February 11  2015, Wednesday
editorial
DNB not equivalent to MD or MS
Dr KK Aggarwal No.MCI-4(3)/2014-Med./MEDICAL COUNCIL OF INDIA/ POSTGRADUATE MEDICAL EDUCATION COMMITTEE/ Minutes of the Postgraduate Medical Education Committee meeting held on 9th September, 2014 at 10.30 am at MCI office:

Those who pass DNB from a Non-teaching Hospital (other than Medical Colleges/Teaching Institutions recognized by MCI as Teaching Institutions) would be required to have further three years experience as Junior Resident in a Teaching Hospital, before they could be considered eligible for appointment to the post of Senior Resident. They would also be required to work for another one year as Senior Resident (after DNB) in a Teaching Hospital before they could be considered as eligible for appointment to the post of Assistant Professor.

Those who pass DNB from a Teaching Hospital (Medical College/Teaching Institution) would be eligible for appointment to the post of Senior Resident. However, they would be required to work for another one year (after DNB) as Senior Resident/Equivalent post in a Teaching Hospital before they could be considered eligible for appointment to the post of Assistant Professor.
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News Around the Globe
  • Results from a large study published online February 5 in the British Journal of Psychiatry. showed that patients with a current anxiety disorder had shorter telomeres than nonpsychiatric control individuals and those with remitted anxiety disorder, suggesting that telomere shortening can be reversed with adequate treatment of an anxiety disorder.
  • There is no convincing evidence that any of the pharmacological interventions for Achilles tendinopathy work, according to a systematic review in the British Medical Bulletin. Current treatments include injectable corticosteroids, high-volume saline solution, prolotherapy, autologous blood, platelet-rich plasma and a variety of other substances, as well as transdermal topical application of glyceryl trinitrate and other drugs.
  • Etonogestrel implants and levonorgestrel intrauterine devices (IUDs) used longer than recommended showed no increase in failure rate, according to a study published online February 4 and in the March issue of Obstetrics & Gynecology.
  • Many patients with diarrhea diagnosed with inflammatory bowel disease (IBD) are not routinely checked for Clostridium difficile infection (CDI), as reported in Inflammatory Bowel Disease, online January 9.. It's possible that some of these patients may have symptoms because of CDI rather than IBD, and CDI may also trigger "a flare of IBD or worsen existing IBD symptoms and worsen disease course (for example, higher rates of colectomy in UC patients who are hospitalized with a flare.
  • Femtosecond laser-assisted LASIK and photorefractive keratectomy (PRK) are both associated with mild but statistically significant forward protrusion of the posterior cornea. According to results from a new study in Ophthalmology, the forward protrusion fluctuated for a year in patients who received LASIK, but stabilized as early as 3 months after patients received PRK. A similar pattern was seen even after the researchers made adjustments for differences in the preoperative and postoperative parameters between the two treatment groups.
Dr KK Spiritual Blog
The Five Interior Powers

To be in a state of happiness, bliss and ananda is what the ultimate goal of life is. Everybody is born with certain inherent powers, which if cultivated in the right direction will lead to inner happiness.

The ancient Shiva Sutra text talks about the concept of Shiva and Shakti. Shiva is silence, Shakti is power; Shiva is creativity, Shakti is creation; Shiva is love, Shakti is loving.

In computer term Shiva is the knowledge or the information and Shakti is the operational software. Shiva and Shakti both together form consciousness, in other words the soul.

Shiva sutra – teaching about Shiva – describes five inherent powers of Shakti which everybody is born with and these are “Chitta Shakti”, “Ananda Shakti”, “Gyan (Gnana) Shakti”, “Ichha Shakti” and “Kriya Shakti”.

Kriya Shakti is the one which is most visible. Kriya is not same as karma. Karma is action born of cause and effect. Kriya Shakti is at the level of body and mind. Ichha Shakti is the inherent desire, which controls the mind. Gyan Shakti is the inherent desire to learn and is at the level of intellect. Both Ananda and Chitta Shakti are at the level of consciousness and represents the desires or aim to be blissful.

These five powers also decide the needs of a person, which can be at the level of physical body, mind, intellect, ego or the soul. The needs activate the Shakti which in turn leads to action. The purpose of life should be to direct the needs and the Shaktis towards the soul and not towards the ego.

The power of Kriya Shakti should have all the actions directed towards the soul; Gyan Shakti should be directed towards the knowledge of the true self; Ichha Shakti towards the desire or intention to unite with the self; Anand Shakti and Chitta Shakti towards the awareness of God and to experience the bliss of God. All thoughts, speech or actions in life should be directed on two basic goals providing happiness to others and ending up with self-happiness. Every action and relationship in life should involve these five powers to attain inner happiness.

Most computers in the body require a key to get activated and the key in the case of Shakti is “intention or intent”. Intentions are something, which are under the control of a person, or one can practice control over them.

“Intention” always requires the association of its buddy “attention” with it. Attention is the focus of action on that particular intention. The combination of intention and attention can change perceptions of life and ultimately change the reality. It has been an old Upanishad saying that you are what your thoughts are. Right intention leads to the right thought; the right thought to right action; the right action to the right habit; the right habit to the right character and the right character leads you to what you are. The punch-line, therefore, is to have right intention which should be directed towards one of the five Shakti to acquire spiritual well-being.

Health is not mere absence of disease but a state of physical, mental, social, environmental and spiritual well-being. Spiritual wellbeing has now been added as the fifth dimension of the health. It has been said that the body is the largest pharmaceutical armamentarium in the world and has the capacity to produce each and every drug available in the universe. This is based on the fact that no drug can go into the body without a receptor. The very fact the body has a receptor for every drug means that it has the capacity to produce that drug.

All yogic paths to liberation are also directed towards these Shaktis. One adopts karma Marg by activating Kriya Shakti, Gyan Marg by activating Gyan Shakti and Bhakti Marg by activating Ichha Shakti.

Faulty lifestyle also involves distractions of three of these powers: Ichha, Gyan or Kriya Shakti.

Correct lifestyle involves the correct use of Kriya Shakti in doing actions, correct use of Gyan Shakti by acquiring knowledge about self and healthy behavior and correct use of Ichha Shakti by learning the do’s and don’ts of life and controlling the mind towards various addictions of life which can be addition of food, sex, drugs, alcohol, smoking, sleeping, not walking and or eating faulty Rajsik cum Tamsik high refined carbohydrate diet.
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Cardiology eMedinewS
  • Young and middle-aged women who are recovering from acute MI have higher levels of perceived stress than men, and this higher degree of stress is associated with worse recovery, according to the results of a new study published February 9, 2015 in Circulation.
  • The US Food and Drug Administration (FDA) has cleared the Enroute Transcarotid Neuroprotection System (Enroute TNS, Silk Road Medical) to reduce the risk for stroke during carotid angioplasty and stenting, the first such device to use neck rather than groin access. "It is the first device designed to access the carotid arteries through an incision in the neck, instead of the groin, and uses a blood flow reversal system to capture pieces of the blockage dislodged during the procedure," a statement released by the FDA today notes.
Pediatrics eMedinewS
  • Hypnotherapy, cognitive behavioral therapy, and probiotics are effective in the treatment of pediatric abdominal pain-related functional gastrointestinal disorders according to findings of a systematic review online February 9 in Pediatrics. Data are inconclusive, however, with regard to the efficacy of fiber supplements.
  • In a January 29th online paper in JAMA Otolaryngology Head and Neck Surgery, Drs. Zhaoping He and Robert C. O'Reilly of Nemours/Alfred I. duPont Hospital for Children, Wilmington, Delaware and colleagues note that extraesophageal reflux is one of the mechanisms that may drive middle ear disease in children.
Make Sure
Situation: A patient with LBBB in ECG developed acute pulmonary edema.

Reaction:Oh my God! Why was the underlying low cardiac functions not suspected?

Lesson: Make sure all patients with LBBB undergo echo to rule out ejection fraction. This may not be true for RBBB.
Beneficiaries of Sameer Malik Heart Care Foundation Fund
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Medicolegal
(Contributed by Dr MC Gupta, Advocate)

Q. I outsource samples to larger laboratories and give the test reports to the patients on my own letterhead. Sometimes the patients want me to provide the original report from the laboratories concerned but the latter do not want me to do so. Please let me know the legal implications.


A.
  • If you are a doctor and collect samples and give reports on your own letterhead without clearly stating that you are merely a collecting agent for the specified laboratory, giving out openly its name and contact details etc., you are apparently holding out that the test has been carried out directly or indirectly by you and, thereby, you assume the role of service provider to a consumer of services. The patient will be legally entitled to sue you for any perceived deficiency in service. He will also be entitled to sue the laboratory concerned.
  • If the laboratories concerned do not want you to give their details to the patients/consumers, it amounts to lack of transparency and deficiency in service. The patient has full right to know who carried out the tests and in what manner.
  • If you do not have a qualification in Pathology, you would be further compounding your fault.
In my opinion, your actions are likely to be held violative of the Consumer Protection Act, 1986, and the Code of Medical Ethics Regulations, 2002.
Dr Good Dr Bad
Situation: A patient with Mediclaim needed chemotherapy.
Dr. Bad: Get admitted for 24 hours.
Dr. Good: Take it as day care.
Lesson: Admission limit of 24 hours is not applicable for chemotherapy, radiotherapy etc.

(Copyright IJCP)
IJCP Book of Medical Records
IJCP’s ejournals
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Twitter of the Day
Dr KK Aggarwal: Cinnamon in Nonalcoholic Fatty Liver Disease Cinnamon (dalchini) helps improve lipid profiles and improve (cont) http://tl.gd/n_1rvf2c6
Dr Deepak Chopra: Love is what we are in our essence. The more love we feel in our hearts, the more it will be brought to us http://bit.ly/DC_Ananda #ananda
CPR 10
Total CPR since 1st November 2012 – 101090 trained
Rabies News (Dr A K Gupta)
How is RIG injected locally? What is the mode of administration of full dose of RIG?

It is important to infiltrate all wounds with rabies immunoglobulin (RIG). Intramuscular (IM) administration of RIG is of very little value. The previous recommendation to give antirabies serum half into wounds and half IM no longer holds true and may lead to treatment failure. As much of the calculated dose of RIG as is anatomically feasible should be infiltrated into and around all the wounds. In the event that some volume of RIGs is left over after all wounds have been infiltrated, it should be administered by deep IM at a site distant from the vaccine injection site.

If the calculated dose of RIG is insufficient to infiltrate all wounds, sterile saline can be used to dilute it 2 or 3 fold to permit thorough infiltration.
eMedi Quiz
The following are true regarding Lyme's Disease, except:

1. It is transmitted by ixodes tick.
2. Erythema chronicum migrans may be a clinical feature.
3. Borrelia recurrentis is the etiological agent.
4. Rodents act as natural hosts.

Yesterday’s Mind Teaser: The earliest immunoglobulin to be synthesized by the fetus is:

1. IgA.
2. IgG.
3. IgE.
4. IgM.

Answer for yesterday’s Mind Teaser: 4. IgM.
Correct Answers received from: Daivadheenam Jella, Dr. Mahesh, Dr Avtar Krishan.
Answer for 9th Feb Mind Teaser: 4. Practice proper hand washing.
Correct Answers receives: Dr Avtar Krishan, Daivadheenam Jella.
Video of the Day
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 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
About the Editor
National Science Communication and Dr B C Roy National Awardee, Honorary Secretary General IMA, Immediate Past Senior National Vice President IMA, Professor of Bioethics SRM University, Sr. Consultant Medicine & Cardiology, Dean Board of Medical Education, Moolchand, President Heart Care Foundation of India, Chairman Legal Cell Indian Academy of Echocardiography, Editor in Chief IJCP Group of Publications & eMedinewS, Member Ethics Committee Medical Council of India (2013-14), Chairman Ethical Committee Delhi Medical Council (2009-14), Elected Member Delhi Medical Council (2004-2009), Chairman IMSA Delhi Chapter (March 10- March13), Director IMA AKN Sinha Institute (08-09), Finance Secretary IMA (07-08), Chairman IMAAMS (06-07), President Delhi Medical Association (05-06)
IMA NEWS
IMA National Leaders Meet
Making hospitals free of bio-medical wastes

Indian Medical Association

Background
  • Biomedical waste refers to all wastes generated from healthcare, health research facilities and associated laboratories; a small percentage of which can be deemed infectious and/or hazardous.
  • These include infected sharps and wastes with infectious, hazardous, radioactive, or genotoxic characteristics, which if inadequately treated and managed can have adverse impact on the environment and on public health.
  • Therefore institutionalizing effective waste management systems in all healthcare facilities is a key prerequisite for improving efficiency and effectiveness of healthcare services.
Situation analysis
  • Per bed biomedical wastes: 250 grams per day
  • Total Bed strength in the country: 28.89 Lakhs (Central Bureau of Health Intelligence)
  • Total biomedical waste generated per day in country: 7.22 Lakh Kilograms
  • Existing facilities for managing biomedical waste in a professional manner:
    • Only a few states have proper biomedical waste management systems, even in these states, total beds are not covered, for example in Delhi only about 50% of the beds are covered properly.
Why and How?
  • To reduce hospital acquired infections, for clean hospital environment and prevention of multi drug resistant organisms, scientific biomedical waste disposal is essential
  • The process begins at the bed side of the patient where the waste has to be categorised, segregated and disposed in different containers. Needle has to be burned before disposal.
  • All these process goes a long way in universal precautions against infectious diseases and hospital acquired infections.
Drug resistance & Infection control
  • Newer antibiotic molecules have not been discovered in last 30 years, only modifications of the existing molecules have been tried out. Multidrug resistant microbials is a real threat. The recent New Delhi metallo-beta-lactamase 1 strain is a stark example. So the need for scientific biomedical waste disposal needs no further emphasis.
  • IMA Kerala state has pioneered a centralised biomedical disposal concept and is effectively carrying this out, covering the total bed strength of the state- both private as well as government.
Legal framework
  • Bio-Medical Waste (Management and Handling) Rules, 1998 Ministry of Environment and Forests New Delhi – 1998)
  • The expenditure involved in for setting up individual waste disposal units by hospitals as per 1998 rules is very huge and unaffordable.
The operational part 1
  • Free land has to be acquired from government for this purpose
    • Bio medical waste management unit should be declared tax free
    • For 15,000 beds, the bio medical waste production= 250gm per bed * 15,000 beds= 3750 kg
  • Autoclave: At 200 kg per autoclave per cycle of 90 minutes(including preparation and rest period), 2 autoclaves and one stand-by is required Steam temperatures over 121° C and exposure times of over 45 minutes ensuring destruction of all organisms including Bacillus stearothermophilus.
    • The high temperature and pressure cycles also ensures volume reduction
The operational part 2
  • Shredding unit- One for both plastic wastes and specifically for the plastic bags used for transporting and handling the waste materials will be installed. These are expected to have capacities to handle around 500-700 kgs of waste per hour.
  • Incinerator: One Incinerator can autoclave 250kg per hour; at this rate (10 hrs per day working)- two incinerators plus one stand-by is required
    • Dual fuel firing capabilities
    • Stack height of 30 meters high
    • High primary and secondary chamber temperatures
    • Low output of sterile ash
The operational part 3
  • Effluent treatment plant- One
  • Hydraulic compressor- One
  • Recycling Unit/sell for recycling
  • Needle pits
Buildings and Civil Structures
  • Office Building
  • Security and Office
  • Drivers Rest Room
  • Plant Building
  • Vehicles cleaning and garages
  • Treatment Facility Building / Shed
  • Campus Boundary Walls
Essential Utilities
  • Fuel storage tank
  • Bore well and Pump
  • Overhead waste tank and pump
  • Effluent Treatment Plant
  • Standby Generator
  • Ash storage and handling area
  • Weighing machines
  • Transformer- 1l kv, 100 kva
  • Air Compressor
  • Land requirement: Minimum 5 Acres of land
  • Financial requirements: Minimum 3 Crores investment apart from land; Loan facility will be available
  • Financial feasibility: At INR 10 per day, for 15,000 beds, for one month, 45 lakhs is the expected revenue
    • Income from sale of scrap: 500,000 per month, for 15,000 beds, approx
  • Running cost: INR 6 per bed (Vehicle, Electricity, Water, Diesel, Manpower, Financial cost)
  • Profit: 18 lakhs per month
    • If the running is outsourced, 80% of the profit goes to the agency(except scrap, 20% to IMA; approximately 8.6 lakhs, amounting to 1 Cr profit per year
    • Headquarters share: 50%, amounting to 50 Lakhs per year
IMA highlights glaring gaps in treatment of mental health
BINDU SHAJAN PERAPPADAN: THE HINDU: Highlighting the fact that there are glaring treatment gaps when dealing with mental health issues the Indian Medical Association (IMA) on Monday announced that it will be encouraging activities to ensure mental health through all its 1,700 branches across the country.

“Mental health has been neglected for too long in our country. It should be given priority to foster the health of our people. According to the World Health Organisation (WHO), among the 10 diseases causing maximum Global Burden of Disease, five are mental and substance use disorders,” noted IMA national president Marthanda Pillai.

As part of the new initiative the Association will encourage mental health activities in an attempt to bridge the glaring treatment gaps.

“IMA will undertake mental health awareness programmes at a national level and will also take up the matter with the Medical Council of India to ensure that adequate training in psychiatry and examination during MBBS is provided to students,” said IMA honorary secretary general Dr. K. K. Aggarwal. The Association is also working at establishing psychiatry units in all taluk and district hospital of the country. Uniform de-addiction protocols for general practitioners would also be started. Regarding the new Mental Health Care (MHC) bill being introduced in the Lok Sabha, the Association has noted that the proposed bill is severely deficient in many respects.

“The mentally ill being vulnerable sections of society need their rights protected in all circumstances and the mandate “protection of the rights of the mentally ill during delivery of treatment” is a very narrow view of the rights of the mentally ill,’’ states the release issued by the Association.

IMA has warned that as the bill seeks to bring in all types of mental health care facilities under its ambit where admission procedure, discharge policy, treatment decisions will be placed under the control of non experts/non professionals, it will delay and deprive timely treatment of many.

The IMA is working at establishing psychiatry units in all taluk and district hospital of the country
Clinician – Patient Communication
Vinay Sharma, New Delhi, 8 February, 2015

Counseling Skills
G: Greet
A: Ask
T: Tell
H: Help
E: Explain
R: Return

Medscape Family Physician Lifestyle Report 2015

Family Physicians Burnout and Marijuana Use

A 2014 Gallup poll reported that 38% of Americans have tried marijuana, an increase of only 5% since 1985. Only 7% say that they are currently using it. Family physicians report a slightly lower rate of marijuana history, with about 20% reporting ever having tried it. However, about 3% say they've used marijuana in the past year, which is a lower percentage than that found in the Gallup poll in the general population and is in line with use reported by physicians overall in our survey. As with drinking, burned-out and non–burned-out family physicians do not report different rates of marijuana use. (Source: Medscape)
Media
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Inspirational Story
The Old Man and the Rose

During the mid 1950s when I was a kid, my dad worked in a furniture shop at Spadina and Queen in downtown Toronto. Sometimes, I got to go to the shop with him and I made a bit of pocket change running to the restaurant and getting coffee for everybody. I would pass the rest of the day away just hanging around the store, not doing much of anything and not paying much attention to all the hustle and bustle of people and things that were all around me.

One day, as my dad and I were driving to the shop, I looked out the passenger window of the car and I saw an old man standing at the street corner. For some reason, our eyes met and held for about 20 seconds as we went by the corner. There was nothing fearful about this man but it was a significant encounter for me. Up to that point in my life, I had given no thought to anyone I saw on the street, in stores or anywhere else. My life was my family and my friends on the block and that was it. I had no interest in anyone beyond that circle.

But I was intrigued by that old man. For the first time I had an empathy and an interest in what that person was all about. What kind of life had he lived? Where had he been in his time? How had he come to this corner just at the moment I was going by?

Over the years I had long forgotten about this old man, but he came to mind for me recently and I remembered those twenty seconds or so that I looked into the eyes of a stranger and wondered what he was all about.

It seems we are all so busy these days. There are so many details, so many calls to make and so many things to look after that we barely have time for sincere and genuine interest in others.

We are inundated by warnings from great thinkers in our society encouraging us to 'stop and smell the roses'. But I'm afraid it has taken me decades to really appreciate the wisdom of these words.

If I ever have the opportunity to speak to a young person today, I do my best to convey this message. But unfortunately, young people are too busy to heed good advice. Much like I was so many years ago. Youth indeed is so often wasted on the young.

If I had the chance, I would tell young people to stop what they are doing and look around. I would tell them to try as hard as they could to fully understand what is right in their line of sight, what is in the range of their hearing at the moment, what is in their immediate reach and grasp.

I would like so much to tell people, especially young people, that if you are thoughtless and indifferent to others on your road in life, then you are missing life itself. Do not be intrusive or tactless, for heaven’s sake, but take a moment and ask someone, how did you come here or how did you get into this business?

No matter what that person tells you, their answer will make you richer. You can grow emotionally, you can excel as a person and you can be wealthy by every measure if you just appreciate the gifts that people and life all around you are ready to give right at this moment just by their simple presence.

We should appreciate that great symphonies were written from only seven simple notes that God gave the entire universe. We should know that great works of art are measured by the emotions they evoke, not just how they look next to the plant stand.

We should never forget that heartache cannot be cured but can be eased by someone willing to give genuine sympathy. The true greatness of joy can only be known when it is shared with others.

Recently, I attended a trade show at the convention centre in downtown Toronto. During the lunch break I went to a book sale along the trendy Queen West area. I was thinking about returning to the show or carrying on my walk when I realized I was standing at the corner of Spadina and Queen. At that moment a car went by and I caught the eye of a young boy looking at me from the passenger window. We looked at each other for about twenty seconds before the car disappeared around the corner. I wondered if that boy was thinking about what sort of person I was.

And I realized that I was now an old man. Like the man I saw so many years ago. I wondered if 50 years had just simply flashed by or whether that boy and I had just simply changed places in the span of 20 seconds.

Before I returned to the trade show, I stopped at a florist. I bought a rose and put it in the lapel of my jacket. For some reason, I felt it was the most important thing I would do for the rest of the day.
Quote of the Day
If I have the belief that I can do it, I shall surely acquire the capacity to do it even if I may not have it at the beginning. Gandhi
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Reader Response
  1. Dear Sir, Thanks for the updates. Regards: Dr Trishna
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Wellness Blog
Profession, passion and fashion

I have written about this topic earlier too, but this is an update. Profession is at the level of physical body and mind, fashion is at the level of ego and passion is at the level of the soul. If your passion, profession and fashion are in synchrony with each other, you are a perfect leader.

If you are not passionate about your profession, you can never be successful. To be passionate about your profession is only not important, it is also equally important to let others know about your passion for your profession.

When you do so, it becomes a fashion. Our aim in life should be to let people know that you are passionate about your profession. When the passion is too much, it becomes an obsession.
IMA Humor
There was this man driving along in his car when he suddenly got a flat tire. When he pulled over he was at the fence of a mental hospital. When he got out of the car one of the patients came to the fence and asked "Can I help you?" And the man said "No, I need to figure out how to make it home with only 2 lugs on this wheel."

The patient asked again "Are you sure you do not need any help?" And the man said "No." The man tried to figure it out when all of a sudden the patient said "If I were you I would take one lug off the other 3 wheels and put them on that wheel and you should be able to get home." The man asked "How did you think of that?"

The patient replied "I am in here because I'm crazy not because I'm stupid."
Press Release of the Day
Reactive depression can last for a few months

Politicians, who have lost the election, can suffer from anxiety and reactive depression which may last from a few weeks to months said Padma Shri Awardee Dr K K Aggarwal Honorary Secretary General IMA and President Heart Care Foundation of India.

They should take it easy and not isolate themself. The best way is to communicate and communicate with others to take the depression away.

Heart and diabetic patients should be especially careful and ask their doctors if they need extra dose of their regular medicine.

Sudden anxiety can precipitate asthma, heart attack and make the blood pressure rise to a very dangerous level.

Emotionally stressful events, and more specifically, anger, immediately precede and appear to trigger the onset of acute heart attack. Episodes of anger are capable of triggering the onset of acute heart attack and aspirin can reduce this risk.