emedinews
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FIRST NATIONAL DAILY eMEDICAL NEWSPAPER OF INDIA
emedinews is now available online on www.emedinews.in or www.emedinews.org
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; Member 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


13th May, Thursday, 2010

Commonwealth Games 2010…Taking Care of Health Commonwealth

Dear Colleague

Commonwealth Games 2010 are fast approaching. More than one lakh visitors from all over the world are likely to visit the country and New Delhi, in particular, for the Games…a totally different health environment from what they have been exposed to. In this context, Travel Medicine assumes significance and highlights the need to sensitize all including the medical fraternity about travel–related diseases and their treatment and most importantly, prevention.

The forthcoming issues of eMedinewS would periodically feature various topics relating to travel medicine.

In the first in the series, we take a look at Traveler’s diarrhea or Delhi Belly, as it is more popularly known.

Traveler’s Diarrhea (Part I)

  • Traveler’s diarrhea will be the most common illness in persons traveling to India during Commonwealth Games. It is anticipated that 40% to 60% of travelers may develop diarrhea in terms of number, this may amount to 40 to 60,000 patients.

  • Though most episodes are nearly always benign, the resultant dehydration that can accompany diarrhea may be severe and cause more complications than the diarrhea itself.

  • While classifying diarrhea, amongst the international travelers, the internationally accepted classification must be adhered to. Under this, a traveler diarrhea can be classified as Mild, Moderate and Classic.

    • Mild traveler’s diarrhea is said to occur when a traveler passes one or two unformed stools in 24 hours without any associated symptoms (nausea, vomiting, fever, abdominal pain, blood in stool).

    • Moderate traveler’s diarrhea is when a traveler passes one or two unformed stools in 24 hours with at least one of the above symptoms or more than two unformed stools in 24 hours without any symptoms.

    • Classic traveler’s diarrhea is when the traveler passes 3 or 4 unformed stools in 24 hours with at least one of the above symptoms.

  • Traveler’s diarrhea should not be confused with the term ‘acute diarrhea’ which is used for 3 or 4 loose or watery stools per day. In traveler's diarrhea, even one unformed stool will be considered as mild diarrhea.

  • Traveler’s diarrhea may occur between 4 to 14 days after landing in New Delhi or any part of India. If the contamination is high, travelers can also develop diarrhea in less than four days. It will also be a differential diagnosis when diarrhea appears within 10 days of the person returning home.

  • Traveler’s diarrhea is invariably by contaminated food and or water.

  • The causative agent invariably is caused by bacteria. Viruses or parasites may also cause diarrhea. In 90% cases, it is caused by the bacteria, Escherichia coli (Enterotoxigenic E. coli)

  • Spices in food and change in climate do not cause traveler's diarrhea. The stress of travel may exacerbate diarrheal symptoms.

  • For diarrhea to develop, the ingested organism must reach the small intestine. This can easily happen in patients who are taking antacids, H2–blockers, proton pump inhibitors (PPIs), or post GI ulcer surgery state, blind loop syndrome etc.

  • Most worms and parasites require a more contaminated environment than is usually encountered by an average traveler. Thus, parasites as a cause of diarrhea are usually rare.

  • Most of the people coming to India may have taken chemoprophylaxis for malaria; uncommonly, some of them may develop C. difficile diarrhea.

  • The duration of illness usually lasts 1 to 5 days. In 10% cases, it may last more than a week and in 2%, more than a month. Only 20% of patients may require rest otherwise most of them will be able to live a normal working life.

  • In ETEC diarrhea, the characteristicl blood or pus in the stool is absent. The typical presentation is malaise, anorexia, abdominal cramps followed by sudden onset of watery diarrhea with or without nausea, vomiting. Low grade fever may be present. Presence of cramps, blood, urgency, may indicate large intestinal or C. jejuni infection.

  • Giardiasis often presents with belching.

  • Most patients will recover within 48 hours; if the diarrhea persists or symptoms are severe and associated with toxemia, interventions are often necessary.

  • Stool culture is not warranted.

  • Treatment includes fluid replacements, antibiotics and anti–motility agents.

  • For moderate traveler’s diarrhea, one may give coconut water, fruit juices, alternative salt and sugar drinks or ORS (oral rehydration solution).

  • A classical diarrhea will always need ORS or IV fluids.

  • ORS can be prepared by adding half teaspoon of salt, half teaspoon of baking soda and 4 teaspoons sugar to 1 liter of water.

  • Racecadotril is an effective adjunct to ORS.

  • Antibiotics may be needed in those patients who develop moderate or classical diarrhea or presents with blood, puss or mucus in stool. Some travelers may opt for antibiotics even in mild diarrhea.

  • Ciprofloxacin 500 mg daily can be given for one or two days (not approved for pregnant women and children). Once–a–day newer quinolones should also be effective.

  • Antibiotics lead to resolution of diarrhea in the majority within one day.

  • Even a single dose of ciprofloxacin or norfloxacin may be effective.

  • Ciprofloxacin may be dangerous with coffee as it may increase caffeine levels and cause jitteriness.

  • The newer once–daily moxifloxacin or levofloxacin are efficacious but are not approved for use in infectious diarrhea.

  • In view of developing resistance, azithromycin is increasingly used as an alternative to quinolones. A single 1000 mg oral azithromycin is equivalent to a single 500 mg of levofloxacin. The alternative dose is 500 mg daily for 3 days.

  • Rifaximin given as 200 mg daily for three day is a non–absorbed rifamycin and is becoming a popular drug because of concerns about quinolone resistance.

  • In moderate diarrhea, antimotility drugs do not treat the cause but reduce symptoms. They are to be used in combination with antibiotics to reduce the stool. The drugs used are loperamide or diphenoxylate.(lomotil or imodium)

  • Anti–motility drugs, if given without antibiotics, may prolong the dysenteric illness. These drugs are specifically required in certain special circumstances like prolonged bus or car trip, attending a special social function or meeting. Special concern about hygiene is important in patients on anti–motility drugs as they do not kill the bacteria or stop the secretary process in the intestine.

 

  • Patients may be unaware of how much fluid they have lost

  • Anti–motility drugs should be stopped if abdominal pain is present or other symptoms worsen or if the diarrhea continues for more than 48 hours

Dr KK Aggarwal
Padma Shri Awardee and Chief Editor

 

Photo Feature (From file)

Inauguration of Health Event by Chief Minister

The Chief Minister is an elected representative of the people and works for the welfare of the society. The Heart Care Foundation of India regularly invites politicians for Health Events and thus ensures their participation in communicating important social and health messages to the common man. The photograph shows Smt Sheila Dixit, Chief Minister of Delhi inaugurating a health event organized by the Heart Care Foundation of India. (photo from file)

Dr k k Aggarwal

International Medical Science Academy Update (IMSA): Practice Changing Updates

Important drug interactions

Several studies called attention to concern about proton-pump inhibitors blunting the benefit of clopidogrel in patients with acute cardiac problems. (JAMA 2009;301:937–943 and CMAJ 2009; 180:713–718)

 

Guest editorial

Analgesia: Are acetaminophen/NSAID combinations more effective than one drug alone?

A systematic review indicates that combinations are more effective for relieving acute pain. Although many clinicians recommend combining acetaminophen (paracetamol) and nonsteroidal anti–inflammatory drugs (NSAIDs) for acute pain management, the evidence for this practice has been mixed. An international team of investigators performed a systematic review of all randomized controlled trials (RCTs) in which paracetamol/NSAID combinations were compared to either class of drug alone for managing acute postoperative pain. The study was funded by the manufacturer of a paracetamol/ibuprofen combination tablet.

Twenty RCTs involving 1852 patients compared paracetamol/NSAID combinations with paracetamol alone. An analgesic combination was more effective than acetaminophen alone for at least one of three measures (pain score, need for supplemental analgesia, globally assessed pain relief) in 16 studies (80%). The mean reduction in pain intensity was 35%, and the mean reduction in need for supplemental analgesics was 39%. Fourteen studies involving 1129 patients compared the efficacy of an analgesic combination to that of an NSAID alone. Nine studies (64%) demonstrated that the combination was more effective. The mean reduction in pain intensity was 38%, and the mean reduction in need for analgesic supplementation was 31%. The incidence of side effects did not differ significantly between combination therapy and either single–drug therapy.

Comment: This systematic review supports the use of a combination of acetaminophen and NSAIDs for acute pain. The postoperative pain models used in these studies (orthopedic; ear, nose, and throat; gynecological; general; and dental surgery) may translate well to other acute pain contexts.

Dr NP Singh (Nanu): Professor of Medicine, Maulana Azad Medical College, New Delhi.

DMC Update

Can DMC look into a complaint seeking administrative reliefs?

As per DMC/F.14/DC/Comp.290/2006 order dated 30th August 2006 DMC wrote to Directorate of Health Services; Complaint of D RNS against Dr. AKN "The above noted complaint has been forwarded by Medical Council of India for examination of Delhi Medical Council. On perusal of the complaint it is observed that the relief claimed by the complainant is administrative in nature, hence, the same may be looked into by the Directorate. A copy of the complaint is enclosed herewith for necessary action, under intimation to this office and the complainant".

News and Views (Dr Brahm and Monica Vasudeva)

1. FDA warns consumers against Vita Breath

Vita Breath is marketed as an herbal supplement for people with asthma. FDA is now warning consumers not to buy or consume it after a sample of the product was shown to contain 10,000 times the recommended limit for lead in candy.

2. Certain GnRH agonists may increase risk of diabetes, heart attack, FDA cautions

The Food and Drug Administration is looking into data suggesting a group of prostate cancer drugs increase the risk of diabetes and heart disease.

3. Experts concerned about growing number of caesareans in the US

Caesareans are warranted in certain cases, such as when a baby is breech. But, medical experts are concerned that too many women are using the procedure, particularly since the number of caesareans in the US has increased from 21% in 1998, to about one–third of all births. Some women who have had caesareans refuse to deliver any additional children vaginally because they are worried about the uterus rupturing. But, experts argue that about 74% these women can actually have a successful vaginal delivery.

4. Two–week antibiotic course benefits IBS patients

Some ten years ago, researchers at the Cedars–Sinai Medical Center began studying the breath of IBS patients who had diarrhea and concluded that the symptoms were being produced when the intestines were overgrown by bacteria. Dr. Mark Pimentel explained that the excess bacteria produce large amounts of hydrogen and methane through fermentation. Rifaximin, when tested among 1,260 patients, by day 14, investigators observed some significant results.

Mnemonic of the Day: Check list for diabetes - SUGAR

Sight (annual eye examination)
Urine albumin
Glycosylated hemoglobin
Atherosclerosis (aspirin and lipids; palpate arteries)
Reduce weight (diet and exercise) and Remove footwear (monofilament testing; foot examination)

Quote of the Day

"A theme is a memory aid, it helps you through the presentation just as it also provides the thread of continuity for your audience." –– Dave Carey

Question of the Day

How is nephrotic syndrome investigated?

Nephrotic syndrome is usually defined as combination of massive proteinuria {24–hour protein excretion in excess of 3.5 g/1.73 m2 of body surface area (BSA)}, hypoproteinemia, hyperlipidemia and edema. It is important to emphasize that a number of glomerular diseases, both idiopathic and secondary, can cause nephrotic syndrome.
While diagnosing nephrotic syndrome, it is essential to do a through clinical examination which establishes the presence of massive edema. Then one proceeds to prove that there is massive proteinuria. This can be done by collecting a 24–hour urine sample and testing it for quantitative proteinuria and establish that it is more than 3.5 g/1.73 m2 of BSA by calculating the same with the help of weight and height that has been taken during initial clinical examination.
A 24–hour urine collection at times is cumbersome and inaccurate; hence it is simpler to estimate the spot urine protein creatinine ratio and demonstration that it is more than 3.5 g. This roughly corresponds to 24–hour proteinuria. This is likely to be much more accurate; less cumbersome and can be done regularly during follow–up to judge the effect of treatment.
The next step is to estimate the total serum albumin, which is generally
≥3.5 g. This is estimated by standard methods.
In massively edematous patients, it is important to measure weight of the patient daily to judge the response to dietetic and other specific therapy. The other routine tests included, complete blood count, renal function tests to know for any abnormalities of GFR levels, FBS/PPBS levels to rule out diabetic nephropathy.

Special tests

Kidney biopsy is done to arrive at the exact morphological diagnosis and to decipher the exact cause of renal parenchymal disease. The biopsy needs to be stained as a routine with hematoxylin and eosin (H&E), PAS, silver and trichrome stain. At times, Congo red stain may help in diagnosis when amyloidosis is suspected.

In conditions associated with hematological disorders like multiple myeloma; it is important to do a good peripheral smear followed by a bone marrow examination for presence of plasma cells. Other abnormal cells of myeloid and lymphoid series would point to hematological malignancies. Serum protein electrophoresis is then done if there is abnormal globulin to look for abnormal M bands which establishes the diagnosis of multiple myeloma.

Kidney biopsy will not only give the diagnosis of the type of idiopathic and secondary glomerular diseases, but also give a clue to inherited disorders like Alport’s syndrome, nail–patella syndrome and congenital nephritic syndrome especially in children. It would also help in establishing inherited metabolic disorders like cystinosis, hyperoxaluria, etc. There should be a strong clinical suspicion of those disorders which would be enhanced and proved on kidney biopsy.

A genetic study for gene protein phenotyping has become necessary in inherited disorders to arrive at definitive diagnosis.

Suggested reading

  1. Oxford Textbook of clinical nephrology, Eds. Davison A, Caneron JS, et al. Volume III, 2005: 415-35 and 2255–420.

  2. Diseases of the kidney and the urinary Tract. Ed. Schrier RW, Volume 3:1585–2007.

eMedinewS Try this it Works: An overlooked cause of anemia

The exact cause of anemia remains a mystery even after an extensive diagnostic evaluation in many patients. An overlooked explanation is blood donation. This procedure results in the loss of 200 to 250 mg of iron per unit of donated blood. In patients who already are predisposed to iron depletion for the reasons noted above, two or three trips to the blood bank annually can lead to iron deficiency

International Vaccines recommendations

Yellow fever vaccination is sometimes recommended 10 days before travel

Dr Good Dr Bad

Situation: A patient with stroke came for evaluation.
Dr Bad: Get your echo done.
Dr Good: Get your heart, carotid and aorta studies done.
Lesson: In most of the patients, the source of paralysis can be traced by finding plaques in carotids or aorta.

Make Sure

Situation: A patient with diabetes shows deteriorating kidney function. Reaction: Oh my God! His HbA1c is very high.
Lesson: Make sure that strict glycemic control is maintained in patient.

IMADNB Joke of the Day (Dr Tarun Gupta)

The little boy was clad in an immaculate white suit for the lawn party, and his mother cautioned him strictly against soiling it. He was scrupulous in his obedience, but at last he approached her timidly, and said:

"Please, mother, may I sit on my pants?"

 

Formulae in clinical practice

Corrected reticulocyte count
Formula: Corrected reticulocyte count = % of
reticulocytes × Patients Hct %/Average Normal Hct
Average HCt = 45 %

Milestones in Cardiology

Alexis Carrel

Heart transplantation has become a reality through the pioneering work of Alexis Carrel. He mastered the technique of suturing blood vessels as a young physician in Lyon, France, and received the Nobel Prize in 1912.

Lab Test (Dr Arpan Gandhi and Dr Navin Dang)

5-HIAA (5-hydroxyindoleacetic acid; HIAA)

To help diagnose and monitor treatment for a serotonin–secreting carcinoid tumor.

List of Approved drugs from 1.01.2009 to 31.10.2009

Drug Name

Indication

DCI Approval Date

Mesalamine PR Tablets 1.2gm

For the induction of remission in patients with active, mild to moderate ulcerative colitis.

30.03.09

MCI Update

When will Dr Desai get bail?

The Delhi High Court on Tuesday sought a response from CBI on the bail plea of MCI President Dr Ketan Desai. Justice S L Bhayana issued the notice to the investigating agency and asked it to file the response by June 3 when the matter would be taken up for further hearing. Dr. Desai submitted that the alleged bribe money of Rs. 2 crores was not recovered from him. As for granting recognition to medical colleges, he said the decisions were taken by a three-member committee, of which two were independent medical professionals. "I am suffering from hypertension and sleep disorders and have severe breathing trouble as well," Desai said in his petition.

The bail application case of J P Singh, another arrested in the same case has been listed for 24th May. If he gets bail, Dr Ketan Desai can move his bail application again. The regular case in CBI lower court will come up on 14th May where the bail is unlikely for any one of them.

It was expected that Dr Desai would get bail on medical grounds but this was not given and the next hearing is not before 3rd June. He is suffering from morbid obesity, severe sleep apnea, is on 12–hours CPAP and on anti hypertensive drugs. These are enough grounds normally to get a bail on medical grounds.

The government in the mean time is trying to take control of MCI, a step which the medical profession should oppose.  The health ministry wants to arm itself with powers so as to intervene if charges of misconduct are hurled against the council's members. Presently, the MCI is a body of elected members and the government has no right to intervene in its affairs. Under the proposed changes, the health ministry will have the authority to take charge of the council if the president’s post falls vacant. The government can also nominate members for vacant posts, including that of the vice president. A draft legislation also seeks to limit the terms of the president and vice–president to a maximum of two. Also, it will give the central government power to dissolve the executive committee or dismiss its office–bearers under specified conditions.

The MCI is a statutory body that oversees the standards of medical education in India. It grants recognition to medical degrees, gives accreditation to medical colleges, registers medical practitioners, and monitors medical practice in the country. An earlier amendment along the same lines in 2005 was rejected by a parliamentary committee on the plea that it will destroy the autonomy of the prestigious institution. But the mood in the health ministry changed after arrest of Dr Ketan Desai for recognizing a medical college in Punjab though it did not meet MCI’s quality standards. The Union Health Minister, Ghulam Nabi Azad had told the parliament that the Medical Council Act will be amended to give greater authority to the government vis–a–vis the council

Bail on medical grounds?

Dr. Desai is suffering from Morbid Obesity and is under a weight reduction programme for the last many years. The same requires a periodic medical supervision and repeated testing. Severe hypertension on drugs also require periodic monitoring.Severe sleep apnea which requires auto CPAP machine usage throughout the night also is risky to life.

Can all this be a ground for bail?
1. Bail depends upon case to case as there is no settled law in the country. A judge may allow treatment to be given in the jail hospital, a government hospital or in special circumstances, in a private hospital where the expenditure will have to be borne by the patient himself. Grounds for bail depends upon nature of offence which may be bailable like 304A where bail has to be granted. The offence can also be non-bailable. The examples of which are – dacoity, robbery with injury, grave offence, extortion, ransom, murder, rape, corruption, POCA.

2. Generally, even in cases which are non-bailable, bail is easily granted unless the case is a high profile which invariably ends up into the media trial. In such cases, bail is usually granted by the High Court. POCA is a serious offence and is usually tried by special courts.

3. Obstructive sleep apnea is associated with nocturnal cardiac arrhythmias. Patients whose respiratory disturbance index of more than 30 events per hour of sleep have a higher prevalence of nocturnal atrial fibrillation which can cause paralysis, non-sustained ventricular tachycardia, complex ventricular atopic. Both can lead to sudden death.

4. Bradycardia and asystole during sleep are the most prominent and significant pulse disturbances associated with sleep apnea. In extreme cases, ventricular asystole can last longer than 10 seconds.

 

Public Forum (Press Release for use by the newspapers)

Exercise reduces Depression

Quoting a British study published in the American Journal of Epidemiology Dr KK Aggarwal Padma Shri and Dr BC Roy National Awardee, President Heart Care Foundation of India, said that those who get regular vigorous exercise are less likely to develop depression or an anxiety disorder over time.

In general, men who reported regular vigorous exercise –– such as running or playing soccer –– were about one-quarter less likely than their less active peers to develop depression or anxiety over the next 5 years.

Even Small Amounts of Exercise Are Beneficial

In a study, published in the Journal of the American Medical Association, by Dr Timothy Church of Louisiana State University System it has been shown that even small amounts of physical activity––approximately 75 minutes a week––can improve cardio respiratory fitness levels of sedentary overweight individuals.


Commenting on the study, Dr KK Aggarwal said that while this level of exercise is lower than that currently recommended to produce weight loss, the current findings may be used to encourage those people who don’t exercise at present to start some form of physical activity.
Improvements in fitness are associated with a reduction in the risk of cardiovascular disease and death.

The National Institutes of Health Consensus Development Panel recommends at least 30 minutes of moderate–intensity physical activity on most days of the week, the reports suggest that 60 minutes of exercise each day may be necessary to prevent weight gain.

Readers Responses

  1. Dear sir, I read the excellent summation of the views of the DMA in the editorial below! http://www.emedinews.in. Thank you so much to all of the doctors at DMA for a balanced stand against corruption and malpractice in the MCI. The ideas enunciated are well thought out and good for the public and the profession. It is extremely important to have a corruption free MCI and other governing bodies, with self–regulation being the ideal method. The silence by all the MCI members, is damning and equal to agreement with the blatant corruption charges thrown at them. Likewise, the leaders of the national IMA also have failed in their duty of damage limitation for a long time, by not coming out with a firm stand against corruption. This is important for maintaining the goodness of a profession in the public eye. The fact remains though that unless we keep checks on corruption at MCI and other professional bodies we have, it will hurt us drastically as a group and individually too. So it is in our best interests to stop such bad influences among ourselves, and add legitimacy to our quest for autonomy. What we do from now on, to do that, is very important.
    We wish to see IMA STAND TALL & UNITED and as an organization with moral authority and is concerned solely with the welfare of the profession, the doctors and the association, and also the Indian public whom we will always serve with love and dedication. We do not need to support MCI as it is now–– Our main aim is to see that there is no third time repeat of the same scenario in MCI who ever comes to power there –––especially our bretheren from the medical profession… It is ok for politicians to be blamed for corruption and favoritism… Not for doctors like us… (Rtn Dr NV Girish Kumar: O’Brien Bone & Joint Clinic, Coimbatore
     
  2. I totally agree with your opinion regarding MCI. Everybody knows that the inspection committee is Corrupt Body and demands money to sanction MCI recognition. It is an open secret and politician also want to share it. If there were no corruption and there was no posibility of corruption, who would want to take over the MCI. Politicians came to know that lot of power and money is involved that is why they are after it. Thank you very much for starting professional issues also in your Medinews. It is getting wide acceptance: Dr Alex Franklin
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eMedinewS–Padma Con 2010

Will be organized at
Maulana Azad Medical College, New Delhi on July 4, 2010, Sunday to commemorate Doctors’ Day. The speakers, chairpersons and panelists will be doctors from NCR, who have been past and present Padma awardees.

 
 

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 hungama and live webcast. Suggestions are invited .

 

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