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Dr K K Aggarwal

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



10th November Tuesday 

Dear Colleague,

 Pneumonia Update

1. X ray can be normal in the first 24 hours of pneumonia.
2. In pneumonia X ray can also be normal in dehydration or with low TLC count.
3. For diagnosis of pneumocystis carinii pneumonia, one should do spiral CT scan instead of X ray chest.
4. When there is a discrepancy between X ray and clinical features, one should suspect viral pneumonia.
5. Pneumonia can be community acquired or hospital acquired.
6. Community acquired pneumonia is pneumonia occurring in the community in a person without history of health care contact.
7. If a person develops pneumonia in 48 hours after getting admitted to hospital, it is hospital acquired pneumonia.
8. If a person develops pneumonia after 48 hours of endotracheal intubation it is called ventilator associated pneumonia.
9. HCAP is health care associated pneumonia and occur in a non hospitalized patient but with extensive healthcare contact.
10. Suspect HCAP if: If the patient has received any intravenous therapy in the last 30 days.
11. Suspect HCAP if: the patient in the last 30 days has been going to a doctor for a wound care.
12.  Suspect HCAP if: If the has received intravenous chemotherapy in the last 30 days.
13.  Suspect HCAP if: the pneumonia has occurred in a patient residing in an old age home or a long term care facility.
14.  Suspect HCAP if: the patient in the last 3 months was admitted for two or more days in any hospital with facility of acute care.
15.  Suspect HCAP if: If the patient in the last one month has visited a hospital or  hemodialysis clinic.
16. Uncomplicated community acquired pneumonia (CAP) can be treated in a clinic as it has low mortality.
17.  Patients with CAP requiring admission have 37% mortality.
18.  High risk community acquired pneumonia patients can be remembered by the formula CURB 65: C stands for confusion (anoxia), U stands for Urea more than 20(pre renal azotemia), R stands for respiratory rate more than 30 (anoxia) and B stands for low blood pressure less than 60 (CO2 retention)
19. Any patient of Community acquired pneumonia who does not respond in 72 hours should be treated as high risk patient.
20. Pneumonia patients have low mortality if they have received pneumonia/flu vaccination in the past.
21. Most patients with pneumonia will not die of pneumonia. They will either die of ARDS or acute coronary event.
22. For community acquired pneumonia treatment, one can treat only on the basis of clinical features and X ray. But in health care associated pneumonia, one needs to have sputum culture examination.
23. The best antibiotics are macrolide, cephalosporin or Levofloxacin.  
24. Antibiotics should be given for minimum five days (for azithromycin, 3 days is sufficient). Rough formula is one can stop antibiotic three days after fever has subsided.
25. Do not give azithromycin if a patient has received it in the last three months.
26. Levofloxacin intravenous or oral has same effect.
27.  In admitted CAP patients, do not give cefurexime as it is not effective against macrolide resistant organisms.
28. Uncomplicated CAP:  treat with amoxicillin 500mg three times a day for five days or azithromycin 500 mg daily for three days. Do not given Levofloxacin as the first line drug.
29. CAP with associated co morbid conditions or has taken antibiotics in last three months: treat with Levofloxacin 750 mg daily for five days or a combination of cefexime for 5 days and azithromycin for 3 days.
30.   Admitted CAP: Give a combination of cefexime + azithromycin or monotherapy with 750 mg of Levofloxacin daily.
31.  Do not treat X-ray, breathlessness or cough as they may persist for a long period of time. Cough in pneumonia may last for a week and X ray may take four weeks to clear in normal individuals and 12 weeks in the elderly.
32. The day patient can take oral medication, he should be discharged.
33. Repeat X ray after one week of discharge is not necessary. However follow up X ray is required at 8 to 12 weeks to document resolution of pneumonia and to exclude underlying malignancy.
34. For simple health care associated pneumonia where MDR is not suspected: Treat with IV 2 g of ceftriaxone or Levofloxacin  750 mg daily or ampicillin sulbactam 3 g intravenous every six hours. The best bet is to give 750 mg Levofloxacin every day.
35. If a patient is suspected to have MDR or is not responding after three days of treatment with Levofloxacin, one should change to 3 drug combination.
36. Three drug combination is Piperacillin/tazobactam 4.5 gm IV every six hours + linezolid 600 mg twice daily + either Levofloxacin  750 daily or any of the gentamycin group of drugs IV.
37.  For health care associated pneumonia, one will require antibiotic for minimum 7 days.
38. In summary, treat simple pneumonia with azithromycin for three days or with a combination of azithromycin for three days and cefexime for five days. In health care associated pneumonia, start with Levofloxacin 750m mg daily for three days and if the patient does not respond in three days, add linezolid 600 mg twice daily and Injectable Piperacillin/tazobactam 4.5 gm intravenous every six hours for next seven days.

 Dr K K Aggarwal


 What to look for in head lice
1. Look for small white dots (they are actually eggs, called nits) on strands of hair that stick and are difficult to remove.
2. Look for an outbreak of small, red bumps that appear on the shoulders, neck and scalp.
3. Wear gloves and inspect the scalp beneath a bright light. Try using a magnifying glass.
4. Carefully inspect all hair on the head and the entire scalp.

 Prevention of Adolescent Depression
A JAMA study has shown that children and adolescents of depressed parents are four to six times more likely to develop depressive symptoms themselves than children of non-depressed parents. This translates to approximately 61% of children of parents with depression developing a psychiatric disorder during their life.  (Dr Soni Verma)

Working Overtime May be a Risk for Dementia
Cognitive impairment in midlife is already established as a risk factor for Alzheimer's Disease and other forms of dementia. A new report from the Whitehall II Study, published in the American Journal of Epidemiology finds that long working hours in midlife are associated with a decline of cognitive function, and possibly dementia. (Dr Prachi Garg)

 Vitamin B12 update

Vitamin B12 is one of several B vitamins.  It is needed to make new red blood cells and help nervous system work well.  Vitamin B12 is found naturally in meat, fish, eggs, and dairy products.  It is not found naturally in plant-based foods, such as fruits, vegetables, and cereal grains.  Some people need to take vitamin supplements or vitamin B12 shots to get enough.

Vitamin B12 deficiency develops slowly, and symptoms appear so gradually that they can be missed.  Vitamin B12 deficiency can cause anemia over time.  The symptoms of anemia include feeling weak, tired, and faint; heart palpitations; looking pale; and shortness of breath.  Vitamin B12 deficiency can also cause tingling of hands and feet, changes in ability to walk, loss of vision, memory problems, seeing things that aren't there, sadness, and changes in personality. Infants and young children who are vitamin B12 deficient might have problems growing, weak muscle tone, delays in development, and general weakness.
The chances for developing vitamin B12 deficiency increase with age, untreated pernicious anemia, gastric (stomach) surgery, or long-term use of strict vegetarian (vegan) diet.  Infants and young children born to and breastfed by women who are vegans are also more likely to develop this deficiency.


Why Do Schizophrenics Smoke Cigarettes?
Patients with schizophrenia are almost always heavy cigarette smokers, given a choice. Generally, the rate of inpatient smoking among schizophrenics is three to four times higher than the general smoking population. In one British study of 100 institutionalized schizophrenics cited by Lyon, 92% of the men and 82% of the women were smokers. Moreover, schizophrenics smoke more cigarettes per day than other smokers do, and they commonly smoke high-tar, unfiltered cigarettes.

Because of high rates of smoking, people with mental illness have 30% more heart disease and 30% more respiratory disorders.

Schizophrenic smokers are self-medicating to improve processing of auditory stimuli and to reduce many of the cognitive symptoms of the disease. Of particular interest is the interaction between nicotine and dopamine in the nucleus accumbens and prefrontal cortex.  Several of the symptoms of schizophrenia appear to be associated with dopamine release in these brain areas. A 2005 German study concluded that nicotine improved cognitive functions related to attention and memory. There is substantial evidence that nicotine could be used by patients with schizophrenia as a self-medication to improve deficits in attention, cognition, and information processing and to reduce side effects of antipsychotic medication. Smoking is also an issue of importance for health professionals as smokers require higher levels of antipsychotics than nonsmokers. Smoking can lower the blood levels of some antipsychotics by as much as 50%.
( Sent by Dr Maj Prachi Garg) 

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Clinical context ( Bell's plsy)
Bell's palsy is a common inflammatory condition of the facial nerve which can be distressing to the patient. Both the herpes simplex virus and the varicella zoster virus have been implicated in promoting this inflammation, and the annual incidence of Bell's palsy is 20 to 30 cases per 100,000 persons.
Clinical Implications
Slightly more than 70% of individuals with Bell's palsy fully recover facial nerve function without treatment. The current meta-analysis suggests that corticosteroids are effective in improving outcomes of Bell's palsy, and adding antiviral medications may make treatment even more effective. However, antiviral agents alone do not improve Bell's palsy. [Sent by Dr.G. M. SINGH]

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