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FIRST NATIONAL DAILY eMEDICAL NEWSPAPER OF INDIA
eMedinewS is now available online on www.emedinews.in or www.emedinews.org
 
  From the desk of editor in chief
Dr KK Aggarwal

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 ...

11th November 2010, Thursday

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

MRI may help determine time of stroke onset

Brain MRI could expand the number of stroke patients eligible for tissue plasminogen activator (tPA) according to a new study, published online and in the December issue of the journal Radiology. tPA can only be administered within four and a half hours of the onset of a stroke; when given beyond that window of time, the drug can cause bleeding in the brain. Over a quarter of all stroke patients cannot be given tPA because they wake up with stroke symptoms or are unable to tell their doctor when their stroke began.

In the study, Dr Catherine Oppenheim, M.D., Ph.D., professor of radiology at Université Paris Descartes in France reviewed data from consecutive patients with acute ischemic stroke treated at Sainte–Anne Hospital in Paris between May 2006 and October 2008. The time of stroke onset was well–defined in all patients and each underwent MRI within 12 hours. The 130 patients in the study included 77 men and 53 women (mean age 64.7). Of those, 63 patients underwent MRI within three hours of stroke onset and 67 were imaged between three and 12 hours after stroke onset. The radiologists analyzed different types of MRI data on the patients, including fluid–attenuated inversion recovery (FLAIR), diffusion–weighted imaging (DWI) and apparent diffusion coefficient (ADC) ratios. Using the MRI data alone, the radiologists were able to predict with greater than 90 percent accuracy which patients had experienced stroke symptoms for longer than three hours. (Science daily)  

Dr KK Aggarwal
Editor in Chief
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  Quote of the Day (Dr. G.M.Singh)

"A ‘No’ uttered from the deepest conviction is better than a ‘Yes’ merely uttered to please, or worse, to avoid trouble."

Mahatma Gandhi

 
    Photo Feature (from the HCFI Photo Gallery)

 Heritage
Inter Dancing School Festival


Students performing in the Bharatnatyam (junior category), an inter dancing school competition, as a part of the 17th MTNL Perfect Health Mela.

 
Dr K K Aggarwal
 
    National News

Certificate courses in 2D and 3D Echocardiography/Fellowship Diploma in non invasive cardiology

Contact Dr KK Aggarwal, Moolchand Medcity, email: emedinews@gmail.com

Eight post offices with e–services upgraded

Union Minister of State for Communication and Information Technology Sachin Pilot on Monday dedicated eight post offices under the Project Arrow scheme of the Department of Posts to the Capital’s citizens. These post offices would have a uniform brand hierarchy and a single–window service system to reduce the waiting time for customers. The inaugural function was held at the Andrews Ganj post office from where the other seven post offices were inaugurated through a video link. The other posts offices are at Delhi Cantonment, R.K. Puram–V, Indian Agricultural Research Institute (IARI), Patel Nagar, Bengali Market, South Avenue and SRT Nagar. (Source: The Hindu)

 
    International News

(Dr Monica and Brahm Vasudev)

Malaria mosquitoes evolving

NIH News: The mosquito species most responsible for spreading malaria in Africa seems to be evolving into 2 separate species with different traits. The development may complicate efforts to control the disease.

More women undergoing prophylactic mastectomy

The proportion of women having both breasts removed when breast cancer appears in one has increased more than 10–fold over a 10–year period, despite a limited amount of evidence showing a survival benefit for the procedure, according to a study in the Annals of Surgical Oncology. Removal of both breasts can reduce the risk of breast cancer by as much as 85% for women who have the BRCA1 or BRCA2 genes, which confer a high risk of contracting cancer, but less than 1% of the general population carries either of these genes. (Source: LA Times)

Low vitamin D levels may predict increased risk for diabetes

Individuals with low levels of vitamin D measured 10 years ago showed a trend toward an increased risk of developing diabetes, according to research presented at the World Congress on Insulin, Diabetes and Cardiovascular Disease. (Medpage Today)

Metabolic syndrome risk hiked in CHF patients

Patients diagnosed with congestive heart failure (CHF) are at an increased risk of also having metabolic syndrome. If an individual in the National Health and Nutrition Examination Survey (NHANES) had been told they had CHF, there was a 70% increase in the likelihood of metabolic syndrome, after adjustment for age, sex, race or ethnicity, smoking status, family history of heart disease, and a past myocardial infarction. (Medpage Today)

 
    Infertility Update

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

What is unexplained infertility?

Up to 26% of infertile couples have unexplained infertility. In such cases, abnormalities are likely to be present but not detected by current methods. Possible problems could be that the egg is not released at the optimum time for fertilization that it may not enter the fallopian tube, sperm may not be able to reach the egg, fertilization may fail to occur, transport of the zygote may be disturbed, or implantation fails. It is increasingly recognized that egg quality is of critical importance and women of advanced maternal age have eggs of reduced capacity for normal and successful fertilization. Also, polymorphisms in folate pathway genes could be one reason for fertility complications in some women with unexplained infertility.

For queries contact: banerjee.kaberi@gmail.com

 
    Gastro Update

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

What are the other associated aspects in a case of IBD?

Bone health

In children with Crohn’s disease, osteopenia may be present at diagnosis. Dual–energy X–ray absorptiometry scans can be used to document bone density, but there is no indication for routine use. Improved nutritional state may improve bone health. Calcium and vitamin D supplementation should be considered in children with significant nutritional impairment during the pubertal growth spurt and during steroid treatment.

 
    Medicolegal Update

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

What is the first aid for poisonous bites and stings?

People often panic if they have been bitten or stung. You should tell the patient that many snakes, spiders, insects and sea creatures are harmless and that even the bites and stings of dangerous animals often do not cause poisoning.

Keep the patient calm and still. Moving the bitten or stung limb speeds up the spread of venom to the rest of the body. Fear and excitement also make the patient worse. The patient should be told not to use the limb and to keep it still and below the level of the heart. The limb may swell after a while, so take off the patient’s rings, watch, bracelets, anklets and shoes as soon as possible. A splint and a sling may help to keep the limb still.

Avoid doing the following:

  • Do not cut into the wound or cut it out.
  • Do not suck venom out of the wound.
  • Do not use a tourniquet or tight bandage.
  • Do not put chemicals or medicines on the wound or inject them into the wound (for e.g., potassium permanganate crystals).
  • Do not put ice packs on the wound.
  • Do not use proprietary snake bite kits.
  • The patient should lie on one side in the recovery position so that the airway is clear, in case or vomiting or fainting.
  • Do not give the patient anything by mouth - no food, alcohol, medicines or drinks. However, if it is likely to be a long time before the patient gets medical care, give the patient water to drink to stop dehydration.
  • Try to identify the animal, but do not try to catch it or keep it if this will put you, the patient or others at risk. If the animal is dead take it to hospital with the patient, but handle it very carefully, because even dead animals can sometimes inject venom.
  • As soon as possible, take the patient to a hospital, medical dispensary, or clinic where medical care can be given. The patient should not walk but should keep as still as possible. If there is no ambulance or car, carry the patient on a stretcher or trestle, or on the crossbar of a bicycle.
  • Antivenom should only be given in a hospital or medical Centre where resuscitation can be given, because the patient may have an allergic reaction. If available, antivenom should be used if there is evidence of severe poisoning. It should not be used when there are no signs of poisoning.
 
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    Gyne Update: Question of the Day

What are the treatment options for threatened abortions? (Dr Duru Shah, Dr Wani Reena)

Threatened abortion clinically implies any bleeding during the first half of pregnancy in the presence of a closed cervix. With availability of ultrasound, the term is taken to mean an ongoing pregnancy with bleeding per vaginum. Evaluation of the pregnancy must be done, including hematological tests, screening for infections and structural anomalies, for Down’s syndrome and other conditions as indicated by the clinical evaluation. Detailed maternal history and examination may indicate a specific etiology.

  • Treatment of any cause identified should be initiated.
  • Natural micronized progesterone therapy can help to support the decidua; however, it is often used empirically. Documented cases of luteal phase deficiency will respond well to progesterone supplementation. Cases where USG shows subchorionic hemorrhage too can benefit from progesterone.
  • Continuing with folic acid and multivitamin supplementaion, rest (avoiding vigorous physical activity, intercourse) and reassurance are also important aspects of management.

Suggested reading

  1. Shehata KI, Mahmood TA. Clinical management of first trimester spontaneous miscarriage. In: Progress in Obstetrics and Gynecology. Studd J (Ed.), Churchill Livingstone, 2005:16.
  2. Arora M. Recurrent pregnancy loss. Jaypee Brothers Publications, New Delhi, 2004.
 
    Lab Update

(Dr Arpan Gandhi and Dr Navin Dang)

ASMA – Anti–smooth muscle antibody

To help diagnose chronic active autoimmune hepatitis and distinguish it from other causes of liver injury

    Medi Finance Update

Understanding Mutual Funds

Within each of these fund classes, funds can be further broken down based on the actual investments within the fund. Generally, funds can be broken down into four categories:

  • By geography
  • By company size
  • By industry
  • By goals of the fund.

To understand what type of fund you are buying, first look at the asset class in which it is investing and then look at the specific investment categories within the fund.

 
    Drug Update

List of Drugs Prohibited for Manufacture and Sale through Gazette Notifications under Section 26a of Drugs & Cosmetics Act 1940 by the Ministry of Health and Family Welfare

Drugs prohibited from the date of notification

Antidiarrhoeal formulations containing Phthalyl Sulphathiazole or Sulphaguanidine or Succinyl Sulphathiazole

 
    IMSA Update

International Medical Science Academy (IMSA) Update

Nocturnal leg cramps

A systematic review of treatments for nocturnal leg cramps identified limited data to support the use of several agents, including calcium channel blockers and vitamin B complex.

(Ref: Katzberg HD, et al. Assessment: Symptomatic treatment for muscle cramps (an evidence–based review): Report of the Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology. Neurology 2010;74:691).

 
    IJCP Special

Dr Good Dr Bad

Situation: A diabetic smoker with A1C 6.5% came for follow up.
Dr Bad: Very good control.
Dr Good: Its good control but you should also stop smoking.
Lesson: Smoking cessation is essential for diabetic patients who are smokers.

Make Sure

Situation: A patient on 10 units of insulin developed hypoglycemia after taking light breakfast.
Reaction: Oh My God! Why was insulin dose not reduced?
Lesson: Make sure that insulin dose is correct. The formula is 500/total daily dose. The value will be the amount of sugar fluctuation with ten grams of carbohydrates.

 
    Lighter Side of Reading

An Inspirational Story
(Contributed by Paramjit Chadha)

The Perfect Boss

There were about 70 scientists working on a very hectic project. All of them were really frustrated due to the pressure of work and the demands of their boss but, everyone was loyal to him and did not think of quitting the job.

One day, one scientist came to his boss and told him, "Sir, I have promised my children that I will take them to the ongoing exhibition in our township. So I want to leave the office at 5.30 p.m. His boss
replied, "OK, you're permitted to leave the office early today." The scientist started working. He continued his work after lunch. As usual, he got involved to such an extent that he looked at his watch when he felt he was close to completion. The time was 8.30 p.m. suddenly, he remembered of the promise he had given to his children. He looked for his boss. He was not there. Having told him in the morning itself, he had closed everything and left for home. Deep within himself, he was feeling guilty for having disappointed his children. He reached home. Children were not there. His wife alone was sitting in the hall and reading magazines. The situation was explosive; any talk would boomerang on him. His wife asked, "Would you like to have coffee or shall I straight away serve dinner if you are hungry.

The man replied, "If you would like to have coffee, I too will have, but what about the children?" The wife replied, "You don’t know? Your manager came here at 5.15 p.m. and has taken to the exhibition."
What had really happened was that the boss who granted him permission was observing him working seriously at 5.00 p.m. He thought to himself, this person will not leave the work, but he has promised his children they should enjoy the visit to exhibition. So he took the lead in taking them to exhibition. That’s why all the scientists at Thumba continued to work under their boss even though the stress was tremendous.

By the way, can you hazard a guess as to who the boss was? He was none other than Dr. APJ Abdul Kalam, Former President of India.

-------------------

Mind Teaser

Read this…………………

one another
one another
one another
one another
one another
  one another  

Yesterday’s eQuiz :

A 76-year-old male is being treated for Acute Myeloid Leukemia. He presents with a chronic subdural hematoma that is evacuated. Postoperatively, patient develops seizures that do not respond to Lorazepam, Phenytoin and Levetiracetam. He is intubated and a Pentobarbital coma is induced with a loading dose appropriate for patient’s weight. Continuous bedsides EEG monitor reports ongoing bursts of seizure activity. Pentobarbital dose is incrementally titrated till seizures are suppressed on day 2 of ICU. He developed severe hypotension and needed Norepinephrine and Vasopressin support. Infection screen is negative. The following are his pertinent labs before and during his ICU stay.  

Date/data

Pre–ICU

ICU 1

ICU 2

ICU 3

Bicarbonate

26

24

19

10

Anion gap

4

4

8

27

Lactate

16

>20

Osmolar gap

35

What is the explanation for this patient’s profound metabolic acidosis?

A. Profound sepsis
B. Blast Crisis
C. Propylene glycol toxicity
D. Adrenal insufficiency due to infiltration

Answer for yesterday’s eQuiz: "C. Propylene glycol solvent "

Propylene glycol is a diol (double alcohol) that is a benign antifreeze agent (unlike ethylene glycol) and is generally considered safe for human consumption. It is a small hydrophilic molecule widely used in the pharmaceutical industry as solvent for intravenous, oral and topical preparations. Lorazepam, diazepam, pentobarbitone, phenobarbitone, some preparations of sulfamethoxazole/trimethoprim, nitroglycerin and topical sulfadiazine contain propylene glycol. No one knows the safe dose for this solvent but patients with liver or kidney disease, chronic alcoholics and pregnant women & children below age 4 are particularly vulnerable. Propylene glycol toxicity manifests as an acute kidney injury, anion gap metabolic acidosis and even a SIRS/sepsis like syndrome (like our patient). This patient received over 150 gms of propylene glycol while on the pentobarbital drip for two days and developed the classic toxicity with acute kidney and liver failure, profound hypotension and high osmolar gap and anion gap metabolic acidosis. Critical care physicians need to be aware of this potential risk while using lorazepam (it has the highest concentration of propylene glycol as solvent compared to any other drug) or other drugs mentioned here when using them on the ICU as continuous infusions for prolonged period of time and/or high doses. Interestingly, topical sulfadiazine when used in large amounts has led to a similar picture.  

Correct answers received from: Dr. Anjani, Dr.K.Raju

Answer for 9th November Mind Teaser: "Gross incompetence"
Correct answers received from: Neelam Nath, Dr Vijay Kansal

Send your answer to ijcp12@gmail.com

-------------------

Humor Section
(Joke Dr G M Singh)

Class work

An English professor wrote the words, "Woman without her man is nothing" on the blackboard and directed his students to punctuate it correctly.
The men wrote: "Woman, without her man, is nothing."
The women wrote: "Woman: Without her, man is nothing."

 
    Readers Responses
  1. Very good and useful articles .Congrats sir. Dr.Nitin Jain, Child Specialist, President - IAP (Kawardha Branch)
  2. Dear Editor, Very good medical updates. We are grateful. Please give the mind teaser question once again along with the correct answers received. Otherwise we tend to forget the question. C.Vaishnavi
 
    Public Forum

(Press Release for use by the newspapers)

Diabetes and Dental Screening

Periodontal or gum disease is a common complication of diabetes and itself contributes to poor glycemic control, said Padma Shri & Dr. B.C. Roy National Awardee, Dr. KK Aggarwal, President, Heart Care Foundation of India. Severe periodontal disease has been shown to be an independent risk factor for mortality from ischemic heart disease and nephropathy.

Annual dental examination is recommended in both dentulate and edentulate diabetic patients.

Patients with diabetes mellitus should also receive influenza flu vaccination yearly and pneumococcal vaccination. The pneumococcal vaccine should be repeated once after 65 years of age if the initial vaccination was prior to this age. Tetanus and diphtheria vaccinations should also be updated.

Diabetes is considered equivalent to known coronary disease in predicting the risk of future cardiac events. Smoking cessation is essential for patients who smoke. Cardiovascular morbidity can also be significantly reduced with aggressive management of hypertension (goal blood pressure less than 130/80 mmHg), cholesterol (goal LDL less than 100 mg/dL) and use of aspirin (75 to 162 mg/day) in patients over age 40 years, and in younger patients with additional cardiovascular risk factors.

Aspirin alone may not be the answer as a latest Japanese research has shown that low–dose aspirin does not reduce the risk of cardiovascular events in people with type 2 diabetes.

 
    Forthcoming Events

eMedinewS Events: Register at emedinews@gmail.com

Workshop on Kidney Transplant

International Medical Science Academy, eMedinewS , Moolchand Medcity Board of Medical Education, IMA New Delhi Branch and IMA Janak Puri Branch

Date: Sunday 28th November
Venue: Moolchand Medcity Auditorium, 9-12 noon
Moderators: Dr KK Aggarwal, Dr Kamlesh Chopra, Dr Sanjay Sood, Dr A K Kansal, Dr Archna Virmani

9.00 - 9.30 AM: Kidney transplant scenario in India: Dr Sandeep Guleria, Transplant Surgeon, AIIMS
9.30 - 10.00 AM: Kidney Transplant: What every one should know: Dr Ramesh Hotchandani, Senior Nephrologist, Moolchand Hospital
10.00- 10.30 AM: Transplant immunobiology and immunosuppression. Dr Monica Vasudev, Assistant Professor Division of Allergy and Clinical Immunology, Medical College of Wisconsin, Milwaukee
10.30-11.00 AM: Dr Brahm Vasudev, Assistant Professor of Medicine, Division of Nephrology, Director, Nephrology Fellowship Program, Medical College of Wisconsin
11.00 -12.00 AM: Panel discussion
12.00: Lunch

(Registration free: email to emedinews@gmail.com)

eMedinewS Revisiting 2010

The 2nd eMedinewS  – revisiting 2010 conference will be held at Maulana Azad Medical College, New Delhi on January 08–09, 2011.

January 08, 2011, Saturday, 6 PM – 9 PM – Opening Ceremony, Cultural Hungama and eMedinewS Doctor of the Year Awards. For registration contact – emedinews@gmail.com

January 09, 2011, Sunday, 8 AM – 6 PM – 2nd eMedinewS revisiting 2010, A Medical Update

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