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Dr KK Aggarwal

From the Desk of Editor in Chief
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

12th August 2010, Thursday

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

Breaking News
NDM-1: The New Superbug Threat

WHO has announced that Swine Flu H1N1 Pandemic is over but they have announced a new threat NDM-1 Bacteria.
Originating from New Delhi, Called New Delhi Metallo-beta-Lactamase-1, is a new Superbug identified by the researchers and is resistant to all known antibiotics.  Lancet Infectious disease journal reports 50 such cases. Most of them have carried this infection from India, Pakistan and Bangladesh. The superbug NDM-1 is named after the national capital, where a Swedish patient was reportedly infected after undergoing a surgery in 2008. It is much more dangerous than the notorious MRSA infection. 

NDM-1 is an enzyme produced by certain bacteria, which allows them to neutralize the harmful effects of carbapenem one of the most powerful types of antibiotics. 

Currently no new types of antibiotics are in the development pipeline that will be effective against it. Enzymes such MDM-1 are produced by strands of DNA which bacteria are known to transfer between one another. Currently E Coli and Klebsiella Pneumoniae are the two bacteria who are host to MDM-1. What makes the superbug more dangerous is its ability to jump across different bacterial species. The superbug has the potential to get copied and transferred between bacteria, allowing it to spread rapidly. If it spreads to an already hard-to-treat bacterial infection, it can turn more dangerous.

The current treatment option is to treat them with a cocktail of antibiotics. Most new antibiotics currently under development are effective only against gram positive bacteria like super bug MRSA. Unfortunately, bacteria that carry the MDM-1 enzymes are gram negative.

A joint study was led by Chennai-based Karthikeyan Kumarasamy, pursuing his PhD at University of Madras and UK-based Timothy Walsh from department of immunity, infection and biochemistry, department of medicine, Cardiff University. They found the bug in most of the hospitals in Chennai and Haryana with estimated prevalence of this infection 1.5%. They reported the superbug in 44 patients in Chennai, 26 in Haryana, 37 in the UK and 73 in other places across India, Pakistan and Bangaladesh. 

How to identify that my patient has NDM1: gram negative sepsis with culture report: resistant to all antibiotics. We have been seeing such cases in the last few years. Now we have a name for this disease. Many of the doctors are deying its existance and linking it to a move against medical tourism in India. But the ICMR, NICD should work on it and come out with guidelines for this infection as no one can deny the fact that we do see cases of gram negative sepsis with E Coli or Klebsiella with culture report resistant to all antibiotics.

About the resistance: Carbapenemases are carbapenem-hydrolyzing beta-lactamases that confer carbapenem resistance. This mechanism is distinct from other mechanisms of carbapenem resistance such as impaired permeability due to porin mutations, although the susceptibility patterns for isolates with a carbapenemase and those with porin mutations can be identical. The carbapenemases have been organized based on amino acid homology in the Ambler molecular classification system. Class A, C, and D beta-lactamases all share a serine residue in the active site, while Class B enzymes require the presence of zinc for activity (and hence are referred to as metallo-beta-lactamases).

Class B beta-lactamases:  are also known as the metallo-beta-lactamases (MBLs), which are named for their dependence upon zinc for efficient hydrolysis of beta-lactams. As a result, MBLs can be inhibited by EDTA (an ion chelator), although they cannot be inhibited by beta-lactamase inhibitors such as tazobactam, clavulanate, and sulbactam. The first MBL, IMP-1, was described in Japan in 1991.

Subsequently, additional groups of acquired MBLs have been identified: IMP, VIM, GIM, SPM, and SIM. There are a number of variants within each MBL group (for example, there are 19 IMP variants within the IMP group).

There are both naturally occurring and acquired MBLs. Naturally occurring MBLs are chromosomally encoded and have been described in Aeromonas hydrophilia, Chryseobacterium spp and Stenotrophomonas maltophilia.
Acquired MBLs consist of genes encoded on integrons residing on large plasmids that are transferable between both species and genera.

In a hospital outbreak involving 62 patients (including 40 intensive care unit patients), for example, an MBL gene (bla IMP-4) spread among seven different gram-negative genera (Serratia, Klebsiella, Pseudomonas, Escherichia, Acinetobacter, Citrobacter, and Enterobacter).

Laboratory detection of MBL-producing organisms can be especially difficult if the organisms carry "hidden" MBL genes; these isolates appear susceptible to carbapenems using standard testing methods (including those advocated by the Clinical and Laboratory Standards Institute (CLSI) and the British Society for Antimicrobial Chemotherapy (BSAC)).

The MBL E-test (a commercially available assay) cannot consistently identify MBL-producing organisms that are truly resistant to carbapenems. Therefore, MBL-producing organisms should be considered carbapenem-resistant regardless of carbapenem susceptibility results.

Other identification methods take advantage of the zinc dependence of MBLs by using EDTA, which chelates the zinc. Combination disc tests using imipenem and EDTA discs or using two carbapenem discs (including one with EDTA incorporated) have been reported. A more sensitive MBL detection method uses an agar plate with three components: a double disc synergy test with imipenem and EDTA discs, a combined disc test comprising two imipenem discs (with one disc also containing EDTA), and an aztreonam disc to detect aztreonam susceptibility. This method was able to detect the presence of MBL in both carbapenem resistant and carbapenem sensitive isolates, and genotypic validation of the method demonstrated high sensitivity and specificity (100 and 98 percent, respectively). Carbapenem susceptible isolates that are resistant to both ceftazidime and ticarcillin-clavulanate should be considered for MBL testing. Genotypic identification using PCR amplification with primers specific for MBL genes (eg, blaVIM or blaIMP) is an accurate method for the detection of MBL-producing organisms.(Source uptodate)

Treatment options: Selection of antibiotic therapy should be tailored to antimicrobial susceptibility results for agents outside the beta lactam and carbapenem classes. In addition, antibiotic susceptibility testing should be requested fo tigecycline, colistin and aztreonam.

 Dr KK Aggarwal
Editor in Chief
drkkaggarwal Dr K K Aggarwal on Twitter
Krishan Kumar Aggarwal Dr k k Aggarwal on Facebook  


Photo Feature

2nd BSNL Dil Ka Darbar 2010 will be held on 26th September (8 am - 8 pm) at MAMC Auditorium, Maulana Azad Medical College, Delhi Gate New Delhi  This was announced by Padma Shri and Dr BC Roy National Awardee, Dr KK Aggarwal, President HCFI and Perfect Health Mela in a press conference. The one-day Darbar is being held on the same lines as during the Mugal times. The theme for this year is Preventing Sudden Cardiac Death

Left to right: Mr Sanjay Sinha Jt. DDG (PR), BSNL, Star attractions of the press conference Mr Ramesh Sharma, Guineas Book record holder for long nails, Padma Shri and Dr B C Roy National Awardee Dr KK Aggarwal, President Heart Care Foundation of India, BSNL Dil Ka Darbar & MTNL Perfect Health Mela,  Mr Rinku Nigam, eminent Film Producer and President, Film Piracy Eradication Cell, Dr K S Bhagotia, CMO, Dir. of  Health Services, Delhi Govt. and Acharya Dr Sadhvi Sadhnaji Maharaj, Chairperson, World Fellowship of Religions.


Dr k k Aggarwal


News and Views ( Dr Monica and Brahm Vasudev)

Tongue piercing can cause costly gap in front teeth

A case study published in the July issue of the Journal of Clinical Orthodontics suggests that, Tongue piercing can lead to a damaging habit that causes a gap to appear between the upper front teeth, which could cost thousands of dollars to fix.

Excess weight may protect women from type of glaucoma

According to Harvard researchers, overweight women may have a lower risk of developing primary open–angle glaucoma (POAG), one of the most common age–related eye diseases. In particular, overweight women may be especially protected from a variant of POAG called normal–tension glaucoma. But don’t gain weight to protect your eyes, experts say.

Most doctors will face malpractice suit, AMA says

More than 60% of doctors over the age of 55 have been sued at least once, according to a new survey by the American Medical Association (AMA). Although most of those claims are dropped or dismissed, the new survey from the AMA shows that most physicians will be sued for malpractice at some point in their careers. This works out to an average of 95 medical malpractice lawsuits having been filed for every 100 physicians now in practice, according to the association.

Polytobacco’ users cause for concern

In a CDC survey of 13 states, one in four adults reported using tobacco in some form; one in five smoked cigarettes, and 2.5% used a variety of tobacco products. Such "polytobacco use" includes cigarettes, smokeless tobacco, snuff, and imported products such as kreteks, which are sometimes called clove cigarettes and usually contain tobacco, cloves, and other ingredients, according to a report in the Aug. 6 issue of Morbidity and Mortality Weekly Report.


Legal Column

Forensic Column (Dr Sudhir Gupta, Associate Professor, Forensic Medicine & Toxicology, AIIMS)

Forceful/Artificial feeding and hunger strike–what is the role of doctor?

Many of our medical doctors do not have clear legal and ethical guidelines of medical duty in a case of force full feeding/medical intervention to any person particularly when a person/arrested person/prison willingly in hunger strike with his own valid consent. The Council of the World Medical Association met in Tokyo in October 1975 to discuss the various aspects of forcible feeding in case of hunger-striking person/detainees/prisoners. This problem, vividly illustrated by recent events in Northern Ireland, which has been discussed in the British Medical Association Handbook on Medical Ethics 1981. In our Indian context the medical ethics of forcible feeding or providing IV fluids may be regarded as a Special case of the much discussed question of ‘the right to die’/euthanasia. In whatever context this problem may be considered, the physician is confronted by two conflicting ethical imperatives: his duty to do all in his power/skill to preserve human life along with his obligation to respect the right of a rational patient to refuse even a life–saving medical/surgical intervention.


Experts’ Views

Interesting Tips in Hepatology & Gastroenterology

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

Childhood Pancreatitis: Medical Therapy

The treatment of acute pancreatitis is largely supportive, and the intensity of therapy is decided by the severity of inflammation.

Question of the day

Does obesity enhance the risk of new–onset atrial fibrillation?

(Dr. Amit Rai, Ghaziabad)

Obesity is an important, potentially modifiable risk factor for atrial fibrillation (AF). The excess risk of AF associated with obesity appears to be mediated by left atrial dilatation. These prospective data raise the possibility that interventions to promote normal weight may reduce the population burden of AF. Wang TJ and his group analyzed Framingham Heart Study data (JAMA 2004 Nov. 24;292(20):2471–2477) and has showed that obesity is associated with atrial enlargement and ventricular diastolic dysfunction, both known predictors of AF. They analyzed prospective, community–based observational cohort in Framingham, Mass. More than 5000 participants (mean age, 57 (SD, 13) years; 2898 women [55%) without baseline AF (electrocardiograph AF or arterial flutter) were studied.

Body mass index (calculated as weight in kilograms divided by square of height in meters) was evaluated as both a continuous and a categorical variable (normal defined as <25.0; overweight, 25.0 to <30.0; and obese, ≥30.0).

In addition to adjusting for clinical confounders by multivariable techniques, they also examined models including echocardiographic left atrial diameter to examine whether the influence of obesity was mediated by changes in left atrial dimensions.

During a mean follow–up of 13.7 years, 526 participants (234 women) developed AF. Age–adjusted incidence rates for AF increased across the 3 BMI categories in men (9.7, 10.7, and 14.3 per 1000 person–years) and women (5.1, 8.6, and 9.9 per 1000 person–years). In multivariable models adjusted for cardiovascular risk factors and interim myocardial infarction or heart failure, a 4% increase in AF risk per 1 unit increase in BMI was observed in men (95% confidence interval (CI), 1–7%; p = 0.02) and in women (95% CI, 1–7%; p = 0.009). These data indicate that obesity probably does enhance risk of AF and hence, efforts should be made to reduce bodyweight in these patients.


Public Forum (Press Release for use by the newspapers)

Even children can have paralysis

One out of every 4,000 babies born in the United States will have a stroke before they’re 28 days old, according to new guidelines issued by the American Heart Association on managing childhood stroke.

They can occur in utero, they can occur in the neonatal period, and they can occur in older children said Padma Shri and Dr B C Roy National Awardee Dr K K Aggarwal, President Heart Care Foundation of India, BSNL Dil ka Darbar & MTNL Perfect Health Mela. One of the biggest differences between childhood strokes and those that happen in older people is that far fewer of strokes in children are what’s known as ischemic strokes. In an ischemic stroke, the blood supply to the brain is cut off, sometimes by a blood clot or possibly due to sickle cell disease. Without blood, the brain can not get the oxygen it needs to survive. Ischemic strokes are the most common types of strokes in adults, accounting for 80 to 85 percent of strokes. In people under 18, about 55 percent of strokes are ischemic.

About 45 percent of strokes in children are hemorrhagic. Hemorrhagic strokes occur when a blood vessel in or on the brain bursts, causing blood to pool in the brain and depriving it of oxygen.

Some of the risk factors for stroke in childhood include sickle cell disease, heart disease, trauma and certain infections, according to the AHA guidelines.

Symptoms include:
• Sudden weakness or numbness occurring on the face arms or legs, especially if it’s one–sided.
• Sudden difficulty speaking or understanding what’s being said.
• Confusion.
• Sudden trouble walking or a loss of balance.
• Dizziness.
• Sudden vision loss or difficulty seeing.
• Severe, sudden–onset headache.


Conference Calendar

Basic Life Support (BLS) Provider Course – Target Audience – All Healthcare Personnel

Date: August 13, 2010.
Venue: V–70 (Old No. 89), Fifth Avenue, Anna Nagar, Chennai, Tamil Nadu


An Inspirational Story

On the edge…

There will be moments when the only thing left is for you to question your existence. Life can be so damned hard for each of us.

There are always days when we get so lonely and depressed. When we cry. When the world has lost its colors. When the rest of the world is happy and you are not.

There will be times when we lose all reasons for living; and problems will seem so hard that we wish there was no such thing as tomorrow.

But then again, we should also know, that they are just another bitterness in life trying to twist the personage in each of us; and corrupt our perceptions about life.

When these times happen, do not succumb to the temptations of giving up. Yes, to live is to suffer and the only way to be happy is to suffer willingly.

Often, the worst of times yields the best lessons in life. We have to go on in life’s extremes. We don’t have to give up. As the famous poet, philosopher, and artist Kahlil Gibran said,

"When you are sorrowful, look again in your heart, and you shall see that, in truth, you are weeping for that which has been your delight."


IJCP Special

Dr Good Dr Bad

Situation: A diabetic patient was gaining weight on insulin.
Dr Good: Take insulin twice daily.
Dr Bad: Stop insulin and shift to oral drugs.
Lesson: The combination of insulin with metformin is also associated with significantly less weight gain than seen with twice–daily insulin injections or insulin combined with sulfonylureas. (Source: Lancet 1998;352:854).

Make Sure

Situation: An HIV patient died after sulfa prophylaxis.
Reaction: Oh My God! You should have known that he was sulfa sensitive.
Lesson: Make sure that patients with a history consistent with Stevens Johnson syndrome and toxic epidermal necrolysis or an exfoliative dermatitis due to a sulfonamide medication should strictly avoid the culprit drug and other agents in the same sulfonamide group. Re–exposure to the same agent may be fatal.

Quote of the Day

A drop of water falls in lake, there is no identity but if it falls on leaf of a lotus it shines like a pearl so chose best place where you can shine. V.Memon

Are you fit to fly?

Deep Vein Thrombosis

  1. Compression stockings can decrease the incidence of DVT associated with prolonged flights.

  2. Among patients considered to be at high risk for clots, use of properly fitted, below–knee graduated compression stockings (12 to 30 mmHg at the ankle) or one prophylactic dose of low molecular weight heparin a few hours before the flight may be protective. Aspirin is not effective in this setting.

International Medical Science Academy Update (IMSA)

Eye care

As of December 2009, the shortage of 0.5 percent erythromycin ophthalmic ointment in the United States had resolved with the production of sufficient quantities to meet the demand for neonatal ocular prophylaxis.


  1. van Ierland Y de Boer, M de Beaufort AJ. Meconium–stained amniotic fluid: discharge vigorous newborns. Arch Dis Child Fetal Neonatal Ed 2010;95:F69.

Drug Update

List of Approved drugs from 01.01.2010 TO 30.4.2010

Drug Name


DCI Approval Date

Ivabradine Hcl Tablets 5/7.5mg (Additional Indication)

For symptomatic treatment of chronic stable angina pectoris in coronary artery disease patients with normal sinus rhythm, indicated in combination with beta–blockers in patients inadequately controlled with an optimal beta–blocker dose and whose heart rate is >60bpm.



Medi Finance

Q If payment of expenditure is made to related person, which is unreasonable as per the view of assessing officer, then will it be allowed as deduction?

Ans. If payment of expenditure has been made to related person and assessing officer is of the opinion that such expenditure is unreasonable as compared to fair market value, then the expenditure considered unreasonable may be disallowed.


Lab Test (Dr Arpan Gandhi and Dr Navin Dang)

Beta–2 Microglobulin

To help evaluate the severity and prognosis of multiple myeloma, leukemia, or lymphoma; to distinguish between kidney disorders and to detect kidney damage.


Lateral thinking

Read this………………


The answer for yesterday’s puzzle "split level"

Correct answers received from: Dr Ashok Wasan, Dr Anuraj Jain,

Correct answer received for 10th August Puzzle: Dr Gagan Shrivastava, Dr. Gitanjali Arora, Dr Vijay Kansal

Send your answer to ijcp12@gmail.com


Humor Section


This is a short story written by Dr Kishore Shah…he is a gynecologist in Pune and a very gifted writer…enjoy this extremely funny story.

My wife is an ENT Surgeon while I am a Gynecologist. This can lead to some complications, as I recently learned to my anguish. A General Practitioner called me up and told me that she is sending a patient of hers for an abortion. Unknown to me, she had also referred a female with earwax for removal of the wax to my wife.
I duly informed the receptionist to send the patient right in as she was expected (and expecting!) As Murphy lays down the laws of our hospital, it was but natural that the patient who wanted the wax removed from her ear, landed up with me. This is the conversation that I had with the patient.
"Please come in. Be seated." I said with a big smile. I always have a big smile, when I am going to earn some money. The patient gave a feeble smile and sat hesitantly on the edge of the chair. "Relax."
"Doctor, will this hurt a lot?"
"Not at all."
The patient relaxed visibly. "You know something, Doctor, we tried removing it at home, but failed."
I was shocked. "Thank God. Trying this at home can cause serious complications."
"I first tried to remove it by jumping up and down, but it just wouldn’t budge."
I smiled and said, "If it were that easy, who would need doctors?"
She gave a cute smile and said, "Yeah! My neighbour tried to remove it with his finger, but the hole is so small that he used a hair pin."
"Oh my God!"
"Yes! My mother even tried a matchstick."
My blood pressure was shooting skywards. I just sputtered without uttering a word.
"Tell me, doctor, how do I avoid getting this dirt inside me?"
I knew that it was an unwanted pregnancy, but calling it dirt was too much.
I replied a bit angrily, "There are tablets which can prevent this happening. Or you could use protection at night."
Now it was the patient’s turn to be confused, "You mean to say that it happens only at night?"
I saw her point. "No! No! I meant anytime of the day, whenever you are in the mood, you should use protection."
She was even more confused, "It depends on my moods?"
Again I saw her point. "My mistake. You need not be in any sort of mood. It just happens."
"My neighbour advised me to go to one of those chaps who sit by the roadside."
"You mean that pin man?"
This neighbour of hers seemed to be a very dangerous man. Besides using pins, he was sending her to such quacks. The only safety he knew was among the pins. "You were wise not to heed his advice."
"But I tried his other advice. He told me to put warm oil inside and wait.
However, that also did not work."
This was getting more and more bizarre. Her neighbour deserved to be locked up either in a padded cell or a barred one.
"But have you taken your husband’s permission?"
Now the patient looked confused. "Do I have to take my husband’s permission? Because if you need his sign, he is working in Dubai. We were not able to meet for the last one year."
It was my turn to be shocked. I gave a sly smirk. It was one of ‘those’
cases. The pin–wielding neighbour seemed to me the usual suspect. I reassured her. "No! No! The husband’s sign is not at all needed."
"However, I did inform him on phone."
Her husband seemed to me a very broad–minded fellow. I didn’t know whether to congratulate her or to commiserate with her. So I hastily turned to other aspects. "Its good that you came a bit early."
"Actually I wanted to come early in the morning, but I had some other work."
"Oh! I did not mean early today. I meant that if you had delayed this removal, it would have started moving. Then it would have developed a heartbeat."
The patient was staring at me wide eyed as if watching a horror movie.
Looking at her face, I decided that she was not fit to listen to the grotesque details. I decided to relieve her a bit. I said, "You will bleed a bit, but only for a few days."
By now, the poor patient was trembling, "how–H–How much bleeding?"
"Oh, only slightly more than your menstrual period, and it will continue only for a week or so."
By now the patient was clutching her hair in her fingers and staring at me wide–eyed. I asked her soothingly, "Why don’t you lie down on the examination table? Remove your clothes and relax."
This was the final straw. She didn't even wish me goodbye. I saw just a blur of motion leaving my consulting room at top speed.


 Readers Responses

  1. Dear Dr Aggarwal: The comments of Dr. R.S. Bajaj about doctor / hospital in negligence is very valid. A consultant will not be in a hospital for all the 24 hours, so he is not responsible what is happening to the patient after he has left the hospital. You will appreciate, that to save money, hospitals are employing sub-standard paramedical staff including resident doctors. I have personally experienced how patients in Grade 1 hospitals, even in ICU's are neglected due to overcrowding of patients’ think this point should be taken up with Govt. and relevant courts on a very priority basis. Dr. Parashar
    eMedinewS responds: Residents are covered under infrastructure.  The hospital will be liable if the resident cover is not up to the mark
  2. Dear Dr Aggrawal, I agree with Dr Bajaj that time has come to take action or else doctors will find themselves being badly exploited and tortured. The corporate hospital as such are  not Bound  or covered by medical council, these hospitals do not follow HIPPOCRATES OATH. Even  Doctors admitted are charged Doctors fees,  neither the treating doctors ever say that the fess may be waived.  The doctors are not given any discount on investigation, bed room, procedures earlier Doctors owned medical establishment, were following the HIPPOCRATES OATH. Now is the time to take up the issues like these , the clinical establishment bill, PNDT ACt and others not just on the forums of IMA but on streets, advocacy with legislature and legal recourse. with kind regards Dr Anil Varshney

Forthcoming Events

eMedinewS Events: Register at emedinews@gmail.com

5th September: 3 PM to 5 PM – A dialogue with His Holiness Dalai Lama at C 599 Defence Colony Acharya Sushil Ashram in association with Acharya Sushil Muni Ahimsa Peace Award Trust

26 th September: Sunday- BSNL Dil ka Darbar A day-long interaction with top cardiologists of the city. 8 AM - 5 PM at MAMC Auditorium, Delhi Gate.

17th MTNL Perfect Health Mela 2010 Events: Venue: NDMC Ground Laxmi Bai Nagar, New Delhi

24th October, Sunday: Perfect Health Darbar, Interaction with top Medical experts of the city from 8 AM to 5 PM
30th October, Saturday: eMedinewS Update from 8 AM to 5 PM
29th October, Friday: Divya Jyoti Inter Nursing College/ School Competitions/ Culture Hungama
30th October, Saturday: Medico Masti Inter Medical College Cultural festival from 4 PM to
10 PM
31st October, 2010, Sunday: Perfect Health Darbar, An interaction with top Cardiologists

eMedinews Revisiting 2010

The 2nd 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 Hungama and Live Webcast. Suggestions are invited.

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