15th February 2010, Monday
Heart Disease: His and Hers
Medical research is confirming that, even in heart disease, while men and women share a lot of similar risk factors, there are some important differences, as reported in a Harvard Newsletter.
Smoking: Cigarette smoking tops the list of lifestyle risk factors for men and women alike. But for women who take birth control pills, smoking increases the risk of heart attack and stroke even more.
Cholesterol: Levels of ‘bad’ LDL cholesterol above 130 mg/dL are thought to signal even greater risk for men, while levels of ‘good’ HDL cholesterol below 50 mg/dL are seen as greater warnings for women. High triglyceride levels (over 150 mg/dL) are also a more significant risk factor for women.
High blood pressure: Until age 45, a higher percentage of men than women have high blood pressure. During midlife, women start gaining on them and by age 70, women, on average, have higher blood pressure than men.
Inactivity: Only about 30% of Americans report getting any regular physical activity, but men tend to be more physically active than women, with the greatest disparities in the young (ages 18 to 30) and the old (65 and older).
Excess weight: Being heavy has long been thought to set one on the road to heart disease, but the location of the extra pounds may be more important than their number. Abdominal fat, which releases substances that interfere with insulin activity and promote the production of bad cholesterol, is more toxic than extra padding on the hips. Many health authorities consider a waist measurement of 35 inches or more for women and 40 inches or more for men as a more precise indicator of heart disease risk than body mass index.
Diabetes: Diabetes more than doubles the risk of developing heart disease for both men and women; however, diabetes more than doubles the risk of a cardiac death in women, while raising it to 60% in men.
Metabolic syndrome: Having any three of the five features of metabolic syndrome – abdominal obesity, high blood pressure, high triglycerides, low HDL cholesterol, and high blood sugar or insulin resistance – is riskier for women than for men, tripling the risk of a fatal heart attack and increasing the chance of developing diabetes 10–fold. The combination of a large waist and high triglycerides is especially toxic to women.
Psychosocial risk factors: The depth of the heart–head connection is still being plumbed, but there’s enough evidence to implicate certain factors as contributors to heart disease, such as chronic stress, depression, and lack of social support. Neither sex fares better than the other overall, but research indicates that some factors predominate in men and others in women.
Stress is an equal–opportunity burden. Women are twice as likely to be depressed as men and to suffer more from emotional upheaval. In fact, the reported cases of ‘broken heart syndrome’ – the sudden, but usually reversible, loss of heart function after an intense emotional experience – are almost exclusively in older women. Anger and hostility have long been cited as risk factors in men, but that’s probably because most studies of heart disease excluded women. It’s well documented that men are more likely to lack social support – especially after retirement – than are women.
Inflammation: Chronic inflammation is now thought to set the stage for the deposition of atherosclerotic plaque. Women have much higher rates of conditions that often lead to persistent, low–grade inflammation. For example, lupus more than doubles the risk of heart attack and stroke for women.
Dr KK Aggarwal
News and Views (Dr G M Singh)
Statin for primary prevntion
The US FDA has approved rosuvastatin for primary prevention of cardiovascular disease, making it the first statin to receive this indication. The new labeling, also marks the first time that a drug label will include an indication based on the biomarker highly–sensitive C–reactive protein, an inflammatory marker.The new indication would be for men 50 or older and women 60 or older who have fasting LDL of less than 130 mg/dL, a highly–sensitive CRP of 2.0 mg/L or greater, triglycerides of less than 500 mg/dL, and no prior history of heart attack or stroke, or coronary heart disease risk. The basis for the new labeling was the JUPITER trial, a randomized, placebo–controlled trial of 17,802 men and women with a mean age of 66 and no history of atherosclerosis. All participants had LDL of less than 130 mg/dL and a highly–sensitive C–reactive protein concentration of 2 mg/L or higher.
Upto 2 soft drinks per week safe
A new Singaporean study has found that Chinese men and women living in Singapore who drank two or more soft drinks per week were 87% more likely to contract pancreatic cancer after the researchers adjusted for factors such as smoking (95% CI 1.10 to 3.15). (Feb. 8 issue, Cancer Epidemiology, Biomarkers & Prevention)
Fulminant ulcerative colitis can cause pulmonary embolism
Patients with active inflammatory bowel disease are at greater risk for potentially deadly blood clots. Nonhospitalized patients with active IBD are 16 times more likely to suffer venous thromboembolism than the general population, with an occurrence rate of 6.4 per 1,000 person–years (P<0.0001), according to an online report in the Feb. 9 issue of The Lancet.
New ACS markers
Two proteins known as endothelin–1 (ET–1) and monocyte chemoattractant protein–1 (MCP–1) appear to be highly sensitive and specific markers of–excitement-induced acute coronary syndromes (ACS), according to Ute Wilbert–Lampen, MD, and colleagues at Ludwig–Maximilians–Universität in Munich.
Rituximab improved lung function in patients with scleroderma
At one year, patients randomized to receive rituximab had a median 10.25% increase in forced vital capacity (FVC) compared with baseline, while those who received standard treatment had a deterioration of 5.04%, according to Dimitrios Daoussis, MD, and colleagues from the University of Patras in Greece.(February issue of Rheumatology).
Eye care snippets by Dr. Narendra Kumar (OptometryToday@gmail.com)
Neutralization is a fairly accurate method of determining the strength of a lens.
By moving a spherical lens before the eye and looking at an object, the object appears to move. The movement is rapid if the lens is strong and slow if the lens is weak. The object seems to move in the opposite direction if the lens is convex or plus. In this case the object also appears enlarged. The object seems to move in the same direction if the lens is concave or minus. In this case, the object also appears smaller.
When a cylinder is moved before the eye in the direction of its axis, the object looked at does not appear to move. But when the cylinder is moved in the opposite direction (at right angle to the axis), the object appears to move as in the case of spherical lenses i.e. in the opposite direction in case of a convex cylinder, and in the same direction in case of a concave cylinder.
To neutralize a given lens, a lens of opposite kind and known strength is taken from the trial case and placed in front of the one to be tested, and the two lenses moved in front of the eye. The power of the lens from the trial case is gradually increased till a stage reaches when there is no apparent movement of the object when the combined lenses are moved in front of the eye. The neutralizing lens to stop all apparent movement of the object in all directions, thus, can be a spherical or a cylindrical or a combination of sphero–cylindrical power, and the lens being tested will likewise be of spherical, cylindrical or sphero–cylindrical power. The lens being tested will be of opposite kind but of same strength as that of the lens from the trial case.
Lens under examination
+0.50 D sph
–1.00 D sph
–0.25 D cyl axis 180°
+0.75 D cyl axis 90°
–0.25DS/+0.50DC × 75°
+0.75DS/–1.00DC × 120°
–0.50 D sph
+1.00 D sph
+0.25D cyl axis 180°
–0.75 D cyl axis 90°
+0.25DS/–0.50DC × 75°
–0.75DS/+1.00DC × 120°
All heart patients do not need angiography
All heart patients with heart blockages do not need angiography, said Dr. K K Aggarwal President, Heart Care Foundation of India and Editor eMedinewS.
Dr. Aggarwal said that failure of adequate medical treatment to provide desired quality of life is the main indication for angiography.
Quoting a formula, Dr. Aggarwal said that any person who can walk two kilometers, climb two flights of stairs or can have sex with his or her partner without any shortness of breath or uneasiness in the chest has no significant blockages inside the heart and may not need angiography.
He said that if a patient does not want angioplasty or bypass surgery, no angiography is needed. Also, patients with angina, or unstable angina where bypass surgery or angioplasty is not feasible, should not subjected to angiography.
Angiography is also not indicated for asymptomatic patients with coronary artery disease as a screening test. As well as after successful PTCA or bypass or in patients with acute heart attack, in absence of symptoms.
However, he said management of acute heart attack in the first three hours requires either clot dissolving therapy or opening up of the vessels with urgent angiography and angioplasty.
All young patients with heart blockages, survivors of cardiac arrest, heart disease with low functioning of the heart and symptomatic patients with heart blockages need angiography evaluation at the earliest and possible surgery and angioplasty.
Question of the day
What is the effect of HIV status in Individuals who have an attack of malaria?
Malaria and HIV are two of the most common and important health problems facing developing countries. It is estimated that over 40 million people are living with HIV globally1 and there are 350–500 million clinical malaria episodes annually.2
HIV immunosuppression increases the risk and severity of malarial infection. In addition, malaria infection activates T–cells, promoting HIV replication.2,3 Since increased HIV RNA levels are associated with accelerated disease Progression.4,5 malaria could potentially facilitate faster progression to AIDS and Death.6
Malaria–HIV interactions have been clearly demonstrated in young children, in whom malaria–induced anemia leads to blood transfusions, which may transmit HIV.7-9 Also, in pregnant women, HIV contributes to higher malaria infection rates, higher parasite density, more clinical illness, more anemia, and diminished response to treatment.10-14 Malaria infection also contributes to higher maternal HIV viral load, but whether this leads to increased mother–to–child HIV transmission is uncertain.
The underlying epidemiology and intensity of malaria transmission and the duration of HIV infection and consequent immunosuppression appear to be critical in determining the consequences of coinfection. In areas of stable malaria, with intense continuous transmission, adults acquire substantial immunity against malaria through repeated infections in early life such that infection and clinical illness are uncommon. In contrast, young children who have not yet acquired malarial immunity and pregnant women, who transiently lose some of their acquired immunity, are at particular risk of malaria infection and its complications.
In areas of unstable malaria, with intermittent unpredictable transmission, the entire population has little or no acquired immunity to malaria. While some HIV infected individuals have a rapid course of immunosuppression and associated illnesses, most will develop gradual loss of immune responsiveness over a number of years. This leads to increased susceptibility to opportunistic infections and evidence is accumulating that this includes increased vulnerability to malaria infections and their consequences.
Generally, malaria is clinically indistinguishable from many other causes of fever in HIV–infected individuals.15–18 In many regions, malaria is diagnosed simply on the basis of fever, and drugs are administered without confirmatory testing. Consequently, malarial fever may be overestimated and inappropriately treated if diagnosed without blood film examination.
It can be predicted that responses to antimalarial therapy will be decreased in immunosuppressed individuals coinfected with HIV and malaria living in regions of stable transmission. This may be either because of increased susceptibility to malaria reinfection, or because of recrudescence of infection, since antimalarial therapy is most effective in individuals who already have some acquired immunity.
Effect of HIV on transmission of malaria – No direct evidence has been found to suggest that HIV alters malaria transmission. Investigators have speculated that because HIV infection increases parasitemia and reduces the response to therapy, it will increase the reservoir of infection in the human population and hence increase transmission. In an area with high HIV prevalence (30%), it has been estimated that 20% of malaria infection could be attributable to HIV, assuming gametocytemia parallels asexual parasitemia.
Thus, HIV and malaria coexist in regions with the most poorly developed health surveillance systems, making the public health scale of any interaction difficult to determine. Large sections of the populations of countries with generalized HIV epidemics (>1% HIV prevalence in the general population) and a high malaria burden are at particular risk of coinfection. In low–level and concentrated HIV epidemics (<1% HIV prevalence in the general population), specific population subgroups are likely to be most at risk of coinfection by virtue of their behavior.
1. UNAIDS Joint United Nations Programme on HIV/AIDS. AIDS Epidemic Update. UNAIDS, Geneva 2005 Dec.
2. Froebel J, et al. Activation by malaria antigens renders mononuclear cells susceptible to HIV infection and re–activates replication of endogenous HIV in cells from HIV–infected adults. Parasite Immunol 2004;26:213–7.
3. Xiao L, et al. Plasmodium falciparum antigen–induced human immunodeficiency virus type 1 replication is mediated through induction of tumour necrosis factor–alpha. J Infect Dis 1998;177:437–45.
4. Vlahov D, et al. Prognostic markers for AIDS and infectious disease death in HIV–1 infected injection drug users: Plasma viral load and CD4+ cell count. JAMA 1998;279:35–40,47).
5. Graziosi C, Soudeyns H, Rizzardi GP, Bart P–A and Chapuis A, Pantaleo G. Immunopathogenesis of HIV infection. AIDS Res. Hum. Retroviruses 1998;14:S135–S142.
6. Kublin J, Jere C, Miller W, Hoffman N, Chimbiya N, Pendame R, et al. Effect of Plasmodium falciparum malaria on concentration of HIV–1–RNA in the blood of adults in rural Malawi: a prospective cohort study. Lancet 2005;365:233–240.
7. Greenberg AE, Nguyen–Dinh P, Mann JM, Kabote N, Colebunders RL, Francis H, et al. The association between malaria, blood transfusions, and HIV seropositivity in a paediatric population in Kinshasa, Zaire. JAMA 1988;259:545–549.
8. Moore A, Herrera G, Nyamongo J, Lackritz E, Granade T, Nahlen B, et al. Estimated risk of HIV transmission by blood transfusion in Kenya. Lancet 2002;358:657–660.
9. Snow RW and Omumbo JA. Malaria mortality in sub–Saharan Africa. In: Disease and Mortality in Sub–Saharan Africa Bos E, Jamison D and Baingana F (Eds), World Bank Publications, Oxford, in press.
10. ter Kuile FO, Parise ME, Verhoeff FH, Udhayakumar V, Newman RD, van Eijk AM, et al. The burden of co–infection with human immunodeficiency virus type 1 and malaria in pregnant women in sub–Saharan Africa. Am. J. Trop. Med. Hyg. 2004;71(Suppl. 2):41–54.
11. Steketee RW, Wirima JJ, Slutsker L, Roberts JM, Khoromana CO and Heymann DL. Malaria parasite infection during pregnancy and at delivery in mother, placenta and newborn: Efficacy of chloroquine and mefloquine in rural Malawi. Am. J. Trop. Med. Hyg. 1996;55(Suppl. 1):24–32.
12. Steketee RW, Nahlen BD, Ayisi J, van Eijk A and Misore A. HIV and malaria overlap and do interact in sub–Saharan African pregnant women. XII International Conference on AIDS. Geneva June 1998 [abstract 145].
13. Verhoeff FH, Brabin BJ, Hart CA, Chimsuku L, Kazembe P and Broadhead RL. Increased prevalence of malaria in HIV–infected pregnant women and its implications for malaria control. Trop. Med. Int. Health 1999;4:5–12.
14. Parise ME, Ayisi JG, Nahlen BL, Schultz LJ, Roberts JM, Misore A, et al. Efficacy of sulfadoxine–pyrimethamine for prevention of placental malaria in an area of Kenya with a high prevalence of malaria and human immunodeficiency virus infection. Am. J. Trop. Med. Hyg. 1998;59:813–822.
15. Cohen C, Karstaedt A, Frean J, Thomas J, Govender N, Prentice E, et al. Increased prevalence of severe malaria in HIV–infected adults in South Africa. Clin. Infect. Dis. 2005;41:1631–1637.
16. Grimwade K, French N, Mbatha D, Zungu D, Dedicoat M and Gilks C. HIV infection as a cofactor for severe falciparum malaria in adults living in a region of unstable malaria transmission in South Africa. AIDS 2004;18:547–554.
17. Diallo A, Zerbo G, Sawadogo A and Guiguemide T. Severe malaria and HIV in adult patient. 64(4):345-350. Méd. Trop. 2004;64:1–6.
18. Nwanyanwu OC, Kumwenda N, Kazembe PN, Jemu S, Ziba C, Nkhoma WC, et al. Malaria and human immunodeficiency virus infection among male employees of a sugar estate in Malawi. Trans. R. Soc. Trop. Med. Hyg. 1997;91:567–569.
eMedinewS Try this it Works
Quick pointers on MDI use
Dr Good Dr Bad
Shake the MDI well before use.
Using the MDI is similar to smoking a cigarette, except that the "smoke" is inhaled instead of exhaled.
If after inhaling, you observe smoke exiting the top of the MDI, it means that little medication has entered your body; you may need another dose.
If smoke exits rather than enters the MDI more than two times a week, return to the office for a full demonstration.
Situation: An elderly male had an A1C of 6.5%
Dr Bad: Its very good control.
Dr Good: Reduce the dose of drugs.
Lesson: A1C goal should be set somewhat higher for older patients and those with a limited life expectancy. The American Geriatrics Society suggests an A1C target of 8 percent for frail older adults and individuals with life expectancy of less than five years.(Source: Ann Intern Med 2008;149:11.)
A patient was brought to the ICU in cardiogenic shock.
Reaction: Oh my God! Why didn't you take him for emergency angiography and subsequent PTCA.
Make Sure to perform an emergency diagnostic angiography and mechanical revascularization with PTCA in patients of cardiogenic shock. Results of NRMI–2, an ongoing trial suggest that this intervention is much better than thrombolytic therapy in such patients.
Laughter the best medicine
Good I am not a Gynecologist
A cardiac specialist died and at his funeral the coffin was placed in front of a huge mockup of a heart made up of flowers. When the pastor finished with the sermon and eulogy, and after everyone said their good–byes, the heart opened, the coffin rolled inside and the heart closed. Just then one of the mourners burst into laughter. The guy next to him asked: "Why are you laughing?" "I was thinking about my own funeral" the man replied.
"What’s so funny about that?"
"I’m a gynecologist."
Formulae in Imaging
Ultrasound is not highly sensitive for determining the number or size of stones in the gallbladder. This is especially true for very small stones approaching 1 or 2 mm in diameter that frequently, when present in large numbers, can appear on ultrasonography as one large stone)
Based on its acceptability and low cost, we typically use amoxicillin 500 mg thrice–daily for 5–7 days as initial therapy for acute otitis media (AOM) in patients without penicillin allergy.
Anemia with a high reticulocyte count reflects an increased erythropoietic response to continued hemolysis or blood loss.
Milestones in Neurology
Hermann Oppenheim (1858–1919) was a leading German neurologist. He studied medicine at the Universities of Berlin, GÖttingen and Bonn. He started his career at the Charité–Hospital in Berlin as an assistant of Karl Westphal. In 1891, Oppenheim opened a successful private-hospital in Berlin. His expertise involving brain disease led directly to the first successful removal of a brain tumor, which was performed by R. KÖhler. Together with Fedor Krause (1857–1937), he reported the first successful removal of a pineal tumor. He coined the term dystonia musculorum deformans for a type of childhood torsion disease he described, which was later to became known as the 'Ziehen–Oppenheim syndrome' (named along with psychiatrist Theodor Ziehen (1862–1950).
Mistakes in Critical Care
Write legibly: Aminophylline can be misread as Amitriptyline
GREEN TEA and SODIUM META SILICATE
Green Tea (Camellia sinensis) when used along with Unique Health Supplements like Sodium Metasilicate, Sodium, Phosphate and Ammonium Chloride may help boost Body Metabolism to aid weight loss, block allergic response, slow down the growth of tumours, protect bones, fight bad breath, improve Skin, protect against Alzheimer's and Parkinson’s disease and even delay the onset of Diabetes. The Combination is known to reduce the VLDL and LDL Levels and thus reduce the incidence of Stroke and Heart disease.
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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.
The second eMedinewS–revisiting 2010 conference will be held at Maulana Azad Medical College, New Delhi on January 2, 2011. The event will have a day–long CME, Doctor of the Year awards, cultural hangama and live webcast. Suggestions are invited.
Also, if you like emedinews you can FORWARD it to your colleagues and friends. Please send us a copy of your forwards.
Padma Shri Awardee Dr. K.K. Aggarwal ji, We are very much glad to learn that finally your hard work towards the services of the society in various ways have been recognized and you have been awarded with Padma Shri, India’s 4th highest civilian award. Please accept our hearty congratulations on this happy occasion.
You are a well known person in the country with splendid achievements in the fields of clinical practice, research and social welfare. Your contribution to the society as senior Physician Cardiologist and Dean Board of Medical Education Moolchand Medcity and as the President of the Heart Care Foundation of India is well known. You are a prolific writer having written several articles on Vedic sciences and their relevance to the field of medicine. Several of these have been published in leading newspapers of the country. You are a pioneer in public health education, who has taken upon himself the mammoth task of updating the knowledge and skills of the medical fraternity. Our Samaj feels proud on you achievements and we pray to the God that further achievements may continue in your life. Once again congratulating you on this occasion. We are, Yours faithfully, For All India Vaish Federation- Delhi Pradesh: K. D. Baheti, President, 9212005601
Heartiest congratulations for getting Padma award. We all are proud of you: Sadique
Dr. Aggarwal, hearty congratulations on well deserved honour of Padma Shree 2010: Col. SV Ramany, CREMA
Heartiest congratulations to you, Dr. Aggarwal. You have not only made the medical fraternity proud, but have also made the whole country proud by making your specialised services available to the commonest of the common man and you have truly immortalised and lived upto the motto of Swami Vivekanand by serving God in man: Dr. SC Vats