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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; Member 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

6th June, Sunday, 2010

IMA Working Committee Meeting is On

Dear Colleague

The issue of MCI came up for discussion during the meeting of the Working Committee of IMA held at Ahmedabad. The members spoke at length about the government ordinance. The Working Committee constituted a 5-member committee, convened by Dr Vinay Aggarwal, with Dr Ajay Kumar, Dr Arul Raj, Dr Abbas, Dr S Roy, and Dr Pillai as the members, regarding the action plan. Dr Jitu Patel also attended the meeting.

Whether IMA should agitate; take legal options and/or create public awareness against the ordinance dissolving the elected body was the main agenda of discussion. Unfortunately in the meeting, main issues that education should not go to the Ministry of Human Resources Development (HRD) and that IMA should have a major role in the next MCI Amendment Bill (in process) were not emphasised. Once the ordinance has been passed, why agitate now. The agitation should have been done before it was passsed. Now the only consolation for IMA left is to see to it that any amendments in MCI bill are not done without the active participation of IMA. 

IMA protest for MCI ordinance

1. IMA to bring white paper by 15th June
2.  21-28 th June to be observed as  protest week
3. On both 15th and  28th to organize press conference
4. 28th to be observed as a  black day with a Dharna at IMA head quarters
5. 15th July to have one day token strike.

IMA opposes BRMS and clinical establishment bill

IMA also opposes th BRMS the shortened MBBS equivalent course and the clinical establishment bill in the present form. Committees were formed to represent to the government. The next 28th all presidents secretaries meet at IMA hall will see the next part of discussions on the above issues.

Though in the main hall there was practically no discussion on Dr Ketan Desai at the luncheon foyer, the hot topic of discussion was the fate of Dr Desai and further options available to him.

1. Will he move double bench in the High Court?
2. Will he move Supreme Court?
3. Will he move for anticipatory bail for other cases?
4. Will he wait for 60 days to be over and then seek bail from the regular court once the trial starts?

The dinner was not attended by the main leaders as for the firt time no alcohol was served at thedinner venue. Most of the leaders had left to other places for private meetings.

Dr KK Aggarwal
Padma Shri Awardee and Chief Editor


Photo Feature

Save Trees Save Environment

The Tableau of Heart Care Foundation of India and Dept. of Environment, Govt. of Delhi moving on the streets of Delhi to spread and create awareness about environmental issues among its citizens, and making Delhi, a ‘Green Delhi’, in particular. (4-5th June 2010)

Dr k k Aggarwal
5th June 2010, Observing World Environment Day

International Medical Science Academy Update (IMSA): New FDA Update

Adverse reactions and warnings

Contraceptive patch

Prior studies have suggested that use of a contraceptive transdermal patch was associated with a higher risk of venous thromboembolism than seen with oral contraceptives (OCs). However a claims–database study concluded that the risk of idiopathic venous thromboembolism in users of the patch was not significantly different than that of users of levonorgestrel–containing OCs in women aged 39 years or younger.


  1. Jick SS, Hagberg KW, Hernandez RK, et al. Postmarketing study of ORTHO EVRA and levonorgestrel oral contraceptives containing hormonal contraceptives with 30 mcg of ethinyl estradiol in relation to nonfatal venous thromboembolism. Contraception 2010;81:16.

Mnemonics of the Day (Dr.Varesh Nagrath )

Excessive frothing from mouth (ROPE – M)

Organophosphorus poisoning
Parkinsonism (Extrapyramidal disorders)
Myasthenia gravis:Cholinergic crisis

News and Views

A joint statement released by the American Heart Association, American Diabetes Association, and American College of Cardiology has recommended low–dose aspirin for diabetes patients with a cardiovascular disease risk above 10% over 10 years and no excess bleeding risk.

A study reported online in the journal Stroke observes that discharge use of lipid–lowering drug increased progressively from 75.7% to 84.8% (p<0.001) from 2005 to 2007.

FDA Update

New blood glucose test strips approved

The US FDA has approved blood glucose test strips (FreeStyle Lite; Abbott Diabetes Care) to help patients better manage their diabetes by decreasing the potential for interference by other sugars. The new glucose–specific test strips use the glucose dehydrogenase with flavin–adenine dinucleotide (GDH–FAD) enzyme, thereby avoiding falsely elevated readings that can result from glucose dehydrogenase pyrroloquinoline quinone (GDH–PQQ)–based methods that can be affected by common nonglucose sugars, such as maltose or galactose. Compatible with all FreeStyle Lite monitoring systems, the new test strips also feature a proprietary tapered design (ZipWik) intended to ensure quicker blood application and decrease error messages and wastage.

FDA Safety alert

Warning against contaminated IV antibiotics, the FDA has issued a public health alert warning healthcare professionals not to use certain brands of intravenous metronidazole, ondansetron, and ciprofloxacin because of potential contamination. The FDA alert applies to products sold under the Claris, Sagent Pharmaceuticals, Pfizer, and West–Ward Pharmaceuticals labels.

Conference Calendar

Healthcare Marketing

2 Day Conference & Workshop on Healthcare Marketing
Date: June 5–6, 2010
Venue: M S Ramaiah Memorial Hospital, Bangalore, Karnataka

Quote of the day (From Charu Aggarwal)

HOW a son thinks about his father at different ages

At 4 years, My daddy is great.
At 6 years, My daddy knows everybody.
At 10 years, My daddy is good but is short tempered.
At 12 years, My daddy was very nice to me when I was young.
At 14 years, My daddy is getting fastidious.
At 16 years, My daddy is not in line with the current times.
At 18 years, My daddy is becoming increasingly cranky.
At 20 years, Oh! Its becoming difficult to tolerate daddy. Wonder how Mother puts up With him.
At 25 years, Daddy is objecting to everything.
At 30 years, It's becoming difficult to manage my son. I was so scared of my father When I was young.
At 40 years, Daddy brought me up with so much discipline. Even I should do the same.
At 45 years, I am baffled as to how my daddy brought us up.
At 50 years, My daddy faced so many hardships to bring us up. I am unable to manage A Single son.
At 55 years, My daddy was so far sighted and planned so many things for us. He is One Of his kind and unique.
At 60 years, My daddy is great. 
Thus, it took 56 years to complete the cycle and come back to the 1st Stage.
Realize the true value of your parents before it's too late.

Question of the Day

What are the indications for surgery in "bleeding peptic ulcer"? (Dr. Deepak Govil, Delhi)

Peptic ulcer bleeding is a common and potentially fatal condition. It is best managed using a multidisciplinary approach by a team with medical, endoscopic and surgical expertise. The management of peptic ulcer bleeding has been revolutionized in the past two decades with the advent of effective endoscopic hemostasis and potent acid–suppressing agents. A prompt initial clinical and endoscopic assessment should allow patients to be triaged effectively into those who require active therapy, versus those who require monitoring and preventive therapy. A combination of pharmacologic and endoscopic therapy (using a combination of injection and thermal coagulation) offers the best chance of hemostasis for those with active bleeding ulcers. Surgery, being the most effective way to control bleeding, should be considered for treatment failures. The choice between surgery and repeat endoscopic therapy should be based on the pre–existing comorbidities of the patient and the characteristics of the ulcer. At the time of recurrent bleeding, the dilemma often faced by physicians is whether to repeat endoscopic treatment or to refer the patient directly to surgery. The findings of Lau et al suggest that in the management of patients with recurrent bleeding after initial endoscopic control, a selective approach can be adopted based on the local characteristics of the ulcer and the pre–existing comorbidities of the patients. Large chronic ulcers should probably be treated by expeditious surgery if recurrent bleeding ensues. Those who are poor surgical candidates might benefit from repeated endoscopic treatment.

So practically the indications for surgery are:

  • Severe life–threatening hemorrhage not responsive to resuscitative efforts – prolonged bleeding with loss of 50% or more of the patient’s blood volume
  • Failure of medical therapy and endoscopic hemostasis, if two attempts at endoscopic control unsuccessful, avoid further attempts
  • A co–existing reason for surgery such as perforation, obstruction, or malignancy

Source: Lau JYW, et al. Endoscopic retreatment compared with surgery in patients with recurrent bleeding after initial endoscopic control of bleeding ulcers. N Engl J Med 1999;340:751–6.

MCI Update

J P Singh gets bail (Detailed judgment)

IN THE HIGH COURT OF DELHI AT NEW DELHI + Bail Application No. 799/2010 % Reserved on: 3rd June, 2010 Decided on: 4th June, 2010 Jitender Pal Singh @ J.P. Singh S/o Shri S.S. Giani R/o D–6/13, Vasant Vihar, New Delhi …… Petitioner Through: Mr. Arvind Nigam,Sr. Advocate with Mr. H. C. Bhullar, Advocate versus C.B.I. (State) Through The Investigating Officer CBI/ACU–IX/New Delhi Anti Corruption, Block4, C.G.O. Complex, New Delhi


  1. This is a petition for grant of regular bail in case RC No. 02(A)/10/ACU–IX/CBI dated 22–04–2010 under Sections 7, 8, 11, 13(2) R/w 13(1)(d) of the Prevention of Corruption Act, 1988 (hereinafter ‘the PC Act’). As per the prosecution this case was registered on the allegations that Dr. Ketan Desai, President, Medical Council of India (MCI) entered into a criminal conspiracy with Sh. J.P. Singh, the petitioner herein with an intention to obtain bribe for grant of permission to Gyan Sagar Medical College, Patiala. The concerned management of this medical college became party to this conspiracy by agreeing to pay the bribe in order to get certain shortcomings in the infrastructure overlooked by the MCI. The CBI received a source information on the basis of which enquiry was conducted during which the relevant mobile phones were intercepted.

  2. It is contended that after registration of the case, a team was deployed at the residence of the Petitioner at D–6/13, Vasant Vihar, New Delhi to intercept Dr. Kamaljeet Singh who was coming to deliver the bribe amount of Rs. 2 Crore. At about 12.50 hrs on 22–4-2010, Dr. Kamaljeet Singh while coming out of the house of Sh. J.P. Singh was challenged and interrogated and on his disclosure, Rs.2 crore was recovered from the office located at the ground floor of the residential premises of the Petitioner at D–6/13 Vasant Vihar, New Delhi.

  3. Learned counsel for the CBI states that the present is a case of larger conspiracy wherein the Petitioner along with other persons was acting as a tout to Dr. Ketan Desai, the former President, Medical Council of India (MCI). Dr. Ketan Desai was not only passing on prior information to the Petitioner pertaining to the schedule of inspection by MCI but also ensured that favourable report would be given by the Inspecting Team of MCI. According to learned counsel, despite the fact that the Gyan Sagar Medical College was lacking in certain requisite infrastructure, which could not have been complied with in such a short duration, the Petitioner and Dr. Ketan Desai helped the Institute to get favourable report from MCI in lieu of a consideration of an amount of Rs. 2 crore to be delivered through the Petitioner to Dr. Ketan Desai. In this regard statement of a witness recorded under Sec. 164 CrPC has been relied upon.

  4. Learned counsel for the CBI has also produced the transcript of the conversations between the parties. The transcript of the conversation show continuous interaction between Dr. Ketan Desai, Sukhvinder Singh, Jitender Pal Singh, Kamaljeet Singh, K.A. Paul and N.S. Bhango and the conversations are co–relatable to the dates on which the events took place. The conversation amongst the accused persons reflect the motive, demand of bribe and the modus operandi for the favours shown to the Gyan Sagar Medical College and Hospital, Patiala. It is submitted that the Petitioner has a foreign account and a report in relation to the deposits made therein has been called from the Financial Intelligence Unit. It is submitted that two accused persons i.e., Nirmaljeet Singh Bhango and K.A. Paul are still absconding.

  5. It is also submitted that the investigation is also prima facie revealing that the Petitioner and Dr. Ketan Desai are involved in such an incident relating to one more medical college. According to her, the Petitioner is an influential person and there is every likelihood of his tampering with the evidence in case he is released on bail.

  6. Learned counsel for the Petitioner contends that as per the information received with the CBI, the allegation against the Petitioner is of providing expensive gifts to the co–accused Dr. Ketan Desai from time to time. Even as per the information, the permission to Gyan Sagar Medical College was granted after completing all the necessary formalities. According to learned counsel a Committee was set up by the Central Govt to look into the issue of grant of approval to the Gyan Sagar Medical College which also found no irregularity in it. It is stated that as per the search list, copy whereof was provided to the Petitioner, the investigating agency itself was not aware whose money it was. Moreover, the amount of Rs.2 crore in the search list at item No.50 has been added subsequently after the witnesses had signed the same.

  7. It is contended that taking the allegations on the face of it, the only role alleged against the petitioner was that he was acting as a tout and there is no allegation that the petitioner has received any consideration in the said transaction. The case of the prosecution is that whatever he took was to be passed on to the main accused Dr. Ketan Desai. Thus, at best the petitioner is a carrier. As regards the telephonic conversation, reliance is placed on Mahabir Prasad Verma v. Dr. Surinder Kaur AIR 1982 SC 1043, wherein it was held that the evidence of tape–recorded conversation, at best, is corroborative evidence and in the absence of evidence of any such conversation, the tape–recorded conversation is indeed no proper evidence and cannot be relied upon. Reliance is also placed on Ravi Singhal v. Union of India & Anr., 1993 JCC 306; Sukh Ram v. C.B.I. 64 (1996) DLT 633 and R. Vasudevan v. C.B.I. 2010 III AD (CRL) (DHC) 69 to contend that the petitioner has already spent 44 days in custody and in any case investigation has to be completed with a period of 60 days and thus, the investigation being almost complete, there is no likelihood of the petitioner’s interfering with the investigation. The statement of the witness Lakhvinder Singh is stated to be unreliable, as the search list shows that only one person came out from the car and thus either it could be the other person or the driver Lakhvinder Singh.

  8. With regard to the investigation qua foreign bank account, it is stated by learned counsel for the Petitioner that the CBI has no power to investigate on this aspect and if at all any case for violation of the Foreign Exchange is made, the Petitioner would be dealt for the same in accordance with the provisions of FEMA.

  9. The Petitioner was arrested on 22nd April, 2010 and is in judicial custody since 1st May, 2010. Learned counsel for the Petitioner states that the petitioner is not a public servant, and thus, Sections 7, 11 and 13 of the PC Act are not applicable to him. At best, the only offence which the petitioner can be alleged to be involved in, is under Section 8 of the PC Act wherein the maximum sentence is five years. The investigation is almost complete and nothing is to be recovered from the Petitioner as he is in judicial custody. Moreover, the Petitioner is the only son of his parents and there is nobody to take care of his ailing parents in this old age.

  10. I have heard learned counsel for the parties. I have also perused the statements of the witnesses and the transcript of the conversations. The same prima facie disclose the commission of offences of conspiracy under Sections 7, 8, 11, 13(2) R/w 13(1)(d) of the PC Act. The issue relevant at the present juncture is whether the Petitioner should continue in incarceration pending filing of the charge sheet and trial or should he be released on bail. Undoubtedly, corruption is a menace which is affecting the entire progress of the country and is corroding the entire system. It may be noted that in the present case, the Petitioner was not a public servant but was acting as a tout for a public servant who is the main accused i.e., Dr. Ketan Desai. No further recovery is to be made from the Petitioner. The Petitioner has been in custody for a period of nearly 44 days.

  11. As per learned counsel for the CBI during the course of investigation, the involvement of the Petitioner with Dr. Ketan Desai in another case wherein approval was granted to one more medical college, is also surfacing. It is stated that as and when sufficient prima facie material is available with regard to the other college, a separate FIR will be registered against the accused involved therein.

  12. In view of the fact that the Petitioner is in custody for the last 44 days, at this stage, the purpose is not of pre–trial detention. The petitioner is not the main accused. He was only acting for and on behalf of the main accused Dr. Ketan Desai. There is no evidence as yet that any part of the sum of Rs. 2 crore recovered was meant for the Petitioner. In view of these facts, I am inclined to grant bail to the Petitioner. It is directed that the Petitioner be released on bail on his furnishing a personal bond in the sum of Rs. 1 lakh with two sureties of the like amount, subject to the satisfaction of the Trial court/ACMM. The Petitioner will deposit his passport with the Investigating Officer immediately, who will deposit the same with the trial court on filing of the charge sheet. The Petitioner will not leave the country without the prior permission of the trial court.

  13. The petition stands disposed of. (MUKTA GUPTA) JUDGE JUNE 04, 2010

Liver Fact

If SGOT/SGPT are more than 1000, the diagnosis is acute viral hepatitis/drug induced hepatitis or ischemic hepatitis.

Women Safety Tips

Someone just told me that her friend heard a crying baby on her porch the night before last, and she called the police because it was late and she thought it was weird…

The police told her ‘Whatever you do, DO NOT open the door…’ The lady then said that it sounded like the baby had crawled near a window, and she was worried that it would crawl to the street and get run over.

The policeman said, ‘We already have a unit on the way, whatever you do, DO NOT open the door. He told her that they think a serial killer
has a baby’s cry recorded and uses it to coax women out of their homes thinking that someone dropped off a baby. He said they have not verified it, but have had several calls by women saying that they hear baby’s cries outside their doors when they're home alone at night.

7 Myths about Bipolar Disorder (5) (Dr GM Singh)

Once you start feeling better, you can stop taking medication.

eMedinewS Try this it Works

Digital rectal removal of fecal sample

Obtaining specimens by digital rectal examination in hospitalized patients for fecal occult blood examination has a high false–positive rate and should not be done.

Dr Good Dr Bad

Situation: An elderly male had reduced sleep efficiency.
Dr Bad: Take a sleeping pill.
Dr Good: Get diabetes ruled out.
Lesson: Sleep duration is a risk factor for the development of diabetes in middle–aged and elderly men. Both short i.e. < 5–6 hours of sleep per night and long i.e. >8 hours of sleep per night, sleep durations were associated with an increased incidence of diabetes. (Diabetes Care 2006;29:657–61.)

Make Sure

Situation: A patient with platelet counts of 72000 after coronary stent developed stent thrombosis.
Reaction: Oh my God! Why was clopidrogel not given?
Lesson: Make sure all patients with platelet counts of more than 30000 are not denied clopidrogel.

IMANDB Joke of the Day (Anuj Goyal)


A zealous church member in a Kentucky village made an earnest effort to convert a particularly vicious old mountaineer named Jim, who was locally notorious for his godlessness. But the old man was hard–headed and stubborn, firmly rooted in his evil courses, so that he resisted the pious efforts in his behalf.

"Jim," the exhorter questioned sadly at last, "ain’t you teched by the story of the Lord what died to save yer soul?"

"Humph!" Jim retorted contemptuously. "Air ye aimin" to tell me the Lord died to save me, when He ain't never seed me, ner knowed me?"

"Jim," the missionary explained with fervor, "it was a darn sight easier for the Lord to die fer ye jest because He never seed ye than if He knowed ye as well as we–alls do!"

Formulae in Clinical Practice

Arterial blood oxygen content

Formula: CaO2 = O2 dissolved in the blood + CaO2 – O2 carried by Hb = (0.0031 × PaO2) + (1.34 × Hb in g% × SaO2 in %)
Comments: Normal value 20 ml %.

Milestones in Urology

1980: A Lithotriptor is a medical device used in the non–invasive treatment of kidney stones (urinary calculosis) and biliary calculi. Lithotripsy was developed in the early 1980s in Germany by Dornier Medical Systems, and came into widespread use with the introduction of the HM–3 lithotriptor in 1983.

Lab Test (Dr Arpan Gandhi and Dr Navin Dang)

Magnesium, Serum

Magnesium levels may be used to monitor pre-eclampsia patients being treated with magnesium sulfate, although in most cases monitoring clinical signs (respiratory rate and deep tendon reflexes) is adequate and blood magnesium levels may not be required.

List of Approved drugs from 1.01.2009 to 31.10.2009

Drug Name


DCI Approval Date

Quinapril 20mg + hydrochlorothiazide 25mg film coated tablet

For the treatment of mild to moderate hypertension in adult patients (in whom combination therapy is appropriate) who have been stabilized on the individual components given in the same proportion




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eMedinewS–revisiting 2010

The second 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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Public Forum (Press Release for use by the newspapers)

Do not ignore breakfast

Taking a good breakfast made of carbohydrates and lean protein, can help lessen cravings and hunger during the rest of the day, which can lead to significant weight loss, said Padma Shri and Dr B C Roy National Awardee Dr KK Aggarwal, President Heart Care Foundation of India.

A new research by Dr. Daniela Jakubowicz, a clinical professor at Virginia Commonwealth University and an endocrinologist at the Hospital de Clinicas Caracas in Venezuela has shown that sedentary, obese women lost almost five times as much weight on the "big breakfast" diet as did women following a traditional, restrictive low–carbohydrate diet.

While treating obese people we need to treat carb cravings and hunger. On waking up in the morning, the body is primed to look for food. The metabolism is revved up, and levels of cortisol and adrenaline are at their highest. The brain needs energy right away, and if one doesn’t eat or eats too little, the brain needs to find another fuel source. To do this, it activates an emergency system that pulls energy from muscle, destroying muscle tissue in the process. Then when you eat later, the body and brain are still in high–alert mode, so the body saves energy from the food as fat.

Also the levels of the brain chemical serotonin are highest in the morning and the craving levels are at the lowest and you may not feel like eating. As the day wears on, serotonin levels dip, and you get cravings for chocolate or cookies, and such similar foods. If you eat these foods, your serotonin levels rise, and your body begins to associate good feelings with them, creating an addictive cycle.

The high protein, carbohydrate mix in breakfast gives the body the initial energy boost it needs in the morning. Throughout the rest of the day, the meals are made up of protein and complex carbohydrates, like vegetables. Because protein is digested slowly, you won’t feel hungry.

If you have to eat chocolate, eat it in the morning; having a small piece of chocolate or candy when serotonin levels are high won’t taste as good, and the brain won’t feel the same serotonin boost, which will eventually help cut down on cravings.

Eating breakfast with high glycemic foods may be harmful. After eating cereal or a doughnut, the blood sugar and insulin levels spike. Once that blood sugar is used up, you’ll still have excess insulin circulating, which makes you hungry and makes you crave carbohydrates.

(Advertorial section)

Forthcoming eMedinewS Events: Register at emedinews@gmail.com

13th June: IMSA clinical workshop with Dr KK Aggarwal at Moolchand Hospital 8-10am

5th September: 3 PM to 5 PM – A dialogue with His Holiness Dalai Lama at Parliament Street Annexe in association with Acharya Sushil Muni Ahimsa Peace Award Trust

12th September: BSNL Dil ka Darbar – A day-long interaction with top cardiologists of the city.
8 AM – 5 PM at MAMC Auditorium, Dilli 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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If you like eMedinewS you can FORWARD it to your colleagues and friends. Please send us a copy of your forwards.

Readers Responses

  1. Patients with acute knee swelling should receive plain radiographic studies, and ultrasound and MRI may be used in select cases. Blood tests are unnecessary for most patients with a swollen knee. Dr G M Singh

  2. Respected Sir, fight with RAJNEETI against Dr Desai, V r with him by heart, he hs dne a lot 4 the upliftment of doctor community: Dr Sanjay Rai IMA Banaras