.in and www.emedinews.org

6th January 2010 Wednesday  

Dear Colleague,

Bypass Anemia Drugs in Chronic Kidney Disease: Twist in the current practice

During our medical college it was taught to keep CKD patient's Hb to over 9 mg% with oral iron or blood transfusions. The practice changed over time with the introduction sof ESA industry. But now there is a U turn to the same concept and the same recommendation has come back. Similar twist we also saw in the  practice of using steroids in treating rheumatoid arthritis and asthma.

New twist in the anemia practice is that anemia in most chronic kidney disease patients should be managed with iron supplements or blood transfusions, if anything, rather than erythrocyte stimulating agents.

Long term ESA should be for those who are transplant candidates or have severe anemia with a hemoglobin under 9 g/dl that cannot be managed with transfusions (Source Ajay K. Singh, of Harvard and Brigham and Women's Hospital in Boston, Editorial online in the Journal of the American Society Nephrology).

This guidance comes in the wake of the TREAT trial findings that turned the world of anemia management upside down.

That landmark trial, reported nearly two months ago at the American Society of Nephrology meeting and simultaneously online in the New England Journal of Medicine, showed darbepoetin alfa was no better than placebo in mortality or cardiovascular or renal outcomes in patients with comorbid diabetes. But the drug nearly doubled stroke risk and increased thromboembolism and possibly cancer as well.

Two other large trials of nondialysis patients with chronic kidney disease have also weighed in on the issue, both open-label comparisons.
In CHOIR, epoetin-alfa  targeted to a hemoglobin of 13.5 g/dl raised the composite rate of death, MI, heart failure, hospitalization, and stroke by 34% compared with target of 11.3 g/dl.

In CREATE, immediate anemia treatment with epoetin beta (Micera) targeted to a hemoglobin of 13 to 15 g/dl increased risk of a first cardiovascular adverse event by 22%, though it was not statistically significant, compared with a late strategy holding off treatment (targeted to 10.5 to 11.5 g/dl) until hemoglobin levels dipped below 10.5 g/dl.
Despite differences between the agents and treated populations, the results of all three trials are complementary rather than contradictory.

1. Focus on iron therapy, exclude occult bleeding and suppress any inflammation in patients with mild to moderate anemia (hemoglobin 9 to 11 g/dl)
2. Oral iron should be tried for the first three months of anemia management, with intravenous iron attempted only if this fails.
3. Worsening anemia to under 9 g/dl should be treated with rescue short course erythrocyte-stimulating agents or a blood transfusion.
4. Use a high threshold for ESA agents, even in symptomatic patients with a history of cancer or those undergoing chemotherapy.
5. For transplant candidates or severe anemia that cannot be managed with blood transfusions, consider a dose of 500 to 1,000 U per week of epoetin-alfa (or its equivalent in darbepoetin).

Dr KK Aggarwal

Chief Editor



Finally DMC has its President

Dr A K Agarwal Dean Maulana Azad Medical College took over as the President of Delhi Medical Council for the second five years term. Dr Vinay Aggarwal past hony. secretary of the national IMA was eleceted as the Vice Presidemt. The council has twenty members and has a lot of challanging decisions to face. emedinews comngratulates both of them.

Make Sure:
A patient was brought to the ICU in cardiogenic shock.
Oh My God! Why didn't you take him for emergency angiography and subsequent PTCA.
Make Sure to perform an emergency diagnostic angiography and mechanical revascularization with PTCA in patients of cardiogenic shock. Results of NRMI-2, an ongoing trial suggest that this intervention is much better than thrombolytic therapy in such patients.

Medilaw: Does One Need to Possess Only Average Degree of Skill and Knowledge?
Several judgements of the Hon'ble Supreme Court, answer this question. Relevant quotes are:
1."The practitioner must bring to his task a reasonable degree of skill and knowledge and must exercise a reasonable degree of care. Neither the very highest nor a very low degree of care and competence judged in the light of particular circumstances of each case is what the law requires"
2."A doctor can be held guilty of negligence only when he falls  short of standard of reasonable medical care. A doctor cannot be found negligent merely because in the matter of opinion he made an error of judgement."
3. "Under the provisions of our Code, this case would be very differently dealt with according to circumstances."

If A kills Z by administering abortives to her, with the knowledge that those abortives are likely to cause her death, he is guilty of voluntary culpable homicide. The same will be voluntary culpable homicide by consent, if Z agreed to run the risk. It would be murder if Z did not so agree.

In conclusion, the degree of skill and knowledge is of little consequence provided reasonable degree of medical care has been observed.

Suggested readings:
1.In Dr. Laxman Balkrishna Josh vs. Dr. T. Bapu Godbole AIR 1969 SC 128, decided by the Hon'ble Supreme Court.
2.In N.T. Subramanaya vs. Dr. B. Krishna Rao 1969 (2) CPR 247 (N.C.), decided by the National Commission (Consumer Forum).
3.Lord Macaulay on Indian Penal Code: “Speeches and Poems with the Report and Notes on the Indian Penal Code” by Lord Macaulay (Houghton, Mifflin and Company, published in 1874).
NCDRC: National Commission: 29 of 1993/ decided 15.09.2001/: S. Gurunathan (Dead) vs. Respondent.

AMA News (Dr Moinica Vasudeva)
1. Overuse of antibiotics on farms identified as serious emerging concern: People are increasingly at risk from the widespread practice of feeding livestock antibiotics. A flurry of new research" linking antibiotic usagein animals to drug resistance in people. (Centers for Disease Control and Prevention director Dr. Thomas Frieden)

2. Bedside exam may be superior to CT in detecting post-brain surgery complications: According to a study appearing online in the Journal of Neurosurgery, the low cost, simple, but elegant neurological exam appears to be superior to a routine CT scan in determining return to the operating room due to post brain surgery complications.

3. Powerful new technique for editing genetic text may afford HIV immunity: If a natural mutation could be mimicked in human blood cells, patients could be endowed with immunity to HIV. (A University of Pennsylvania team)

4. Children exposed to tobacco smoke more likely to develop emphysema as adults: Columbia University scientists found that children exposed regularly to tobacco smoke at home were more likely to develop emphysema in adulthood, suggesting that lungs may not heal completely from early life exposure. (American Journal of Epidemiology).

5.Longevity associated with emotional stability, activity, conscientiousness: Research from the National Institute on Aging reveals longevity is associated with being conscientious, emotionally stable, and active.[July/Aug. issue of the journal Psychosomatic Medicine]

6. Risk for cardiovascular disease higher in obese men: according to a paper published online Dec. 28 in the journal Circulation, there appears to be no such thing as metabolically healthy obesity. The risk of cardiovascular disease is 52 percent higher in overweight men without metabolic syndrome, 74 percent higher in overweight men with metabolic syndrome, 95 percent higher in obese men without metabolic syndrome, and 155 percent higher in obese men with metabolic syndrome.

Tip from other systems of medicine: Creepers: All vegetables grown on creepers like tinda, ghiya, tori, etc. have some diuretic action.

Mnemonic to Know: Causes of ST elevation in ECG: ELEVATION
Early repolarization
Ventricular hypertrophy
Treatment (eg pericardiocentesis)
Injury (AMI, contusion)
Osborne waves (hypothermia)
Non-occlusive vasospasm

Mile Stone:
Alvimopan is a peripherally-acting, mu-opioid receptor (PAMOR) antagonist. It antagonizes the peripheral effects of opioids on gastrointestinal motility and secretion, by binding to gastrointestinal tract mu-opioid receptors. Alvimopan accelerates the time to upper and lower gastrointestinal recovery after bowel resection surgery. It was approved by FDA in May 2008.

Laughter the best medicine
A man said to his doctor, "I think there's something wrong with me; I've got a pain here, one over there..."He went on and on about his symptoms.
Everytime he paused for breath the doctor said, "Fine! Fine! Go on, go on!"
When he'd finally finished the story, the doctor said, "You know, you've got a disease that was supposed to have been extinct long ago."

Finance Tip: What is the best advice for investment planning a new born?
A:  Daadi maa advice has been that for the birth of a son one should plan money for his education and for a daughter one should plan both for her education as well as her marriage.

Dr Good Dr  Bad:
A diabetic came for routine evaluation.
Dr Bad: Get fasting sugar and A1C done
Dr Good: Get fasting sugar, A1C and GFR test done
Lesson: Impaired glomerular filtration rate (GFR), a complementary sign of kidney damage, is also associated with increased risk. GFR estimated using serum cystatin C was more strongly associated with mortality than GFR estimated using serum creatinine. These findings support current recommendations to regularly assess GFR in the clinical care of patients with diabetes.


Panjab & Sindh Bank 
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Central Bank of India

 SILICIC ACID and HERBS: A New Approach.
Various Clinical Studies have Proved that Silicic Acid as  Sodium Meta Silicate, has a Synergistic Effect with concomitant use of Relevant Herbal Extracts when both are used in conjunction. Silicic Acid and Herbs Compliment each other and in fact, The Herbs Potentiate the Absorption, Assimilation and Response to Sodium Meta Silicate.  Herbal Extracts are Known to Enhance the Bio-availability of Sodium MetaSilicate at the cellular Level and thus have a significant role to be a part of Silicic acid Supplementation. Interestingly, The Most Popular Brands of Silicic Acid  Health Supplements, Available in the USA Market contain Herbal Extracts along with the Silicic acid as a major Ingredient.

emedinews: revisiting 2009
IJCP Group, Heart care Foundation of India and World Fellowships of Religions are  is organizing emedinews: revisiting 2009, day long conference on the top health happenings in the year 2009 on 10th Jan 2010 at Maulana Azad Auditorium. There is no registration fee however advanced information is required.  Top experts (Dr KK Aggarwal (revisiting 2009), Dr Naresh Trehan (what's new in cardiac surgery), Dr Anupam Sibal (A decade of successful liver transplants in India), Dr Ajay Kriplani (Current Trends in the Management of Morbid Obesity), Dr Praveen Chandra (The Indications of Interventional Treatment in Cardiology), Dr Kaberi Banerjee (IVF- Where We Stand Today?), Dr N K Bhatia (TTI infections), Dr V Raina ( molecular genetics), Dr Ajit Saxena (ED and male infertility), Dr S C Tewari (Nephroprotection), Dr. Ambrish Mithal (Diabetes), Dr Vanita Arora (ECG arrhythmias), Dr N Subramanium (Current concept in Male infertility ), Dr Neelam Mohan (Coeliac Disease), Dr. Sanjay Chaudhary (Eye Update), Dr Harish Parashar (aluminum toxicity), Dr Praveen Khillani (Whats new in field of critical care in past decade?), Dr Rohina Handa ( Whats new in rheumatology), Dr Ajay Kumar ( Fatty Liver), Dr P K Julka (Whats new in oncology), Mr.  B.N.S Ratnakar, will deliver lectures

CME will be followed by lively cultural evening guest performances by Shabani Kashyap, Vipin Aneja and perfomances by medical professional singers Dr Praveen Khilnani, Dr Lalita and Dr N Subramanium, Dr Lata Tandon, Dr Arti Pathak, Dr Sudipto Pakrasi, Dr Harjeet Kaur, Dr Ramni Narsimhan, Dr Sanjay Chugh (on the drum), Dr Yash Gulati (Anchor) Dr Reshma Aggarwal (Anchor), doctors of the year award, dance and dinner. For registration mail emedinews@gmail.com. We have crossed 1200 registrations.

1. PSB & Aviva is proud to be associated with Emedinews: Revisiting 2009. To know more about us, please visit our stall on day of the conference. http://avivaindia.com

2. Kindly enjoy not stop tea and coffe at NESTLE counter

3. Refresh yourself with mineral water, coke, soda and other  drinks from COKE counter.

4.  Silicic Acid is available as Sodium Meta Silicate in U.S.A and is being Launched in India During the  IJCP  Emedinews revisiting 2009 Conference at New Delhi on January 10th,2010.

Update about the conference
1. The conference starts at 8am at MAMC. Kindly collect your registration kit before that. The kit has pen, pad, folder, key chain, watch, lunch and dinner coupons.
2. Enjoy the soft drinks at the COKE counter round the clock and tea coffee at the NESTLE counter.
3. There will be no lunch time. Rice Kari, Puri Aloo will be available 9-5pm non stop, eat any time and attend the seminar.
4. Dinner will be cocktails, soft drinks, snacks and chhat party 5-9pm
5. Cultural hangama will be non stop 5-9pm
6. We have over booked the registrations. Facility for webcast and plasma TV out side the auditorium will be available.
7. The CME will be accredited for 9 DMC credit hours.
8. The program details are available at www.emedinews.org or www. emedinews.in

emedinews-revisiting 2009 Program

8.00   AM  -  8.30 PM   Dr KK Aggarwal  Revisiting the year 2009
8.30   AM  -  8.45 AM   Dr Neelam Mohan, Advances in Paedatric Diseases ( Non Liver)
8.45   AM  -  9.00 AM   Dr S C Tewari, Nephroprotection
9.00   AM  -  9.15 AM   B.N.S Ratnakar (GM CBI), Presentation
9.15   AM  -  9.45 AM   Dr Ambrish Mithal, Newer treatments in diabetes
9.45   AM  -  10.00AM   Dr Harish Parashar, Aluminium Toxicity
10.00 AM  -  10.30AM   Dr N K Bhatia, Screening for TTI
10.30 AM  -  10.40AM   Anshu Gupta, Probiotics Update
10.40 AM -   11.10AM   Dr Praveen Chandra, Indications of Cardiac Interventions            11.10 AM -   11.25AM   Dr Sanjay Chaudhary, What's new in Lasik
11.25 AM -   11.55AM   Dr Naresh Trehan, What's New in Cardiac Surgery
11.55 AM -   12.10PM   PSB-AVIVA, Presentation
12.10 PM -   12.40PM   Dr Anupam Sibal, A Decade of Succesful Liver Tansplant in India
12.40 PM -   1.10 PM    Dr Ajay Kriplani, Current Trends in the Management of Morbid Obesity
1.10   PM -   1.40 PM    DR Vanita Arora, Common Arrhythmias
1.40   PM -   2.10 PM    Dr N Subramanium, Current Concept in Male Infertility
2.10   PM -   2.40 PM    Dr V Raina, Molecular Genetics
2.40   PM -   3.10 PM    Dr Kaberi Banerjee, IVF: Where We Stand Today?
3.10.  PM -   3.25 PM    Anil Chopra (Bajaj Capital), Mutual Funds
3.25   PM -   3.40 PM    Dr Praveen Khilnani, Whats New in Critical Care in Past Decade?
3.40   PM -   4.10 PM    Dr Ajit Saxena, Erectile Dysfunction and Male Infertility
4.10  PM  -   4.20 PM    Dr Ajay Kumar, Whats New in Gastroenterology
4.20  PM -    4.30 PM    Dr Rohini Handa, Whats New in Rheumatology
4.30  PM -    4.40 PM    Dr P K Julka, Whats New in Oncology
5.00  PM Onwards Cultural hangama and awards


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 Letters to the editor
1. Let us all rise in action against this silly and short-sighted proposal to help the poor villagers. BRMS is not a solution to the need of the villagers, ASHA's and other trained nurses, midwifes, can do much more, can be trained in much more numbers to make primary healthcare more effective! All in all, the Govt. needs to start a PINK REVOLUTION in healthcare by injecting a massive 6 to 9% of GDP in Govt. healthcare system (from the measly 2% GDP of Govt. spending for healthcare to the poor), and make the dream of healthcare for the poor and needy in both villages, towns, and cities a reality, instead of blaming the poor doctors all the time! Let us rise against this and help the poor too, by making a public campaign for PINK REVOLUTION in Indian healthcare. Help me friends, and help all of India! (Dr NV Girish Kumar)

2. Dear K. K. Aggarwal & Family, Thanks a lot for your lovely New Year Greetings and for regularly sending the e-Medinews.  We heartily reciprocate and add our own cheers to make the world a better and happier place for all.  At the same time, the consequences of many decades, in fact, centuries, of deviant human behaviour cannot be overlooked or wished away.  Especially, due to widespread distrust and deep-seated quarrelsomeness among the nation-states and religious communities, the path ahead is torturous and there will be catastrophes. The following prediction in the writings of the Baha'i Faith appears to be inevitable. "Adversity, prolonged, world-wide, afflictive, allied to chaos and universal destruction, must needs convulse the nations, stir the conscience of the world, disillusion the masses, precipitate a radical change in the very conception of society, and coalesce ultimately the disjointed, the bleeding limbs of mankind into one body, single, organically united, and indivisible." Dr. A. K. Merchant, General Secretary, The Temple of Understanding-India. 




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