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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 July, 2010, Tuesday

Very low dose steroids 

The efficacy of prednisone at doses below 5 mg/day in rheumatoid arthritis has been shown in a trial in which 31 patients on stable medication regimens, including disease–modifying antirheumatioid drugs (DMARDs), were randomly assigned to continued maintenance therapy of 1- 4 mg/day of prednisone or to slow dose reduction at the rate of 1 mg every four weeks.

Withdrawal from the study for lack of efficacy was significantly less frequent in patients maintained on their initial stable prednisone dose.

Steroids should be used as a bridge between the initiation and therapeutic effect of DMARDs and/or the treatment of acute synovitis. They may be used at lower doses in combination with traditional DMARDs and biologic agents to maintain function and prevent degradation of joints in patients with rheumatoid arthritis.

When deciding whether to initiate steroid therapy, the following clinical features that increase the risk of toxicity must be considered.

  • Established hypertension or diabetes mellitus

  • Pre-existing cataract(s) or glaucoma

  • Significant risk factors for osteoporosis

Most adverse effects of chronic steroid therapy are typically seen at doses of 10 mg/day or higher, with risk of bone loss at lower doses. Dose of steroids should be tapered as quickly as possible to the lowest effective dose, usually 1–5 mg/day of prednisone or its equivalent when chronic use is anticipated. To minimize interference with the normal diurnal hormonal pattern, they are best administered in the morning.

Reference

  1. Pincus T, Swearingen CJ, Luta G, et al. Efficacy of prednisone 1-4 mg/day in patients with rheumatoid arthritis: a randomised, double-blind, placebo controlled withdrawal clinical trial. Ann Rheum Dis 2009;68:1715.

Dr KK Aggarwal
Padma Shri Awardee and Chief Editor

 

Photo Feature (From HCFI file)

 

Quit The Evil Practice Of Tobacco Consumption

This was the message released by Heart Care Foundation of India (HCFI) at a pre event Press Conference organised on May 19th 2005 to mark the occasion of World No Tobacco Day. The objective was to educate people about the harmful effects of tobacco and related products and how to quit this habit.

Dr k k Aggarwal

Mr. Ignatius Camello, famous model and Shibani Kashyap, well-known singer during a Pre Event press conference for World No Tobacco Day. Also in the photo Padma Shri and Dr B C Roy Awardee Dr K K Aggarwal, President HCFI


 

News and Views

Most physicians regard free lunches, small gifts to be OK (Dr Monica and Brahma Vasudeva)

According to a survey published in the June Archives of Surgery, Physicians, especially surgeons, continue to regard gifts from the pharmaceutical and device industries in a positive light. A study reviewed responses from almost 600 physicians and medical students in the Mount Sinai School of Medicine consortium who were asked about their attitudes toward industry interaction. Most respondents favored the use of samples as well as industry sponsorship of lunches, educational materials and medical school and residency programs. More than 50% of the study group also considered receiving dinner at a modest restaurant if an educational component was included to be acceptable. Having the industry pay for travel expenses to a conference was also acceptable to most. A quarter of the participants thought it was OK to take a larger gift, while, slightly less than half of the survey participants found it appropriate to accept a small gift (less than $ 50) from a company. Only about 35% said it would affect their prescribing, while 52% said their colleagues would be influenced.

How do you start bolus insulin? (Dr G M Singh)

Bolus therapy for a patient receiving basal insulin may be added if A1C continues to be ≥ 7% after 2–3 months of treatment and fasting blood glucose (BG) is in the target range of 70–130 mg/dL. The initial dose for a second injection of insulin should be 4 U, and it should be adjusted by 2 U every 3 days until BG is in range.

  • If pre–lunch BG is outside the target range, then a rapid–acting insulin analog should be added at breakfast

  • If the pre–dinner BG is not within range, then rapid–acting insulin should be added at lunch or neutral protamine Hagedorn insulin may be added at breakfast.

  • If the pre–bedtime BG is out of range, then a rapid–acting insulin should be administered at dinner.

Two studies suggest diabetes drug Avandia increases risk of heart problems.

Two major studies have shown that rosiglitazone could create a significant new risk of heart attack and other serious problems. In about two weeks, FDA experts will meet to decide whether or not to withdraw the drug. One study,published online in the Archives of Internal Medicine, involving more than 35,500 people, found that rosiglitazone significantly raises the chances of a heart attack by 28% to 39% as compared with other diabetes medications.. Another study, the largest such study to date, of more than 227,500 Medicare patients, found that rosiglitazone increases risk for strokes, heart failure, and death. The study published in the Journal of the American Medical Association, found that compared with Actos, Avandia was associated with a 25% increased risk of heart failure, a 27% increased risk of stroke and a 14% increased risk of death.

New drug restores hearing after noiseinduced hearing loss in rats

A landmark research from New Zealand reports discovery of a potent new drug, ADAC, which restores hearing after noise–induced hearing loss in rats. Injection of ‘ADAC activates adenosine receptors in cochlear tissues causing recovery of hearing function. The finding has opened up avenues for effective non–surgical therapies to restore hearing loss after noise–induced injury. The study by Dr. Srdjan Vlajkovic and co authors is published in the journal Purinergic Signalling, focusing on the inner ear.

MCI News: CBI slaps FIRs on 9 medical colleges

The CBI has put more than a dozen medical colleges in the dock for gross irregularities in the wake of the arrest of Medical Council of India (MCI) president. Sources confirmed that the CBI has registered FIRs against nine medical colleges and initiated preliminary inquiries (PEs) against five other institutions. The PEs, too, will be converted to FIRs if the prima facie evidence is confirmed. The colleges against which FIRs have been filed include Index Medical College Hospital and Research Centre, Indore; Sri Lakshmi Narayana Institute of Medical Sciences, Puducherry; and KPC Medical College and Hospital, Kolkata. CBI found that these colleges paid huge bribes to secure affiliations from the MCI over several years. [Source: http://www.thehindu.com/news/cities/Chennai/article497149.ece]

 

Legal Column

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

Newer legal aspects of medical examination of rape victims

As per the recent judgment of the Supreme Court in State of Karnataka v Manjanna there is now no need for a victim of rape to first lodge a police complaint in order to get herself examined and/or treated. She can directly go to a hospital/medical professional and get herself examined and/or treated, and subsequently decide on legal action.

Today, a victim of rape can choose her own doctor (female or male) from a government hospital or even the private sector, as per Section 164A of the Criminal Procedure Code. This Amendment, introduced in 2005, has also put an end to the debate on whether a male doctor could examine a female victim of rape.

In many hospitals, the use of Sexual Assault Forensic Evidence kits, largely due to the promptings of the Centre for Enquiry into Health and Allied Themes, or a similar kits developed by the governments department of women and child development, and UNICEF, has enhanced the process of collection of medical evidence in the examination of victims of sexual assault, both adults and children. These kits act as ready reckoners so that crucial medical evidence is not missed during the step-bystep medical examination. Some hospitals have established onestop crisis centers for addressing the needs of distressed victims of physical and sexual violence, which provide medical, surgical, psychological, legal, and rehabilitative support and counseling under one roof. An excellent example is DILAASA, a crisis Centre for women, a joint initiative of CEHAT and the public health department, K B Bhabha Hospital, Mumbai.

 

Experts’ Views

Interesting tips in Hepatology & Gastroenterology
Dr Neelam Mohan, Consultant Pediatric, Gastroenterologist, Hepatologist, Therapeutic Endoscopist & Liver Transplant Physician Sir Ganga Ram Hospital, Delhi

Obesity in children

Childhood obesity is a serious medical condition that affects children and adolescents. In 2005, a survey conducted in 2 districts of India by National Institute of nutrition found that obesity in children aged 12-17 year had more than doubled in a decade. In another recent survey by Delhi diabetes research center in schools of Delhi it was seen that almost one in five children between 8 to 14 years of age were overweight or obese. It occurs when a child is well above the normal weight for his or her height and age. It is particularly troubling because the extra kilos often start kids on the path to health problems that were once confined to adults such as diabetes, high blood pressure and high cholesterol.

Causes of obesity in children are

  • Overeating/ Poor eating Habits
  • Exercising Less
  • Genetic
  • Hormonal
  • Medications (steroids,etc)
  • Depression/ emotional problems
  • Stressful events
  • Obsessive compulsive disorder

Most common cause in children is bad eating habits and overeating. Nowadays children in India are eating a lot of fast foods such as pizzas burgers chips samosas, patties and cold drinks. Cold drinks are a source of unnecessary calories and area associated with a lot of side-effects. This is combined with reduced activity of children due to excessive use of computers, videogames and TV watching.

Question of the Day (Dr. Hemant Malhotra, Ahmedabad)

How important a risk factor is hypertriglyceridemia in our country and how should one approach such a patient?

Hypertriglyceridemia (TG >150 mg/dl) has been considered to confer increased risk for CAD. Indians tend to develop centralized adiposity (preferential deposition of fat on the trunk and intraabdominally) with higher insulin resistance and hyperinsulinemia. Syndrome X or metabolic syndrome is characterized by increased insulin resistance, diabetes, HT, dyslipidemia (high fasting TG and low HDL cholesterol and high platelet activator inhibitor type 1 (PAII.) Some studies have suggested that hypertriglyceridemia is an independent risk factor for CAD. Minor elevations in TG levels (150299 mg/dl) usually are caused by obesity, sedentary lifestyle, smoking, excess alcohol intake and high carbohydrate diets. In other patients, secondary causes such as diabetes, renal failure, Cushing's disease, nephrotic syndrome or medication (e.g., protease inhibitors, corticosteroids, retinoids, oral estrogens) may be responsible and genetic causes may be pertinent to others.

Management:The therapy for this group of patients involves identification and treatment of secondary cause (if present), change in medications and lifestyle changes. Very high TG levels (>500 mg/dl) usually result from genetic defects of lipoprotein metabolism; these patients are at risk for acute pancreatitis. Early and active treatment is required to prevent this condition like (a) Dietary measures (low fat diet <15% calories from fat). (b) Fibrates, niacin, statins in high doses.

Intermediate rise in TG levels (200499 mg/dl) is often a result of a combination of poor lifestyle, secondary causes and genetic factors. These patients often have other markers of increased atherogenic risk such as increased LDL, low HDL or elevated VLDL remnants.

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Public Forum (Press Release for use by the newspapers)

Monsoon and Road Safety Tips For Driving In Rain

During the monsoons, many people become victims of road traffic accidents. The Heart Care Foundation of India today released road safety guidelines to reduce dangers of accidents while driving. Giving the details Padma Shri and Dr B C Roy National Awardee Dr KK Aggarwal, President Heart Care Foundation of India said that it is important for the public to revise their knowledge about the road safety.

He also requested the transport department and the traffic police to intensify their educational campaign in this regard.

HCFI released the following tips to drive safely during the monsoons:

  1. Sl–o–o–o–o–o–w down. Driving too fast is the No. 1 cause of accidents on wet days.

  2. If an accident occurs or your vehicle stalls, pull as far off the road as possible, turn on flashing emergency lights, and move to a safe area. If there is no safe place next to the road, stay in your car and remain buckled up.

  3. Drive in the tyre prints of the car ahead of you. When a car hydroplanes, it’s riding on a thin layer of water between the tires and the road. The water in tire prints has already been displaced, so you get better traction.

  4. If your car hydroplanes, hold the steering wheel steady and lightly apply brakes. When you feel the tires touch the pavement, slow until regaining control.

  5. Don’t speed through standing water.

  6. For motorcyclists, crosswalk lines and pavement arrows are super–slick.

  7. Check the tyres and wipers of your car. According to the Traffic police, many drivers in accidents say their visibility was hampered as the car wipers smeared their windshields on a rainy day.

  8. Keep a safe distance between you and the vehicle in front. Your braking distance is greatly increased in wet driving.

  9. Don’t brake while in a curve if at all possible. Brake before entering the curve.

  10. Use turn signals for all lane changes and turn well in advance so it does not surprise another driver and cause him to brake.

  11. Don’t change lanes.

  12. Dark traffic signals or blinking red lights mean everyone must stop once, assess the traffic and only then drive on.
 

An Inspirational Story (Anuj Goyal)

You are not a Barracuda

Read this story…

Sometimes ago, scientist carried out a simple experiment on a barracuda. They put the barracuda into a big glass aquarium and began to feed the barracuda with small fishes. The barracuda would swim towards the small fishes and in one gulp would swallow them. They continued putting the small fishes into the glass container as good for the barracuda. Then one day the scientist put a glass partition at the center of the glass aquarium. They put the small fishes into the opposite side of the glass aquarium. As the barracuda approached to have it’s food, it would hit against the glass partition. This puzzled the barracuda, but it kept on trying.

And it kept on failing and hitting against the glass partition until one day, it stopped trying. The scientists then removed the glass partition, and the small fishes were released to swim all over the glass aquarium. The amazing discovery was that the barracuda did not attempt to go for the fishes. It had been conditioned to think that it would only hit against the glass partition. The sad thing was that, eventually, the barracuda died surrounded with abundance of food.

Moral of the story… Just like the barracuda, most of us stop ourselves from trying again just because we have experienced failures in the past. We think that since we failed before, trying again would be futile as the result would probably be the same. We prefer to die rather than try, just like the barracuda. We have been conditioned not to try anymore because of the fear of failure. To be successful we have to get rid of this limiting belief, and accept a new and empowering belief, "the future foes not equal the past". What’s past is just history, the future will be different.

If you failed before, don’t worry, stand up and try again. It doesn’t mean that you are going to fail all the time. So don’t get hit by the phobia, the feeling of afraid to lose again. Success will not come in the first try. We use the 'trial and error method' to achieve success; this means that if you have not failed before, you are not going to discover how to succeed.

 

IJCP Special

Dr Good Dr Bad

Situation: A patient with laryngopharyngeal reflux wanted to know about foods avoided.
Dr Bad: All foods are okay
Dr Good: High acidic food should be avoided.
Lesson: Most foods have a pH range between 2.5 and 6.0. Low acid foods, with a pH above 4.6, include meat, poultry, seafood, milk, and fresh vegetables (except tomatoes). Acid foods (pH <4.6) include most fruits (especially citrus), tomatoes, jams and jellies, barbecue sauces, and most salad dressings. Acid foods and spicy foods (hot mustards, curry, hot peppers) directly irritate the throat lining and can cause inflammation. Pepsin is a stable molecule and can be reactivated whenever the pH drops into the proper zone. While many of these foods are otherwise healthy, they can exacerbate reflux at the level of the larynx and it is best to find less-acidic alternatives in patients with severe symptoms.
(vm.cfsan.fda.gov/~comm/lacfphs.html (Accessed on 6/11/05).)

Make Sure

Situation: A patient with renal failure came to a doctor.
Reaction: Oh, my God! Why was he given painkillers?
Lesson: Make sure to avoid painkillers in renal failure as most painkillers (barring nimesulide, paracetamol) are not kidney–friendly drugs.

Mistakes in Clinical Practice

MTX: Methotrexate written in this short form can be mistaken as Mitoxantrone.

Quote of the Day (Dr. Santosh Sahi)

"Do what you can, with what you have, where you are" Theodore Roosevelt

Milestones in Gabapentin

Nystagmus: 1996

Lea AverbuchHeller, et al discovered the use of Gabapentin in acquired pendular Nystagmus.

 

View Point ( MCI- Medical Education)

In this column, eminent Padma Awardees express their thoughts on Medical education. Today, we present the views of Padma Bhushan Awardee Dr M Khalilullah, Consultant Cardiologist, The Heart Centre, New Delhi.

Medical education is a top priority sector that requires deep consideration, planning and execution. Over the years, it appears, we have failed to understand total requirement of medical professionals in the country, be it at the graduate level, at the postgraduate level and at the post doctoral level.

With the rapidly increasing patient load for healthcare delivery teams, there has to be a progressive increase in the number of students admitted at the undergraduate level and a proportionate increase at the post graduate level and so on, even at the post doctor level.

Lack of vertical growth and opportunities at the postgraduate and postdoctoral level is causing significant frustration amongst the new graduate doctors who in spite of aspiring to be specialists and superspecialists to serve the country better in their best possible manner are unable to get into post graduate and post doctoral courses. This is reflecting in the number of students who are now appearing in the entrance tests for admission into medical colleges in the country. It appears that there has been a significant drop in the number of applicants for the premedical test whereas there is an increase in other areas. Detailed statistical analysis of the medical acquirement and extrapolation of the need for progressive growth in number to suit both the rural and urban who are specialized and superspecialized requirement should be carried out so that the country can produce enough high class professionals to serve the people of our country.

I am sure the present Boards of Directors will look into this matter and take appropriate action.

 

IMSA Update

International Medical Science Academy Update (IMSA)

Daily chest radiographs on mechanically ventilated patients (to check endotracheal tube position) are routine in many clinical centers. A trial randomly assigned 21 intensive care units (ICUs) to perform routine daily or as–needed chest radiographs on mechanically ventilated patients’. The number of chest radiographs was significantly lower in the as-needed group without worsening clinical outcomes including mortality, length of ICU stay, or duration of mechanical ventilation.

Reference
1. Hejblum G, ChalumeauLemoine L, Ioos V, et al. Comparison of routine and on-demand prescription of chest radiographs in mechanically ventilated adults: a multicentre, cluster-randomised, two-period crossover study. Lancet 2009;374:1687.

 

Drug Update

List of Approved drugs from 1.01.2009 to 31.10.2009

Drug Name

Indication

DCI Approval Date

Betahistine Mesilate Tablet 6mg/12mg

For the treatment of dizziness and feeling of dizziness resulting from Meniere’s disease, Meniere's syndrome and vertigo.

20.02.09

 

Medi Finance

Understanding Mutual Funds

Balanced funds invest in a mix of stocks, bonds, and cash investments. The mix will change as market conditions change, but it usually stays within predetermined ranges. (For example, stocks 4060%, bonds 3050%, cash 030%).

 

Lab Medicine (Dr Arpan Gandhi and Dr Navin Dang)

Porphyrin Tests: Indications

When a patient has symptoms that suggest an acute neurologic/psychiatric porphyria, such as abdominal pain, tingling in hands or feet, and/or confusion or hallucinations, or that suggest a cutaneous porphyria, such as reddening, blistering, or scarring on sun–exposed skin

 

Humor Section

What’s the difference between a general practitioner and a specialist?
…One treats what you have, the other thinks you have what he treats. l

Funny Definitions

Fester………………………Quicker than someone else

Medical bloopers on medical charts!

The patient refused an autopsy.

 

Readers Responses

  1. Thanks, I read almost every day the eMedinewS. Thanks for providing the news from Kanpur about ‘child crying with pain abdomen’ by Dr Neelam Mohan;,another article of Dr Sudhir Gupta AIIMS regarding road rage maximum in South Delhi and drunken driving is an eye opener; Dr good and Dr bad, try biventricular pacing. The news are interesting and up dating.please continue to send it to me: Dr K P Singh, Junior Cardiologist, Fortis–Escort, Okhla Road, New Delhi 110025

  2. Dear Sir/Madam, A belated but genuine wish on Doctors’ Day. May all of us be the torch–bearers of the noblest profession in the world!!!! Thanks and regards, Dr. Anirban Bagchi

  3. Dear Dr KK: I read your emedinews regularly and congratulate you for the excellent well informative presentation. I am a retired Ophthalmologist (Specialist Cadre of CHS) from Govt of India, Min of Health Deptt of CGHS. I would like to have your valuable opinion and guidence on how to increase your HDL level. I know there are medicines to lower LDL or Triglycerides but no one has discussed the HDL-raising devices. Somebody told me that the bark of ARJUN tree is helpful. Is it really so and if so how? How is the Arjuna tree helpful in cardiac ailments? Looking forward for your views please. Thanks: Dr Prakash Bharadwaj A: By lowering triglycerides the HDL will rise. Othetr interventions are almonds, exercise, low dose alcohol if not contraindicated, red degi pepper, arjuna etc.

  4. Dear Dr. KK: I fully agree with Mr. SK Parashar's true story about the consequences of using a laptop on bed. I use it very very often. And so do my children. Will have to stop it. Gr8 lesson learnt. Thanks to Emedinews.Dr Tarun Gupta
 

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