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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; 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 ...

9th September, 2010, Thursday

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

Tourniquet test

A tourniquet test (also known as a Rumpel–Leede Capillary–Fragility Test or simply a capillary fragility test) determines capillary fragility. It is a clinical diagnostic method to determine a patient's hemorrhagic tendency. It assesses fragility of capillary walls and is used to identify thrombocytopenia (a reduced platelet count).
This test is defined by the WHO as one of the necessary requisites for diagnosis of Dengue fever.

A blood pressure cuff is applied and inflated to a point between the systolic and diastolic blood pressures for five minutes. In DHF, the test usually gives a definite positive result with 20 petechiae or more.

  • The tourniquet test is positive in 39.1% of all DHF cases.
  • A negative tourniquet test may not be sufficient to exclude a diagnosis of DHF in a febrile patient.
  • A positive tourniquet test, repeatedly performed, is clinically useful as a preliminary screening test in dengue infection as recommended by WHO.

Tourniquet test procedure

  • Get blood pressure properly by covering 2/3 of arm with cuff
  • Get the mean blood pressure :
  • Mean blood pressure = systole + diastole / 2
  • Maintain for 5–10 minutes at mean blood pressure
  • Check for petechiae using a 1x1 inch opening on a cardboard
  • A positive tourniquet test means at least 20 petechiae per square inch

Dr KK Aggarwal
Editor in Chief
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  Photo Feature (from the HCFI Photo Gallery)

As a part of CME, a Conference on Rational Use of Blood and Blood components was organized by IMA, Rotary blood bank and IJCP Group of Publications jointly with several NGOs and Govt Departments on June 30, 2002.
In the photo:
Dr A K Walia, Padma Shri and Dr B C Roy National Awardee Dr K K Aggarwal, Dr O P Vaish, Mr Sudarshan Aggarwal Former Governor Uttranchal, Mr J S Verma, former Chief Justice of India

Dr K K Aggarwal
  IMSA Update

International Medical Science Academy (IMSA) Update

Universal influenza immunization

The US Advisory Committee on Immunization Practices (ACIP) expanded the recommendation for influenza vaccination to include all individuals 6 months of age and older. (www.cdc.gov/media/pressrel/2010/r100224.htm)

  National News

 IMA Election

Emedinews requests all its readers to support our editor Dr. K.K. Aggarwal, Padma Shri and Dr. B C Roy National Awardee who is contesting for the post of Vice President of the National Indian Medical Association. Members of Central Council of IMA, Working Committee Members, Presidents and Secretaries of IMA in addition to all office bearers are the voters in this election. Dr. Aggarwal is well-known for his work in the field of academics.

Cover up: Schools’ motto in dengue–hit Delhi

New Delhi: As dengue tightens its grip over the national capital, schools are slightly relaxing their strict rules regarding uniforms for students. With the city reporting over 1300 dengue cases and four deaths due to the vector–borne disease, schools are eager to ensure that children do not suffer from mosquito bites. Several private schools in the city have issued circulars asking children to wear full–sleeve shirts and trousers while the MCD has also said that students in institutions run by it should cover themselves fully. (Source: ndtv.com)

Dr. Dang’s Lab wins the award for Excellence in Patient Experience

Dr. Dang’s Lab- Medical Diagnostic Centre has won the award for Excellence in Patient Care at the FICCI Healthcare Awards 2010 to recognize initiatives, innovations or new products / services that have led to improved customer satisfaction levels, or a better customer experience. Federation of Indian Chambers of Commerce & Industry (FICCI) had organized a 2 day healthcare conference with the theme- “Healthcare for all: Global Standards with Local Touch”. Shri Dinesh Trivedi, Union Minister of State for Health & Family Welfare was the Chief Guest for the ceremony along with Kamal Haasan, Chairman, FICCI Entertainment Committee-South who was the Guest of Honour.

A total of 15 awards were given away in 5 categories besides the lifetime achievement awards.  Dr. Dang’s Lab won the award for the Best Diagnostic Centre in the category for Excellence in patient care. This category of award has been introduced for the first time this year

  International News

(Dr Monica and Brahm Vasudev)

Eat more greens to reduce risk of diabetes

According to a British study, increasing the daily intake of green leafy vegetables could significantly reduce the risk of type 2 diabetes. Daily intake of 1.35 servings of green vegetables led to a 14% reduction in risk compared with consuming only 0.2 servings (HR 0.86, 95% CI 0.77 to 0.96, P=0.01). The findings of the meta–analysis, which included six studies, are reported online in BMJ. Length of the studies ranged from 4.6 to 23 years.

Hepatitis E vaccine shows 700 efficacy rate in study

An investigational vaccine against hepatitis E had an efficacy rate of 700, as per a study from China that involved > 100,000 patients. No patient reportedly developed hepatitis E over a 12–month follow–up after receiving the full three doses of the investigational vaccine (HEV 239 or Hecolin). But, there were 15 cases of hepatitis E in the placebo group (who received a licensed hepatitis B vaccine). The study findings are reported online by Ning–Shao Xia, MD, of Xiamen University in Xiamen, China, and colleagues in The Lancet. The vaccine had equivalent high efficacy when the analysis was expanded to include participants who had received only 2 doses and reached 95.5% among those who got at least one dose, the researchers reported.

CT Colonography enhances screening for colorectal cancers

A review of > 2,000 cases has shown that CT colonography identifies almost 80% more high–risk lesions compared with optical screening by adding extracolonic findings as it allows examination of the entire abdomen and pelvis. It showed extracolonic findings in almost half of the cases, one–quarter of which were considered significant. According to Ganesh Veerappan, MD, of Walter Reed Army Medical Center in Washington, and co–authors, CT colonography not only identifies colorectal cancer but also doubles the yield of identifying significant early extracolonic lesions. They recommend considering CT colonography either as an alternative to optical colonoscopy CRC screening or as a one–time procedure to identify significant treatable intracolonic and extracolonic lesions. The study is reported in the September issue of the American Journal of Roentgenology.

FDA recalls Huber Needles

The FDA has issued a class I recall for Huber needles. Huber needles were found to produce cores – slivers of silicone – when they penetrate a vascular access port. In its recall notice, the FDA states that Coring may lead to infection, damage or death of tissue, swelling, or other severe adverse health consequences, due to the core traveling through blood vessels into the patient’s lungs of the patients which may be potentially fatal. The FDA has also asked clinicians to immediately discontinue use of the recalled products. The recall is for Multi–Med’s 22 Gauge, 1 inch straight and right angle Huber needle; and Navilyst Medical’s Vaxcell implantable vascular access systems, which contain Huber needles.

A class I recall is the most serious type of FDA recall as there is a likelihood of serious injury or death.

Obesity can lead to the following conditions (Contributed by Dr.G.M.Singh)

  •   Type 2 diabetes
  •   High Blood pressure or heart disease
  •   Osteoarthritis
  •   Sleep apnea or respiratory complications
  •   Heartburn
  •   Depression
  •   Infertility
  •   Urinary problems
  Vaccine Update

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

Immunization pain

A meta-analysis of randomized controlled trials that studied the use of sucrose or glucose for control of pain before immunization in infants (1 to 12 months) found significant reductions in the incidence and duration of crying when compared with water or no treatment. (Arch Dis Child 2010; 95:406.)

  Infertility Update

Dr. Kaberi Banerjee, Infertility and IVF Specialist Max Hospital; Director Precious Baby Foundation

Q: What are the sociocultural issues of infertility treatment?

A. Generally, the pressure to achieve a pregnancy soon after marriage is more strong in our society. The couple therefore gets stressed if pregnancy is not achieved within 3–4 months of marriage. They soon go and seek help either sometimes medical or more often astrological or visit their family priest. Many go to quacks who ‘treat’ them for months and sometimes years, with no avail. Some go to astrologers and pandits who ‘treat’ them by asking them to wear expensive rings, eat certain food items, etc. Not only do these patients lose money, they also lose precious time. This is so because as the lady grows older, the number and quality of her eggs goes down and chances of conception even with the technologically advanced techniques like IVF fail.

  ENT Update

Dr. Aru Handa MS, DNB, Dept. Co–ordinator and Senior Consultant Deptt. of ENT, Moolchand Medcity

What are the signs and symptoms of Otomycosis?

  • Ear itching, pain with or without swelling and inflammation of external auditory canal.
  • Ear blockage due to grey or blackish white (called wet newspaper print appearance due to the presence of spores) fungal debris blocking the canal.
  Gastro Update: Question of the day

What are the indications for antibiotics use in acute infectious diarrhea? (Dr Naresh Bhat, Bangalore)

Because the majority of patients have mild, self–limited disease due to viruses or non–invasive bacteria, empiric treatment of all patients is not warranted.

  • Empiric treatment is indicated in patients with suspected invasive bacterial infection, traveler’s diarrhea or immunosuppression. The drugs of choice are quinolones (e.g., ciprofloxacin, 500 mg twice daily for 5–7 days). These agents have good coverage against most invasive bacterial pathogens, including Campylobacter, Shigella, Salmonella, Yersinia and Aeromonas species. Alternatives are trimethoprim/sulfamethoxazole, 160/800 mg twice daily, or erythromycin, 250–500 mg four times daily. Metronidazole, 250 mg three times daily for 7 days, is given for suspected giardiasis.
  • For selected travellers to highrisk destinations, a quinolone (e.g., ciprofloxacin, 500 mg/day) is a preferred prophylactic agent, offering a protection rate of around 90%. Other prophylactic agents include trimethoprim–sulfamethoxazole and bismuth subsalicylate. Specific pathogens that should be treated include Shigella, Vibrio cholerae, C. difficile, parasites, extraintestinal salmonellosis, traveller’s diarrhea and sexually transmitted infections (gonorrhea, syphilis, chlamydiosis and herpes simplex infections).
  • Pathogens that should probably be treated include noncholera Vibrio, Yersinia and Campylobacter and if the symptoms are prolonged with Aeromonas, Plesiomonas and enteropathogenic E. coli.
  • The preferred treatment for patients with C. difficile diarrhea is oral metronidazole, 250–500 mg four times a day for 7–10 days. Vancomycin is an alternative agent, but it is more expensive and has to be taken orally because it is not effective when administered parenterally. Intravenous metronidazole is given for patients who cannot tolerate oral intake.

Source: Soffer EE. Diarrhea. In: Cecil Essentials of Medicine 5th Edition, Andreoli TE, et al. (Eds.), WB Saunders, Philadelphia 2001:316–320.

  Medicolegal Update

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

What is the right to refuse medical interventions? Right to die

Karen Ann Quinlan was taken off the ventilator and was able to breathe on her own. She was kept alive for nine more years with artificial nutrition and hydration. The Quinlan case changed the focus in cases of treatment refusal from a right of religious freedom to a person’s so–called "right to die". Throughout the last part of the 1970s and 1980s, many state courts, particularly in California, Florida, Massachusetts, and New Jersey, established the legal norms for terminating life-sustaining treatment. Nearly 15 years of rulings at the state level were solidified when the US Supreme Court decided the Cruzan case in 1990, a case that is very similar to the Quinlan case.

  Medi Finance Update

Taxation Tips

  • Preferably invest in mutual funds with growth scheme and not with investment scheme, as returns are
  • likely to be better.
  • Exemption from distribution tax for open ended equity oriented funds has been extended.
  • In a partnership firm, one can only pay a maximum of 12% interest to partners on money invested.
  Drug Update

Drugs prohibited for manufacture, sale and distribution from subsequent date

Drug Formulation


Parenteal Preparations fixed dose combination of streptomycin with Pencillin

GSR 93(E)

  Lab Update

Laboratory Findings typical of Dengue fever (DF)

  • Leukopenia is common in both adults and children with DF and is a useful diagnostic feature.
  • Thrombocytopenia is noted in most patients with DF.
  • Platelet counts <100,000 cells/mm3 ( in 16 – 55 % of patients).
  • SGOT and SGPT levels are frequently elevated in both adults and children with DF; the elevations are usually modest (2 to 5 times the upper limit of normal values), but marked elevations (5 to 15 times the upper limit of normal) are occasionally noted.
  • SGOT > SGPT 
  IJCP Special

Dr Good Dr Bad

Situation: A 66–year–old male patient with normal lipid profile came for repeat checkup.
Dr.Bad: Repeat Lipid Profile.
Dr.Good: Lipid Profile is not necessary.
Lesson: Lipid levels are less likely to increase after the age of 65.

Make Sure

Situation: A patient who had blood in the urine one month back was found to have large bladder cancer.
Reaction: Oh my God why was a cystoscopy not done at that time?
Lesson: Make sure that all cases of painless bleeding in the urine are investigated for cancer at the time of first presentation.

Quote of the Day

"Great minds discuss ideas; Average minds discuss events; Small minds discuss people"……Eleanor Roosevelt
(Contributed by Dr Prachi Garg)

Hypertension Alert

Antihypertensive treatment is associated with reductions in chances of paralysis by 35–40%, heart attack by 20–25 %; and heart failure by 50%.

  Mind Teaser

Read this……………………


The answer for yesterday’s E Quiz : Correct answer is A.

Metabolic acidosis is the primary disorder in this patient with DKA. Her pH and bicarbonate are low and the arterial carbon dioxide is low due to compensatory hyperventilation.The PaCO2 expected in this patient (Winter’s formula: 1.5 × HCO3 + 8 +/– 2) is 1.5 × 10 + 8 +/– 2 = 21 to 25. So patient does NOT have a primary respiratory disorder. Hence B & C are incorrect.

The expected Anion Gap in this patient = Albumin × 2.5 = 4 × 2.5 = 10. The calculated Anion gap (Na –Cl – HCO3) = 130–80–10 = 40. So she has Anion gap metabolic acidosis.

Delta-delta is change in anion gap/change in bicarbonate. When it is 1–2, patient has pure anion gap metabolic acidosis.

  • When it is < 1, patient has additional non–anion gap metabolic acidosis.
  • If over 2, patient has metabolic acidosis.

For this patient:
Change in anion gap (calculated – expected anion gap) = 40–10 = 30,
change in bicarbonate (24 – measured) = 24 - 10 = 14 so her delta–delta
is 30/14 ≥ 2.
Inference: this patient has a combined anion gap metabolic acidosis and metabolic alkalosis; (A) is the best correct answer.

Correct answers received from: Dr Prachi Garg, Dr G M Singh

Correct answer for 7th September Puzzle: “No two ways about it”

Correct answers received from: Dr Virender Prakash Gautam, Dr. Sukanta Sen

Send your answer to ijcp12@gmail.com

  Humor Section

Interesting aspects of mathematical calculation in human life
Shopping Math
A man will pay $20 for a $10 item he needs…
A woman will pay $10 for a $20 item that she doesn’t need.

(Contributed by Dr. D R Nakipuria)

Funny But True Facts
Life me hamesha Haste raho, muskrate raho, gaate raho, gungunate raho… taki tumhe dekh kar hi log samaj jaye k tum… "UNMARRIED" ho.

(Contributed by Dr Chandresh Jardosh)

  An Inspirational Story

Too Many Days At A Time
There are two days in every week about which we should not worry. Two days which should be kept free from fear and apprehension.
One of these days is yesterday, with its mistakes and cares, its faults and blunders, its aches and pains. Yesterday has passed forever beyond our control. All the money in the world cannot bring back yesterday. We cannot undo a single act we performed. We cannot erase a single word we said. Yesterday is gone!!
The other day we should not worry about is tomorrow, with its possible adversities, its burdens, its large promise and poor performance. Tomorrow is beyond our immediate control. Tomorrow's sun will rise, whether in splendor or behind a mask of clouds. But it will rise. Until it does we have no stake in tomorrow, for it is yet unborn.
This leaves only one day: today.
Any man can fight the battles of just one day. It is when you and I add the burdens of two awful eternities – yesterday and tomorrow, that we break down.
It is not necessarily the experience of today that disturbs one's peace of mind. It is often the bitterness for something which happened yesterday and the dread of what tomorrow may bring. Let us therefore live one day at a time.

  Readers Responses
  1. Dear sir,  I wish you many many happy returns of the day. I know I am a bit late but Happy belated birthday. I hope you had a great day and a very bright year ahead. Apurva Koirala.
  2. Our very dear colleagues 5th September is a great day  when God gifted the medical  profession a   very noble & brilliant  doctor, an unparalleled genius, a  volcano  throwing out new & brilliant  ideas every  time for the welfare of humanity. Wishing you a very happy birthday with many many more to come. May each new year bring you excellent health, wealth & more  knowledge & newer ideas  to improve the health of the nation. Fondest love and regards : K. Kanwar
  3. Dear chief editor, It is great to see to all the articles of the September issue is highly informative. I have one query regarding the cardiology update, Beta blockers decreases the lipid levels. May I know the references? Dr. Praveen
    eMedinewS responds: The effect of beta blockers on serum lipids varies with their pharmacologic characteristics, and may be more prominent among smokers.1 Nonselective and beta-1-selective beta blockers have little effect on cholesterol levels but lead to an approximate 10 percent fall in cardioprotective HDL-cholesterol and, particularly with nonselective agents, a 20 to 40 percent rise in triglycerides2.Lipid levels are relatively unaffected by labetalol and beta blockers with intrinsic sympathomimetic activity (eg, acebutolol and pindolol)2. Newer beta blockers have a more favorable metabolic profile; carvedilol, also prevents lipid peroxidation3,4. One study evaluated 45 patients with non-insulin-dependent diabetes mellitus and hypertension who were randomly assigned to therapy with metoprolol or carvedilol4. Carvedilol was associated with a significantly greater fall in total cholesterol and lesser rise in triglycerides than metoprolol.
    1.  Vyssoulis, GP, Karpanou, EA, Pitsavos, CE, et al. Dyslipidemic effects of cigarette smoking on beta-blocker-induced serum lipid changes in systemic hypertension. Am J Cardiol 1991; 67:987.
    2.  Kasiske, BL, Ma, JZ, Kalil, RS, Louis, TA. Effects of antihypertensive therapy on serum lipids. Ann Intern Med 1995; 122:133.
    3.  Giugliano, D, Acampora, R, Marfella, R, et al. Metabolic and cardiovascular effects of carvedilol and atenolol in non-insulin-dependent diabetes mellitus and hypertension. A randomized, controlled trial. Ann Intern Med 1997; 126:955.
    4.  Bakris, GL, Fonseca, V, Katholi, RE, et al. Metabolic effects of carvedilol vs metoprolol in patients with type 2 diabetes mellitus and hypertension: a randomized controlled trial. JAMA 2004; 292:2227.
  4. Dear Sir, I would like to ask a question to Dr.Kaberi Banerjee regarding the column in emedinews dated: 8th sept where she talks about multiple births & IVF treatment.
    I would like to know the pros & cons of single vs multiple embryo transfer in IVF & also what is the usual practice in Delhi fertility centers regarding the same?Regards, Dr. Kapil Aggarwal
    Kaberi Banerjee responds:Thank you for the query. The answer follows;The initial practice of IVF and Embryo Transfer involved the transfer of multiple embryos usually 3-5 . It was soon realized that the number of multiple pregnancies especially higher order, that is more than three ,was increasing. This was associated with pre-term delivery which led to premature babies and developmental delays with occasional mental handicap in the long run. This leads to enormous psychological and financial burden to the person and society in general. A drive was therefore started in the west in those countries where the government is responsible for healthcare, especially the Nordic countries and UK to limit the number of embryos to be transferred. They have infact suggested  transfer a single embryo to further reduce the chance of twin pregnancy. This would hold good for a system where
    1. The cryopreservation systems are excellent.
    2. The government is funding atleast partially for the IVF treatment ,as the patient's would need multiple attempts at transfer to get a viable pregnancy. In India where the patient has to pay for each cycle, it becomes difficult to justify single embryo transfer. I usually practice transferring between 2-3 embryos. This gives me a good pregnancy rate of 40% verses 25% of single embryo transfer. If the lady has triplets we then offer fetal reduction.
  Public Forum

(Press Release for use by the newspapers)

Dr. K.K.Aggarwal to deliver a lecture on Science behind Indian Mythology at IMSA Conference 2010 London

Padma Shri & Dr. B. C. Roy National Awardee Dr K.K.Aggarwal has been invited by the annual conference of the International Medical Science Academy to be held at Royal Society of Medicine London (UK) and will be delivering a lecture on Science behind Indian Mythology on 10th of this month to be attended by doctors from all over the world. The conference for the first time is having a session on Holism, a challenge in Clinical Medicine.
Dr. Aggarwal who is an expert in allopathic aspects of Indian Mythology has written a book on Alloveda which combines Vedic knowledge with allopathy.
Dr. Aggarwal said that chanting of vowels produces painkillers and chanting of nasal consonant produces Tranquilizers. Dr. Aggarwal said that AUM chanted in spirituality is a combination of a vowel with a nasal consonant.
Dr. Aggarwal said that Bhagwad Gita was the first text book of counseling and first introduction to cardiac resuscitation was in Satyawan Savitri era.
Dr. Aggarwal said that when in trouble one requires multiple counseling sessions and not one. Arjuna in Bhagwad Gita required 18 such sessions. In the first chapter of Bhagwad Gita, Krishna uses the principles of patient listening. He does not utter a word and lets Arjuna comes out with his emotions.
In the second session, Krishna talks in great detail. Second chapter of the Bhagwad Gita is the longest chapter.
From 3 to 17 chapters – Krishna re-discusses, give reason for every word, reassures all the time and yet creates fear in Arjun’s mind while doing continuous counseling and in 18th chapter, he revises the whole teaching. This today forms the principles of conjunctive behaviour therapy.
Dr. Aggarwal talks of every God, religion, dharma, festival and rituals in allopathic language.

  Conference Calendar

1st International Congress of Regional Anesthesia and Pain Interventions 

Date: 15 – 17 September 2010
Razi International Conventwnal center, Tehran, Iran

Website: www.israpm2010.ir

  Forthcoming Events

eMedinewS Events: Register at emedinews@gmail.com

26th September: Sunday– BSNL Dil ka Darbar A daylong interaction with top cardiologists of the city. 8 AM  5 PM at MAMC Auditorium, Delhi 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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