eMedinewS
10th November 2014, Monday

Dr K K AggarwalPadma Shri, Dr B C Roy National Awardee and National Science Communication Awardee. Limca Book of Record Holder (CPR). Gold Medalist

Dr KK Aggarwal

President, Heart Care Foundation of India; Senior Consultant Physician, Cardiologist & Dean Medical Education Moolchand Medcity; Editor in Chief IJCP Group, Senior National Vice President, Indian Medical Association; Member Ethics Committee Medical Council of India, Chairman Ethical Committee Delhi Medical Council, Hony. Visiting Professor (Clinical Research) DIPSAR; Limca Book of Record Holder in CPR, Chairman (Delhi Chapter) International Medical Sciences Academy (March 10–13); 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);
For updates follow at :  www.twitter.com/DrKKAggarwal, www.facebook.com/Dr KKAggarwal

Verapamil can reverse diabetes

Verapamil can increase the beta cell mass: Verapamil, a drug used to control high blood pressure and arrhythmias has been shown by Dr Anath Shalev, University of Birmingham, Alabama to not only prevent type 1 diabetes in mice but reverse severe established diabetes. The drug down regulates a key promoter of type 1 diabetes (thioredoxin-interacting protein) and bolster whatever dysfunctional beta cells remain in the pancreas. The treatment definitely creates an environment where beta cells are allowed to survive.

And now one year human trial, entitled, "The repurposing of verapamil as a beta-cell survival therapy in type 1 diabetes," is expected to begin early in 2015 by the same group.

Over a decade ago, the UAB team was able to identify a protein called thioredoxin-interacting protein (TXNIP), which is dramatically increased in human islet cells in response to high glucose levels. The researchers hypothesized that TXNIP might be involved in beta-cell death associated with diabetes. Even short-term postprandial glucose excursions, as seen in pre-diabetes, may lead to a gradual, cumulative increase in TXNIP expression before any onset of overt diabetes. Furthermore, insulin resistance or any increased demand on the beta cell may also lead to elevated beta-cell TXNIP levels.

The team showed that TXNIP does indeed induce beta-cell death by apoptosis: in mice models in which TXNIP had been genetically deleted, for example, the animals were completely protected against diabetes.

Reduction of intracellular calcium inhibits the transcription and expression of TXNIP, so by using the calcium-channel blocker Verapamil to do this, they were able to mimic the effects of genetically deleted TXNIP in mice and preserve the insulin-producing beta cells.

Even after the animals had developed full-blown diabetes with high blood sugar levels, when treated with Verapamil, blood sugars normalized, and this was due to the reappearance and normalization of insulin-producing beta cells (Mol Endocrinol. 2014:28:1211-1220).

Note: In India use of Verapamil in diabetes will be an off label use and hence will require consent. However those with high blood pressure or with hear blockages can be shifted to Verapamil.'

News Around The Globe

  • Professional dental care of ICU patients may reduce the rate of lower respiratory tract nosocomial infections, suggests new research published online in Infection Control and Hospital Epidemiology.
  • Non-contact low-frequency ultrasound accelerates the healing of split-thickness skin grafts and reduces itching, suggests a new study presented at the American College of Surgeons 2014 Clinical Congress.
  • Second-look endoscopy (SLE) after gastric endoscopic submucosal dissection (ESD) may not help prevent bleeding, points new research from Japan published online in Gut.
  • Chronic dental irritation might play a role in the development of oral cancers, especially in nonsmokers, revealed a study published online November 6 in JAMA Otolaryngology–Head & Neck Surgery.
  • Shift work over a period of 10 or more years, and the disruption in circadian rhythm it causes, significantly impairs cognitive function, suggests a new study published online in the Journal of Occupational and Environmental Medicine.

Dr KK Spiritual Blog

Forgetfulness and Age

By the time we cross 40, most of us suffer from minimal cognitive impairment and have a memory loss of very recent events or objects. This is age related and should not be confused with dementia.

This can also happen in patients who are vegetarians and vitamin B12 deficient. People often have difficulty in naming objects and name of the people.

Just as a computer hangs when multi tasking is done, so can the human mind. When you are handling multiple projects at the same time, you may experience thought blocks which is natural and not a sign of a disease.

When we introduce our self to a new person, we often tell our name first. It is possible by the time you finish your conversation, the person may forget your name. Therefore, one should either introduce himself at the end of the conversation or introduce oneself both times i.e. at the start and at the end of the conversation.

Some people introduce themselves before the conversation and hand over their visiting card at the end of a conversation. This is also taught in how to market yourself.

As a medical doctor, quite often we face these difficulties. People send SMSs without their names or call without telling their names. For example, I once got a call “Malhotra bol raha hoon pehchana kya?” As a doctor, we may be handling hundreds of Malhotras and it is not expected from us, especially, after the age of 40 to recall a person just by his surname. Unless full information is given to us by patient on phone, we may do mistakes, especially, if it is a phone consultation. In any way, phone consultation needs to be avoided. Even Supreme Court in one of its judgments said that giving phone consultation may amount to professional misconduct on the part of the doctor.

Inspirational Story

It’s Never Too Late

It was an unusually busy day for the hospital staff on the sixth floor. Ten new patients were admitted and Nurse Susan spent the morning and afternoon checking them in. Her friend Sharron, an aide, prepared ten rooms for the patients and made sure they were comfortable. After they were finished she grabbed Sharron and said, “We deserve a break. Let’s go eat.”

Sitting across from each other in the noisy cafeteria, Susan noticed Sharron absently wiping the moisture off the outside of her glass with her thumbs. Her face reflected a weariness that came from more than just a busy day. “You’re pretty quiet. Are you tired, or is something wrong?” Susan asked.

Sharron hesitated. However, seeing the sincere concern in her friend’s face, she confessed, “I can’t do this the rest of my life, Susan. I have to find a higher-paying job to provide for my family. We barely get by. If it weren’t for my parents keeping my kids, well, we wouldn’t make it.”

Susan noticed the bruises on Sharron’s wrists peeking out from under her jacket. “What about your husband?” “We can’t count on him. He can’t seem to hold a job. He’s got . . . problems.” “Sharron, you’re so good with patients, and you love working here. Why don’t you go to school and become a nurse? There’s financial help available, and I’m sure your parents would agree to keep the kids while you are in class.”

“It’s too late for me, Susan; I’m too old for school. I’ve always wanted to be a nurse, that’s why I took this job as an aide; at least I get to care for patients.” “How old are you?” Susan asked. “Let’s just say I’m thirty-something.”

Susan pointed at the bruises on Sharron’s wrists. “I’m familiar with ‘problems’ like these. Honey, it’s never too late to become what you’ve dreamed of. Let me tell you how I know.” Susan began sharing a part of her life few knew about. It was something she normally didn’t talk about, only when it helped someone else.

“I first married when I was thirteen years old and in the eighth grade.” Sharron gasped. “My husband was twenty-two. I had no idea he was violently abusive. We were married six years and I had three sons. One night my husband beat me so savagely he knocked out all my front teeth. I grabbed the boys and left. “At the divorce settlement, the judge gave our sons to my husband because I was only nineteen and he felt I couldn’t provide for them. The shock of him taking my babies left me gasping for air. To make things worse, my ex took the boys and moved, cutting all contact I had with them.

“Just like the judge predicted, I struggled to make ends meet. I found work as a waitress, working for tips only. Many days my meals consisted of milk and crackers. The most difficult thing was the emptiness in my soul. I lived in a tiny one-room apartment and the loneliness would overwhelm me. I longed to play with my babies and hear them laugh.”

She paused. Even after four decades, the memory was still painful. Sharron’s eyes filled with tears as she reached out to comfort Susan. Now it didn’t matter if the bruises showed. Susan continued, “I soon discovered that waitresses with grim faces didn’t get tips, so I hid behind a smiling mask and pressed on. I remarried and had a daughter. She became my reason for living, until she went to college.

“Then I was back where I started, not knowing what to do with myself – until the day my mother had surgery. I watched the nurses care for her and thought: I can do that. The problem was, I only had an eighth-grade education. Going back to high school seemed like a huge mountain to conquer. I decided to take small steps toward my goal. The first step was to get my GED. My daughter used to laugh at how our roles reversed. Now I was burning the midnight oil and asking her questions.”

Susan paused and looked directly in Sharron’s eyes. “I received my diploma when I was forty-six years old.” Tears streamed down Sharron’s cheeks. Here was someone offering the key that might unlock the door in her dark life.

“The next step was to enroll in nursing school. For two long years I studied, cried and tried to quit. But my family wouldn’t let me. I remember calling my daughter and yelling, ‘Do you realize how many bones are in the human body, and I have to know them all! I can’t do this; I’m forty-six years old!’ But I did. Sharron, I can’t tell you how wonderful it felt when I received my cap and pin.”

Sharron’s lunch was cold, and the ice had melted in her tea by the time Susan finished talking. Reaching across the table and taking Sharron’s hands, Susan said, “You don’t have to put up with abuse. Don’t be a victim – take charge. You will be an excellent nurse. We will climb this mountain together.” Sharron wiped her mascara-stained face with her napkin. “I had no idea you suffered so much pain. You seem like someone who has always had it together.”

“I guess I’ve developed an appreciation for the hardships of my life,” Susan answered. “If I use them to help others, then I really haven’t lost a thing. Sharron, promise me that you will go to school and become a nurse. Then help others by sharing your experiences.” Sharron promised. In a few years she became a registered nurse and worked alongside her friend until Susan retired. Sharron never forgot her colleague or the rest of her promise.

Now Sharron sits across the table taking the hands of those who are bruised in body and soul, telling them, “It’s never too late. We will climb this mountain together.”

Rabies News (Dr A K Gupta)

How is rabies transmitted?

Rabies is transmitted by infected secretions. Most commonly, transmission to humans takes place through exposure to saliva following a bite by an infected animal. Rabies virus can be excreted in saliva, urine, nasal discharge and respiratory secretions.

Cardiology eMedinewS

  • Compared with other antidiabetic drugs, sulfonylureas may increase the risk of cardiovascular events and some may be particularly risky, suggests new research published online in The Lancet Diabetes & Endocrinology.
  • Five-year results from the largest and longest-running clinical trial of a drug-eluting stent for treating peripheral arterial disease (PAD) confirmed long-term patency for patients treated with Zilver PTX. The results were presented at the 2014 Vascular Interventional Advances (VIVA) meeting.

Pediatrics eMedinewS

  • Parents who have one child with peanut allergy may be shielding their other kids from peanuts when it is not necessary, and might actually increase the child's allergy risk, suggests a new study published online in Clinical and Experimental Allergy.
  • In a new systematic, in-depth review focused on the use of behavior theory in interventions aimed to increase fruit and vegetable intake among children, researchers found theory-based interventions to be beneficial for vegetable intake only. The findings are published in the Journal of Nutrition Education and Behavior.

Quote of the Day

  • Luck is what happens when preparation meets opportunity. Seneca

Wellness Blog

Prescribe Insurance To All Patients In The Prescriptions?

When we do not take our car on the roads without insurance then why do we take our body out without insurance?

  1. Everybody should be insured and for those who cannot, the government must pay for their insurance. Insurance should be added in the prescription of any doctor.
  2. Even if a patient has a disease, he or she needs insurance so that he is covered for other illnesses. Remember one is entitled for 1% of the cover as room rent or 2% for the ICU bed.
  3. The coverage amount is for one full year. Do not exhaust it in one admission.
  4. The patients should choose their insurance so that even OPD treatment is added to the coverage.
  5. A person can have more than one insurance policy.
  6. Health is not mere absence of disease but a state of physical, mental, social, environmental, spiritual and financial well being.
  7. The purpose of life should be to desire for inner happiness and for that to earn righteously.
  8. One must plan for the old age; remember that today one can live above the age of 80. Old age treatments can be very costly.
  9. Most disputes are due to property and one must write his or her will in time. Property dispute is number one cause of heart attack in the country.
  10. All doctors should be insured against malpractice. To err is human and malpractice is not a criminal negligence.
  11. The banks should come out with schemes so that patients can get loans for treatments on the spot.

ePress Release

Dengue patients don’t die of platelet deficiency

According to international guidelines, unless the platelet count is below 10,000 or there is spontaneous active bleeding, no platelet transfusion is required, said Padma Shri, Dr. B C Roy National Awardee & DST National Science Communication Awardee, Dr. K K Aggarwal, President Heart Care Foundation of India and Sr National Vice President Indian Medical Association The cause of death in dengue is capillary leakage, which causes blood deficiency in the intravascular compartment, leading to multiorgan failure, he added. At the first instance of plasma leakage from intravascular compartment to extravascular compartment, 20 ml per kg body weight per hour of fluid replacement should be administered to the patient till the difference between upper and lower blood pressure is more than 40 mmHg or the patient passes adequate urine. Giving unnecessary platelet transfusion to the patient can harm the individual. Dr. Aggarwal has created a ‘Formula of 20’ for family doctors to understand the severity of dengue.

  • Rise in pulse by 20
  • Fall in upper blood pressure by 20 mmHg
  • Pulse pressure is lower than 20
  • Hematocrit increased by 20%
  • Platelet count is less than 20,000
  • More than 20 petechiae in the tourniquet test
emedipicstoday emedipics

21st Perfect Health Mela 15th October 2014

Self-Assessment-Quiz

 

expert_choice
press release

Red flag arthritis

video of day

Other Blogs

Video Library

Sameer Malik Heart Care Foundation Fund

The Sameer Malik Heart Care Foundation Fund is a one of its kind initiative by the Heart Care Foundation of India instituted in memory of Sameer Malik to ensure that no person dies of a heart disease because they cannot afford treatment. Any person can apply for the financial and technical assistance provided by the fund by calling on its helpline number +91 9958771177 or by filling the online form.

Madan Singh, SM Heart Care Foundation Fund, Post CAG

Kishan, SM Heart Care Foundation Fund, Post CHD Repair

Deepak, SM Heart Care Foundation Fund, CHD TOF

Total CPR since 1st November 2012 – 101090 trained

cpr10 Mantra The CPR 10 Mantra is – "within 10 minutes of death, earlier the better; at least for the next 10 minutes, longer the better; compress the centre of the chest of the dead person continuously and effectively with a speed of 10×10 i.e. 100 per minute."

CPR 10 Success Stories

Ms Geetanjali, SD Public School
Success story Ms Sudha Malik
BVN School girl Harshita
Elderly man saved by Anuja

CPR 10 Videos

cpr 10 mantra
VIP’s on CPR 10 Mantra Video

Hands–only CPR 10 English
Hands–only CPR 10 (Hindi)

 

IJCP Book of Medical Records

IJCP Book of Medical Records Is the First and the Only Credible Site with Indian Medical Records.

If you feel any time that you have created something which should be certified so that you can put it in your profile, you can submit your claim to us on :

 

Dr Good and Dr Bad

Situation: A 45–year–old male with community acquired pneumonia came for a prescription.
Dr Bad: Start azithromycin and cefuroxime combination.
Dr Good: Start levofloxacin.
Lesson: In a meta–analysis that included 23 randomized trials, respiratory fluoroquinolones (levofloxacin, moxifloxacin, or gemifloxacin) were more likely to result in treatment success than the combination of a beta–lactam plus a macrolide for the treatment of CAP that was mostly mild to moderate in severity (odds ratio, OR 1.39, 95% CI 1.02–1.90) (CMAJ 2008;179:1269–77).

Make Sure

Situation: A patient with pyogenic meningitis developed complications.
Reaction: Oh my God! Why were antibiotics not given when the meningitis was suspected?
Lesson: Make sure that first dose of antibiotics is given at the time meningitis is suspected.

eMedinewS Humor

Who Would Know?

The man passed out in a dead faint as he came out of his front door onto the porch. Someone called 911.

When the paramedics arrived, they helped him regain consciousness and asked if he knew what caused him to faint.

"It was enough to make anybody faint," he said. "My son asked me for the keys to the garage, and instead of driving the car out, he came out with the lawn mower!"

Twitter of the Day

Dr KK Aggarwal: Eat a verity of fruits & Vegetables
Dr Deepak Chopra: The same thing that roots life in suffering also leads to the way out of suffering: self-awareness

IMA News

DNA Mumbai: Doctors slam government's proposal to allow midwives, homeopaths to conduct abortion A week after the ministry of health and family welfare's maternal health division proposed to amend the existing Medical Termination of Pregnancy Act, 1971, several associations of doctors strongly opposed the government's decision to allow ayurveds, homoeopaths and midwives to perform abortion as well.

The Indian Medical Association (IMA) had on Thursday opposed the proposed amendments to the new MTP Act. A step backwards, say doctors

Dr Sudhir Naik, gynaecologist and president-elect of the Association of Medical Counsultants (AMC), said, "The draft bill comes across as one of the most liberal abortion documents but we strongly oppose allowing midwives and ayurveds, homeopaths to perform abortions."

The draft bill, put up on the union health ministry's website for suggestions on Thursday, proposes an increase in cut-off period for abortion from the present 20 weeks to 24 weeks. While doctors praise this move, they say allowing midwives and unqualified doctors to perform abortions legally is a step backwards. In a letter to the health ministry, the doctors have pointed out how the amendment will risk the life of a woman.

Risk to a woman's life: "The procedure of first trimester abortions is a blind procedure with an inherent risk of puncturing the uterus and causing incomplete abortions or massive bleeding and sepsis. The long-term complications in the form of pelvic inflammatory disease causing subsequent infertility are also too real to ignore. Some of these complications could also result in the young woman requiring hysterectomy as a life-saving measure. We shudder at the thought of this dreaded outcome of one simple procedure carried out by semi-qualified personnel," said Dr Sangeeta Pikale, gynaecologist and president of AMC.

The IMA, the umbrella body of allopathy medicine practising doctors, has also written to health minister Dr Harsh Vardhan, saying that the amendment is retrogressive and will increase maternal mortality. "MTP involves alopathy drugs, anaesthesia, the person has to interpret sonography, blood tests, which is not taught in AYUSH or to midwives. IMA is the largest body of doctors and we have not been taken in to confidence before the amendment was made," said Dr KK Aggarwal, present senior national vice president of IMA.

Focus should be on contraception: The doctors said that the health ministry should promote and emphasize on contraceptive methods to prevent unwanted pregnancies and not medical termination. "The focus of the family planning program has to be contraception and permanent methods of sterilization after completing the family, rather than abortions. Involving these AYUSH doctors and trained midwives after proper training in methods of contraception should be the focus of the government," said Dr Naik.

Advocate Varsha Deshpande, who runs 'Lek Ladki Abhiyan', a Satara-based NGO which has been working against pre-natal sex determination said, "Abortion should be done only by a registered medical practitioner. This amendment will encourage sex-selective abortions in the country. It will also reverse our efforts made so far to improve child sex ratio. The government needs to rethink the amendment. Repeated pregnancies and deliveries bring risk to the life of women. Abortions by non-MBBS person will be like cruelty against women," said Deshpande.

While IMA and AMC has openly come out against the amendment, FOGSI is tight-lipped and divided. While most members are against allowing non-MBBS doctors practising MTP, few are for it.

The proposed act that will be called 'The Medical Termination of Pregnancy (Amendment) Bill, 2014' is up for people's review on the health ministry's website tillNovember 10, after which the draft will be finalised.

The Economics Times: The Indian Medical Association (IMA) today opposed the proposed amendments to the new Medical Termination of Pregnancy (MTP) Act which allows Ayurvedacharyas, Homeopaths and Nurses to conduct MTP on pregnant mothers.

Row over changes in abortion law: Sushmi Dey,TNN : NEW DELHI: The proposed new Medical Termination of Pregnancy (MTP) Amendment Draft Bill to allow ayurvedacharyas, homoeopaths and nurses to conduct MTP has triggered a debate on patient safety versus access to healthcare.

The government's proposal was apparently formulated taking a cue from a study conducted by Population Council. The NGO had suggested that expansion of healthcare providers to legally perform abortion services will result in increasing access to safe abortion. But most allopathic practitioners are concerned that abortion by untrained professional may put patients at risk and encourage unethical practices.

"Expanding the number and type of providers able to legally perform abortion services, including manual vacuum aspiration (MVA) and medical abortion (MA), could greatly expand women's access to safe abortion and save many lives each year," Population Council opines in a note on the issue.

However, Indian Medical Association (IMA), a pan India voluntary organization with a membership of 2.5 lakh allopathic practitioners, has strongly opposed the government's proposal. IMA argues the proposal to permit non MBBS doctors and paramedical staff to conduct MTPs is against the provisions of the Clinical Establishments Act, which does not recognize even paramedical personnel trained by the doctors for conducting medical procedures.

"MTP is a procedure meant to be conducted by an allopathic doctor only and cannot be conducted by the paramedical staff on their own or by any other pathies as they are not at all well equipped to handle critical medical conditions arising out of excessive bleeding in some cases specially during incomplete abortions as a result of procedures and prescriptions provided by untrained and unauthorized medical or paramedical professionals during and after MTPs," said Dr Narendra Saini of IMA.

However, World Health Organisation (WHO) also seems to endorse the government's proposal. A technical and policy guidance for health systems by WHO released in 2012 states, "Abortion care can be safely provided by any properly trained health-care provider, including midlevel providers....(e.g. midwives, nurse practitioners, clinical officers, physician assistants, family welfare visitors, and others) who are trained to provide basic clinical procedures related to reproductive health..."

Traditionally, mid-wives or dai have played a key role in catering to urgent medical needs, especially attending to pregnant women for child delivery or even for abortion, in rural areas and villages that lacked medical facilities. Though with time government health centres and private players have reached many such villages, mid-wives continue to exist and attend to many emergencies even today.

Estimates show, in India around seven million abortions are conducted every year. Out of this 50 per cent of the abortions are conducted illegally. The rates of maternal death attributed to complications from unsafe abortions are estimated at eight per cent.

Public health experts say while there is a dearth of doctors and skilled providers, mainly in distant villages, legal restrictions are holding many non-MBBS but trained paramedics or healthcare providers from performing abortion. "Because of legal restrictions, many trained professions opt for the illegal route to perform abortions.

By introducing provisions in the law to make it legal, government can ensure proper training of such professionals while also enabling regulation and monitoring," says Vinoj Manning, Country Director, IPAS, a non-profit organization that works to increase women's ability to exercise their sexual and reproductive rights, and to reduce maternal mortality.

However, the deficiency cannot be filled by substandard solutions, says Dr Anoop Misra, former professor of medicines at AIIMS and chairman Fortis CDOC hospital. Agrees, Dr Mala Srivastava, senior consultant-gynaecology at Ganga Ram Hospital. "Without proper training and qualification, MTP procedures can result in incomplete abortions and infections which can be hazardous for patients," says Dr Srivastava.
 

eMedi Quiz

In a patient with a tumor in superior mediastinum compressing the superior vena cava, all the following veins would serve as alternate pathways for the blood to return to the right atrium, except:

1.Lateral thoracic vein.
2.Internal thoracic vein.
3.Hemiazygos vein.
4.Vertebral venous plexus.

Yesterday’s Mind Teaser: B-oxidation of odd-chain fatty acids produces:

1.Succinyl CoA.
2.Propionyl CoA.
3.Acetyl CoA.
4.Malonyl CoA.

Answer for yesterday’s Mind Teaser: 2.Propionyl CoA.

Correct answers received from: Dr.K.Raju, Dr Poonam Chablani, Dr Jainendra Upadhyay, Dr Avtar Krishan, Dr. B. B. Aggarwal

Answer for 8th November Mind Teaser: 3. Leaves extension at elbow joint intact.

Correct answers received from: Dr. B. B. Aggarwal

Send your answer to email

medicolegal update

(Dr. K K Aggarwal, Padma Shri and Dr. B C Roy National Awardee; Editor eMedinewS and President Heart Care Foundation of India)

Giving wrong advice on email is liable for negligence

If the doctor has charged his/her full fees for the email consultation from the patient or a referring physician regarding a patient, he/she will be liable as if he or she has seen the patient. When giving a written opinion through email one can take the following precautions and write:

  • “Expert opinion provided as a professional courtesy only”
  • “Nominal fee charged is only to cover the secretarial / incidental expenses involved and does not count towards a consideration or contract”
  • “This is only an opinion based on the information provided to me. It is not a final opinion which cannot be given without seeing the patient physically.
  • “This is not a final opinion and you may use this opinion at your own responsibility and discretion”
  • “As it is an opinion given without seeing the patient I take no legal responsibility for the opinion given”.
medicolegal update
  1. Dear Sir, very informative newspaper. Regards: Dr Shagun
  2. Dear Dr.K.K.Aggarwal, I completely agree with you on the issue of MTP. Thanks. Prof S.K.Bhargava

eMedinewS Special

1. IJCP’s ejournals (This may take a few minues to open)

2. eMedinewS audio PPT (This may take a few minutes to download)

3. eMedinewS audio lectures (This may take a few minutes to open)

4. eMedinewS ebooks (This may take a few minutes to open)