emedinews
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FIRST NATIONAL DAILY eMEDICAL NEWSPAPER OF INDIA
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Dr KK Aggarwal

From the Desk of Editor in Chief
Dr B C Roy National Awardee,

Dr KK Aggarwal
President, Heart Care Foundation of India; Sr Consultant and Dean Medical Education, Moolchand Medcity; Member, Delhi Medical Council; Past President, Delhi Medical Association; Past President, IMA New Delhi Branch; Past Hony Director. IMA AKN Sinha Institute, Chairman IMA Academy of Medical Specialities & Hony Finance Secretary National IMA; Editor in Chief IJCP Group of Publications & Hony Visiting Professor (Clinical Research) DIPSAR


Dear Colleague

8th February 2010, Monday

Practice Changing Updates: Magnesium sulfate for fetal neuroprotection
Meta–analyses of randomized placebo–controlled trials have shown that fetal exposure to magnesium just prior to preterm delivery is associated with a significant decrease in postnatal risk of cerebral palsy and severe motor dysfunction.

One can administer magnesium sulfate to pregnant women under 32 weeks of gestation who are likely to have a preterm birth within 24 hours to decrease the postnatal risk of cerebral palsy and severe motor dysfunction.

The optimal dose has not been established. The suggested dose is 4 gram intravenous loading dose followed by a one gram infusion. This therapy should be discontinued by 24 hours after initiation if delivery has not occurred.

References

1. Costantine MM, Weiner SJ. Effects of Antenatal Exposure to Magnesium Sulfate on Neuroprotection and Mortality in Preterm Infants: A Meta–analysis. Obstet Gynecol 2009;114:354.
2. Doyle LW, Crowther CA, Middleton P, et al. Antenatal magnesium sulfate and neurologic outcome in preterm infants: a systematic review. Obstet Gynecol 2009;113:1327.
3. Doyle LW, Crowther CA, Middleton P, et al. Magnesium sulphate for women at risk of preterm birth for neuroprotection of the fetus. Cochrane Database Syst Rev 2009;:CD004661.

 Dr KK Aggarwal
Chief Editor


News and Views

Avastin as effective as Lucentis
Visual acuity show similar improvements with two vascular endothelial growth factor inhibitors used to treat age?related macular degeneration (AMD). In a study published in February issue of Ophthalmology about a fourth of patients treated with bevacizumab (Avastin) or ranibizumab (Lucentis) had ≥20/40 vision at 12 months. The frequency of adverse events did not differ between treatment groups, but bevacizumab patients received fewer injections over the course of a year.

Sleep apneas treatment improves golf performance
Twelve golfers with moderate to severe obstructive sleep apnea who started nasal positive airway pressure treatment saw a drop in their mean handicap from 12.4 to 11.0 (P=0.01), according to Marc Benton, MD, Atlantic Sleep & Pulmonary Associates in Madison, NJ (American College of Chest Physicians meeting). A control group of golfers who did not have obstructive sleep apnea had no change in their handicaps over the same time period.

Clopidrogel can be tapered abruptly
There is no evidence of a platelet aggregation rebound with abrupt discontinuation of clopidogrel in patients undergoing percutaneous coronary intervention. Values for adenosine diphosphate induced platelet aggregation did not differ significantly between patients whose clopidogrel therapy was withdrawn abruptly and those in whom clopidogrel was tapered before discontinuation.(Feb. 9 issue of the Journal of the American College of Cardiology)

Avoid femoral artery cannulization during cardiac surgery Avoiding femoral artery cannulization during cardiac surgery might eliminate some of the rare but potentially catastrophic aortic dissections that occur during the procedure. Doctors identified the femoral location as an increased risk factor in an analysis of records from the Society of Thoracic Surgeons’ national database of more than 2.2 million cardiac surgeries. The search yielded 1,294 incidents of aortic dissection. (Dr Matthew Williams, University of Louisville)

SSRI may delay post partum breast milk
Women taking SSRI antidepressants may experience delays in postpartum breast milk production. Delayed secretory activation occurred in 87.5% of a small group of women taking SSRIs, compared with 43.5% of those not taking the drugs (P=0.02), according to Aaron M. Marshall, PhD, of the University of Cincinnati in the Journal of Clinical Endocrinology and Metabolism.

Ablation for AF
If initial drug therapy fails to control paroxysmal atrial fibrillation, one should opt for radiofrequency catheter ablation. In a prospective randomized trial, catheter ablation succeeded in preventing fibrillation in 66% of patients. (Dr David J. Wilber, Loyola University Medical Center, Maywood) By comparison, only 16% of patients who got renewed drug therapy were free from treatment failure by the end of nine months of follow-up. (Jan. 27 issue, JAMA)

FDA warning for bortezomib
The FDA has revised dosage and safety information for bortezomib, the myeloma and mantle cell lymphoma drug, to reflect an increased toxicity risk. The new labeling includes a warning for patients with moderate?to?severe hepatic impairment and now recommends at?risk patients start at a lower dosage of 0.7 mg for the first cycle of treatment and escalate to 1.0 mg, or reduces further to 0.5 mg, in subsequent cycles.

Eye care snippets (Dr. Narendra Kumar (OptometryToday@gmail.com)
Optical Instrument and Tools
The optical dispenser makes use of an optician ruler for measuring the pupillary distance (PD), the nose bridge size, the size of the lens, palpebral aperture width, diameter of the cornea and the pupil, and the vertex distance of a lens from the wearer?s eye; a lens measure for surface curvature of the lens; a thickness gauge or caliper for measuring the centre or edge thickness of the lens; and a lensometer for ascertaining the power of the lens.

Optician ruler: It is one of the most commonly used tools. It is made of plastic. The scale is divided into 1mm increments and divisions are noted every 10mm or 1cm.

Thickness gauge: In our quest for ‘thinner’ lenses, we sometimes cross the limit. But from safety point of view, lenses must be of a certain minimum thickness. The thickness gauge or caliper is usually made of metal, has pointed jaws that open around a lens, and has a scale in mm and tenths of millimeters. It is used to measure the centre or edge thickness of lenses.

Lens measure: This is a device used to measure the front and back surface curvatures of lenses of 1.523 refractive index in dioptres of curvature. On placement against the surface of a lens, the central of the three pins of the lens measure is depressed and the needle on the dial turns to the appropriate dioptric value. The lens measure has a scale each for convex and concave measurements. Surface powers are recorded first at one position and then at 900 from it. If the surface is spherical, then the two readings will be the same. If these are different, the flattest and steepest curves are determined to find out the lowest and highest values. Nowadays, cylinders are usually made on the front surface of single vision lenses (and on the back surface of bifocal lenses). The lens measure for plastic lenses has rounded metal or nylon tip on the pin ends. The lens measure can also be used to verify the base curve of a lens. Even though wearing an identical prescription, the change from a front surface toric to a back surface toric lens can irritate some patients. The lens measure can be used in such cases to determine whether the front or the back surface of the lens has the cylinder. From time to time, it must be ascertained that there is no error present in the instrument. To check for an error, make sure that the surface registers plano as the lens measure legs are placed on the counter or a flat surface.

Lensmeter: Lensmeter, lensometer or focimeter, is an instrument to verify or determine the power of a lens, and to mark the axis of a cylinder. It will reveal the spherical power, cylindrical power, its axis, presence of prism, and the direction of its base. It incorporates a device to mark the optical centre of the lens. The lensmeter, with the use of an additional holder, can also be used to measure the power of a contact lens. Its major parts include the eyepiece (which is a part of the telescopic focusing system), power drum (a rotating wheel calibrated in 0.25D units), axis drum (a rotating wheel calibrated in 10 increments), lens/frame table (a horizontal reference for lenses/frames parallel to the 0–1800 line), and marking device (to place three ink dots on the lens for subsequent processing). The lensmeter does neutralization, which is the process of defining the prescription of lenses, i.e. the sphere, cylinder and axis of a lens. And, Rxs may be written either in minus or plus cylinder forms by way of transposition.

Prior to use, the eye–piece of the instrument needs to be adjusted. The lens, to be checked, should be placed in the holder with the front surface facing yourself. The adjustment should be such that the position of cross–lines observed in the instrument are centrally located. In case of a spherical lens, the small lines become as sharp as the large lines at the same time. In case of a cylindrical lens, the small lines do not become sharp at the same time with the large lines. To find the power of a cylindrical lens, first find the more plus power (e.g. –2.50 D is more plus than –3.50 D). Then sharpen the small lines. Record this as the sphere power and axis. Next find out the more minus power. The difference between the spherical power and the cylinder power is called the minus cylinder power at the axis determined by the more plus power.

The lensmeter can be placed in the following basic categories:

  1. Manual: A design in which the operator adjusts measuring scales with control knobs, and views the results on an internal/external screen and graticule.
  2. Semi–automatic: A design in which some operations are automated, e.g., centering the lens in the beam path of the instrument.
  3. Automatic: In this design, the majority of the operations, e.g., lens centering and add determination are automatically carried out. Some sophisticated instruments even determine the refractive index of the lens material or the UV and visual transmission.

Hand tools: The optical dispenser also needs a variety of hand tools to fit and adjust frames. The optical screwdriver has a handle and a rotating head, and comes in several blade sizes. Pliers come in variety of jaws for varied jobs of adjusting frames. Lathes and polishing buff are used to restore the finish on metal or shell frames. And, files are used to remove irregularities from the surface of frames.

Conference Calendar
ICRH 2010
International Conference on Reproductive Health and the 20th Annual Meetings of the Indian Society for the Study of Reproduction and Fertility
Time: February 8–10, 2010
Venue: Bhagwat Singh Mehta Auditorium, Nehru Bhawan, Jaipur, Rajasthan

Public Forum
Press Release

Be on the Alert for Symptom of Heart Attack
If you aren’t sure whether you are having heartburn or something more serious––like a heart attack––you should get yourself checked out, said Dr K K Aggarwal President, Heart Care Foundation of India and Editor eMedinewS.

The most common symptom of coronary heart disease is chest pain (angina) or discomfort, which can also occur in the shoulders, arms, neck, jaw or back. People may mistake this pain for indigestion, which can be dangerous.

Sometimes, it’s impossible to tell the difference between the symptoms of heartburn, angina and heart attack, said Dr. Aggarwal. A heart attack occurs when the blood supply to part of the heart muscle is severely reduced or stopped. This can result in death or disability, depending on how much of the heart muscle is damaged. Unfortunately, many people may not be aware they are having a heart attack.

There are some useful pointers that might help a person know whether they're having a heart attack or not, but when in doubt, check it out, said Dr Aggarwal. Symptoms of a heart attack include the sudden onset of tightness, pressure, squeezing, burning or discomfort in the chest, throat, neck or either arm. When these symptoms are accompanied by nausea, vomiting, sweating, shortness of breath or a fainting sensation, Dr. Aggarwal says one should be especially suspicious that you might be having a heart attack. People who have any risk factors that may predispose them to a heart attack should be particularly cautious.

Main points
1. Heart attack pain is never pinpointed
2. Heart attack pain never lasts less than 30 seconds.
3. If you smoke, have diabetes, high cholesterol, high blood pressure, are overweight or have a strong family history of heart disease and have any symptom related to the chest or heart, you should be alert.

Question of the Day
What is the management of coma in malaria?

ABC of coma management
Airway
1. Maintain the airway by keeping airway clean, i.e., free from saliva, vomitus, etc.
2. Unconscious patients should be nursed on side, preferably left lateral position, on a flat surface without a pillow. This reduces incidence of aspiration of gastric contents.
3. Keep changing the side every 2 hours.
4. Insert a nasogastric tube to prevent aspiration pneumonia and aspirate stomach contents.
5. Oral or oropharyngeal airway should be used to prevent the tongue from falling back and to keep the airway clean.
6. If facilities exist, endotracheal intubation should be done in a coma patient if needed.

Breathing: If tachypnea, labored respiration, acidotic breathing is present or develops in the course of the management, patient may need oxygen inhalation and ventilatory support. Hence, it should be referred to centers with facilities for intensive care.

Circulation
1. Check for dehydration by examining the pulse rate, blood pressure, skin elasticity, jugular venous pressure, moisture of the tongue, urinary volume and color.
2. If dehydration is present, infuse IV fluids.
3. Frequently check the rate of infusion to prevent overhydration.
4.
If patient has overhydration, stop or restrict IV fluids and give IV diuretics (furosemide).
5. Suspected infection must be treated with antibiotics. Keep an accurate record of fluid intake and output. Strict intake and output chart should be maintained. Normal urine output is approximately 1 ml/min.

(Suggested reading: World Health Organization. Guidelines for the treatment of malaria. Geneva, 2006)

 Quote: You are what your deep rooted desires are.

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eMedinewS Try this it Works
Determining the severity of abdominal pain in children

Differentiating the severity of abdominal pain in children can be difficult.
1. During history taking, ask the child what his or her favorite food is, and then ask if he or she would want to eat the food if you have some. Chances are, seriously ill children would not want to eat even their favorite food.
2. On physical examination, ask the child to stand and hop up and down a few times. The ability to do this significantly reduces the probability of true peritonitis.

Dr Good Dr Bad
Situation: A CAD patient with GERD was getting repeated angina pains.
Dr Bad: Increase nitrates.
Dr Good: Add PPI.
Lesson: Treating reflux esophagitis in a patient with positive TMT helps in better control of CAD. Esophagitis has a definite link with CAD.

Make Sure
Situation: A patient was denied rheumatic prophylaxis as IM penicillin was under short supply.
Reaction: oh my God! Why was he not given oral penicillin.
Make sure that all such cases are not denied oral penicillin V.

Laughter the best medicine
"Doctor, doctor, I feel like a ten pound note."
"Go Shopping, the change will do you good."

Formulae in Imaging
Liver cysts: The size of the liver mass is an important consideration in guiding the evaluation. Lesions smaller than approximately 1.0 cm discovered at CT are commonly benign incidental findings on imaging studies, and in most cases represent small cysts, hemangiomas, or biliary hamartomas. (Source:Radiology 1999;210:71)

ENT Facts
Treatment regimens for patients who did not respond to the initial antibiotic course include amoxicillin-clavulanate or a second-generation cephalosporin.

SMS Anemia
A low reticulocyte percentage accompanied by pancytopenia is suggestive of aplastic anemia.

Milestones in Neurology
John Hughlings Jackson, (1835–1911), was an English neurologist; born at Providence Green, Green Hammerton, near Harrogate, Yorkshire. He is best remembered for his seminal contributions to the diagnosis and understanding of epilepsy in all its forms and complexities. His name is attached eponymously to the characteristic ‘march’ of symptoms in focal motor seizures and to the so–called ‘dreamy state’ of psychomotor seizures of temporal lobe origin. In 1892, Jackson was one of the founding members of the National Society for the Employment of Epileptics (now the National Society for Epilepsy), along with Sir William Gowers and Sir David Ferrier.

Mistakes in Critical Care
Never write IJ for injection as it may be misread as ‘IV’ or ?intra jugular’. Spell out injection.

LIST OF APPROVED DRUG FROM 01.01.2009 TO 31.10.2009

Drug Name Indication Approval Date
Metoprolol tartrate tablets 50 mg (Addl. Indication)
Adjunct to the treatement of Hyperthyroidism

14.01.09

(Advertorial section)

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Phosphate and Ammonium Chloride may help boost Body Metabolism to aid weight loss, block allergic response, slow down the growth of tumours, protect bones, fight bad breath, improve Skin, protect against Alzheimer's and Parkinson's disease and even delay the onset of Diabetes. The Combination is known to reduce the VLDL and LDL Levels and thus reduce the incidence of Stroke and Heart disease.

Advertising in emedinews
emedinews is the first daily emedical newspaper of the country. One can advertise with a singe insertion or 30 insertions in a month. Contact: drkk@ijcp.com. emedinews@gmail.com 

eMedinewS-PadmaCon 2010 
Will be organized at MAMC on July 4, 2010, Sunday to commemorate Doctors' Day. The speakers, chairpersons and panelists will be various past and present medical Padma awardees of NCR.

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 hangama and live webcast. Suggestions are invited.

Also, if you like emedinews you can FORWARD it to your colleagues and friends. Please send us a copy of your forwards.

Readers Responses (Congratulations messages for Dr KK Aggarwal)

  1. Hardik Shubhkamnayein for har lamha aisi vijay dilaye: Pankaj Aggarwal
  2. Sir, Congratulations: Dr. PH Mishra 9313622552
  3. Sir, congratulations on getting Padmashree award and salute to the services you are delivering for people. Wish you many more success in future: Ruby, ETV
  4. Heartiest congratulations: Dr. D Das, 9312212227,
  5. Congrats from the core of the heart: Dr. JMS Kalra, 9312604535,
  6. Congrats on a well deserved award: Mr Suresh Pathak
  7. Proud to be your student and congrats: Dr. Khanna, 9818912043
  8. Heartiest congrats to have won a great national honor. A matter of pride for medical fraternity: Dr. Manish,
  9. Congratulations. You really deserve it: Dr. Kapoor, 9810117035
  10. Congrats. Welcome to Padma Fraternity: Sudhir Tailang
  11. Congratulations, we are proud of you: Dr Kiran Anand
  12. This is great. My congratulation. It is a recognition for your meritorious services: Harsh Deo.