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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

11th February 2010, Thursday

Asperger Syndrome: A bird’s eye view

‘My Name is Khan’ is a much–awaited film that has recently grabbed considerable space in the media. After the brilliant portrayal of a 13–year–old child who has Progeria by Amitabh Bachchan, its now the turn of Shahrukh Khan. ‘My Name is Khan’, or MNIK, the acronym, by which it is more commonly known, has now put the spotlight on another disease condition, Asperger syndrome. Shahrukh Khan enacts an autistic person, yet another challenging character.

Asperger syndrome (AS) is a form of autism that causes difficulty in relating to others. Though controversial, AS is often regarded as a form of high–functioning autism and placed on the mild end of the conundrum of ASD spectrum disorders with symptoms that differ – only in degree – from classic autism i.e. children with autism who do not have cognitive impairment.

It was first identified in 1944, by an Austrian pediatrician named Hans Asperger. AS became a distinct disease and diagnosis in 1992, when it was included in the tenth published edition of the WHO’s diagnostic manual, International Classification of Diseases (ICD–10). In 1994, it was added to the Diagnostic and Statistical Manual of Mental Disorders (DSM–IV).

The exact cause of AS is not well–defined. But, genetic and environmental factors have been implicated. It is not caused by a person’s upbringing, their social circumstances and is not the fault of the individual with the condition.

Common signs or symptoms: Similar to autism, AS shows impaired reciprocal social interaction, and restricted, repetitive or stereotyped patterns of behavior, interests and activities. But, unlike autism, intellectual ability is normal. Affected individuals do not have the severe language impairments that characterize autism.

Individuals with AS primarily encounter difficulties in
1. Social communication – they find it difficult to express themselves emotionally and socially
2. Social interaction – they have difficulty with initiating and sustaining social relationships; they do not relate well to others in large groups, but may do fine in small groups or one–to–one.
3. Social imagination – they have difficulty with social imagination; but are imaginative in the conventional use of the word.

Though they have normal verbal skills, their speech is characterized by a monotone pitch i.e. is flat and lacking in emotion. They lack the ability to modulate the volume of their voice.

A key feature is repetitive or focused activities. Such individuals may develop an intense, sometimes obsessive, interest in any one particular issue. They may be exceptionally knowledgeable in their chosen field of interest. But such activities far from becoming the basis of a social network are enjoyed in solitude. Individuals with AS are isolated because of their poor social skills and narrow interests.

Other conditions often co–exist viz. ADHD, depression, anxiety disorders, and OCD.

Diagnosis: The diagnosis of AS is very subjective and depends on behavior patterns rather than any physical tests. Making a diagnosis can be difficult.

Management: Treatment addresses the three core symptoms: poor communication skills, obsessive or repetitive routines, and physical clumsiness. Training in social skills to improve interpersonal interactions is the hallmark of intervention. Cognitive–behavioral therapy has been useful to manage associated anxiety. Risperidone may improve negative symptoms similar to those seen in schizophrenia. With effective treatment, individuals AS can learn to cope with their disabilities and can have good relationships, hold jobs and lead highly productive lives.

 Dr KK Aggarwal
Chief Editor

News and Views

1. Sizeable breakfast may lead to lasting weight loss
A study presented at an annual meeting of the Endocrine Society showed that people who ate a sizable breakfast lost more weight and kept it off, compared with those who ate a small breakfast. The premise was that eating a heavier meal in the morning that was high in quality carbs and protein would control cravings and check one‘s appetite later on in the day.

2. Weight gain may be common after knee replacement.
With a knee replacement can come weight gain, according to a study published online in the journal Osteoarthritis and Cartilage. In a study of 106 total knee replacement patients and 31 controls, researchers found that over two years, the surgery group showed a substantial average weight gain––66% of people in that group gained an average of 14 pounds, compared with the control group, which showed virtually no change in body mass.

3. Heavy Internet usage associated with depression
According to a study of more than 1,300 people to be published in the journal Psychopathology, British researchers found that people who compulsively browse, chat, and play online have higher rates of moderate to severe depression than people who aren’t compulsively driven to use the Internet.

4. Botox update
Subcutaneous injection of botulinum toxin A significantly reduced postherpetic neuralgia compared with lidocaine and saline placebo in a small randomized clinical study. Patients randomized to receive botulinum toxin also had significant improvement in sleep and a significant reduction in opioid requirements compared with the lidocaine and saline groups. The differences emerged within one week and persisted to 90 days. (Dr Lizu Xiao, Nanshan Hospital, Shenzhen, China)

5. HRT associated with an increased risk of asthma
Estrogen–only hormone replacement therapy is associated with an increased risk of asthma in postmenopausal women. Recent and current users of estrogen had a 54% increase in the risk of being diagnosed with asthma, according to Isabelle Romieu, MD, ScD, of the National Institute of Public Health in Cuernavaca, Mexico, and colleagues. The risk was even higher in nonsmokers or those who reported an allergic disease before they developed asthma. (Thorax feb 8, 2010)

6. Heart disease differences


Most important risk factors

  • Diabetes
  • Low HDL
  • High triglycerides
  • Waist measurement of 35 inches or more
  • Inflammatory disorders

  • High LDL
  • High blood pressure in young men


  • Unconventional symptoms – fatigue, malaise, shortness of breath, nausea, depression
  • First heart attack at average age 70 with higher fatality rate than men
  • More likely to have microvascular disease


  • Unstable angina warrants immediate attention
  • First heart attack at average age 65

Diagnostic procedures

  • ECG stress test less informative than nuclear test
  • When angiography shows no discrete lesions, IVUS and pressure flow studies also should be performed.

  • Stress tests more reliable than in women
  • Angiography more likely to be informative


  • Less likely to have bypass or angioplasty for coronary lesions
  • Longer hospital stays, higher complication rate

  • More likely to receive bypass surgery, angioplasty for coronary lesions
  • Shorter hospital stays
  • More likely to enter cardiac rehabilitation

Conference Calendar
Rejuvenating E.N.T
Rhinoplasty & Facial Rejuvenation Workshop
February 13–14, 2010
Venue: Forensic Department, BJMC & sassoon Hospital, Pune, Maharashtra.

Public Forum
Press Release

High BP in Pregnancy Increases Risk for Future Atherosclerosis
Women who have hypertension during pregnancy are at increased risk of developing atherosclerosis when they are older said Dr. K K Aggarwal, President, Heart Care Foundation of India and Editor eMedinewS.

In a study Published in Hypertension Dr. Siamak Sabour, of the University Medical Center in Utrecht, the Netherlands, said that hypertension in pregnancy acts as a kind of "nature’s cardiovascular stress test" showing proneness to future disease. Gestational Hypertension Leads to 57% Increased Risk of Calcification Gestational hypertension normally resolves following birth, and blood pressure returns to normal. But women with elevated blood pressure during pregnancy are at higher risk of hypertension, diabetes, and cardiovascular disease later in life. Sabour and colleagues evaluated 491 healthy postmenopausal women selected from participants enrolled in the PROSPECT (Predictors of Response to Cardiac Resynchronization Therapy) study from 1993–1997.

Women with a history of gestational hypertension had an almost 60% increased risk of having coronary calcification several decades later compared with women who had normal blood pressure during pregnancy. The relationship held for women who had mild elevations in blood pressure during pregnancy as well as for those who developed preeclampsia – a more serious complication of pregnancy characterized by very high blood pressure, edema, and risk of organ damage. Hypertension during pregnancy should be an alert for women.

"Up until now it has been assumed that high blood pressure subsides after pregnancy, and there was no structured follow–up of the women who experienced it. Hypertensive disorders are common in pregnancy, affecting 2% to 35% of all pregnancies, and ranking among the leading causes of maternal and perinatal morbidity and mortality worldwide. Preeclampsia or gestational hypertension associated with proteinuria is particularly linked with an increased risk for adverse pregnancy outcomes for both the mother and the fetus.

Punjab & Sind Bank
Central Bank of India

Question of the day
Does Malaria contribute to hypertension during pregnancy?

Malaria contributes to hypertension and pre-eclampsia in pregnant women. In areas where malaria is transmitted, clinicians should consider whether women with hypertension or pre–eclampsia may also have malaria as a complicating factor. If so, these women require effective antimalarial treatment, since malaria can be particularly severe during pregnancy.

Dr Duffy and colleagues investigated the possible association between malaria and hypertension among women aged 18–45 years delivering at a district hospital. Overall, placental malaria appeared to have little relation with blood pressure. Relationships emerged, however, when women were stratified
by age. Among younger women, placental malaria appeared to increase the risk of hypertension, while placental malaria decreased the risk of hypertension in older women.
Serum vascular endothelial growth factor receptor 1 (VEGFR1) levels were significantly elevated in first–time mothers with placental malaria or hypertension, but not during later pregnancies.
In infected placentas, VEGFR1 immunoreactivity localized with cells derived from the fetus, not with maternal inflammatory cells.

In this study, it appears that the mother’s immune cells in the placenta are primarily focused on attacking the malaria parasite, while the fetal cells in the placenta are releasing substances that inactivate the mother’s immune cells, possibly to reduce the inflammation. The substances released by the fetal cells may be causing hypertension in the mother as one of their side effects.

Currently clinicians are examining whether there is any evidence that different variants of the genes that encode VEGF or VEGFR1 may influence susceptibility to hypertension during pregnancy. This may strengthen the hypothesis that malaria causes hypertension by acting on the VEGF–sVEGFR1 axis. (Source: PLoS Med 2006;4:e446.)

eMedinewS Try this it Works
Kinking to cut the backflow

During some surgical procedures, the blood pressure cuff must be used on the same arm as an indwelling IV cannula (eg, during mastectomy, upper limb surgery). As the cuff is inflated, the increased pressure in the venous system can cause backflow of blood through the cannula and tubing and up to the IV bottle, resulting in contamination.

To avoid this problem, secure the IV tubing between the layers of the cuff, so that inflation causes kinking and compression of the IV tube. This prevents any flow until the pressure in the cuff is released and normal circulation through the venous system is reestablished.

Dr Good Dr Bad
Situation: A 30–year–old female with PCOS, on metformin, came for birth control counseling.
Dr Bad: You need no counseling.
Dr Good: You need birth control counseling.
Lesson: Type 2 diabetes mellitus and polycystic ovarian syndrome frequently co–occur. With metformin therapy, females who previously had irregular menses and anovulatory cycles may regain normal menstrual cycles thereby increasing their reproductive potential. Therefore, all females treated with metformin should be counseled regarding the need for birth control. (Diabetes Care 2002;25:89.)

Make Sure
Situation: A patient undergoing surgery was given fourth generation cephalosporin Reaction: Why was a fourth generation drug given
Make sure that later generation cephalosporins are not used for infections due to gram–positive cocci (except penicillin–resistant pneumococci) or Acinetobacter. They are not currently recommended for prophylactic use in surgery.

Laughter the best medicine(Dr Mayur Jain)
A husband wakes up at home with a huge hangover. He forces himself to open his eyes, and the first thing he sees is a couple of aspirins and a glass of water on the side table.
He sits down and sees his clothing in front of him, all clean and pressed. He looks around the room and sees that it is in perfect order, spotless, clean. So is the rest of the house.
He takes the aspirins and notices a note on the table. "Honey, breakfast is on the table, I left early to go grocery shopping. Love You!"
Totally shocked with the note, he goes to the kitchen and Sure enough there is a hot breakfast and the morning newspaper.
His son is also at the table, eating. He asks, "Son, what happened last night?"
His son says, "Well, you came home around 3 AM, drunk and delirious.
Broke some crockery, puked in the hall, and gave yourself a black eye when you stumbled into the door".
Confused, the man asks,
"So, why is everything in order and so clean, and Breakfast is on the table waiting for me?
I should expect a big quarrel with her!"
His son replies, "Oh, that! Mom dragged you to the bedroom, and when she tried to take your clothes n shoes off, You said, LADY LEAVE ME ALONE! I’M MARRIED !"
Moral–––Self–induced hangover – RS 10,000 Broken crockery – Rs 560/–, Breakfast – Rs 250/– Saying the right thing when drunk" "PRICELESS "
There are truly some things that both money and Mastercard can’t buy

Formulae in Imaging
Gall bladder
The mean diameter of the normal common bile duct is 4.1 mm. on USG. (Source: Radiology 1979;133:703–7).

Quote of the day (B K Sapna)
To be victorious means to pass obstacles with ease.

The ones who aim to become victorious never think of not being faced with obstacles. Instead they look at each obstacle as a chance to use and express their own inner powers. So there is constant progress visible in them. When we are prepared for the inevitable challenges that life brings, we will not experience fear, tension or anxiety but will always be confident and fearless. Apart from actually being victorious in the situation, we also experience winning over our weaknesses and discovering new powers within us.
Remove the darkness of the mind and the world will be illuminated .

ENT Facts
A majority of effusions will resolve over the course of 12 weeks, and most patients with OME can be observed over this time period.

SMS Anemia
In the elderly with unexplained, mild, asymptomatic anemia, treatment is not indicated.

Milestones in Neurology
Charles Foix (1882–1927) was a French internist and neurologist. Foix’ main contributions to the neurology was to relate thrombosis of specific arteries at autopsies with symptoms and signs that he had established in his patients and he wrote a book on the blood supply and anatomy of the brain. With Ion Niculescu he published an imposing treatise on the anatomy and blood supply of the midbrain and interbrain.

Mistakes in Critical Care
Never write x3d for ‘three days’. It can be mistaken for ‘3 doses’. Always spell ‘use for 3 days’

LIST OF APPROVED DRUG FROM 01.01.2009 TO 31.10.2009

Drug Name Indication Approval Date
Hyaluronic acid (cross linked) Pre–filled syringe 18mg/0.6ml and 24mg/0.8ml
For intradermal implantation and facial soft tissue augmentation




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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.

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Readers Responses

  1. Ultrasound scan are good as well as safer and affordable in the most cases for screening: Dr V K Agarwal
  2. Dear Dr. Sahib, Heartiest congratulations on winning prestigious award. Wish you good health prosperity and happiness now and forever. Hope many awards come your way very soon. Best regards: Manoj Gautam
  3. Congratulations for Padmashri: Rawat, ONGC
  4. Heartiest congratulations for being awarded the coveted Padmashree. Kindly accept our best wishes: V N Gaur, Dr. Madhulika, Prof. S N Gaur, Dr. Meera Gaur
  5. Heartiest congratulaitons. We are proud of you and your great qualities: Dr.(Prof.)Uppal
  6. Sir, many congrats on this great achievement. May God given you more strength to carry on with your work: Sunit, TOI
  7. Congratulations to you and Dolly: Dr. Anjala