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  From the Desk of Editor–in–Chief
Dr KK Aggarwal

Padma Shri and Dr B C Roy National Awardee
Dr KK Aggarwal
President, Heart Care Foundation of India; Sr Consultant Physician, Cardiologist and Dean Medical Education Moolchand Medcity; Chairman Ethical Committee Delhi Medical Council; Chairman (Delhi Chapter) International Medical Sciences Academy; Hony Director IMA AKN Sinha Institute (08–09); Hony Finance Secretary National IMA (07–08); Chairman IMA Academy of Medical Specialties (06–07); President Delhi Medical Association (05–06), President IMA New Delhi Branch (94–95, 02–04); Editor in Chief IJCP Group of Publications & Hony. Visiting Professor (Clinical Research) DIPSAR


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  Editorial …

15th April 2012, Sunday

Five Things Physicians and Patients should question (Part 5)

American College of Radiology

  • Don’t do imaging for uncomplicated headache. Imaging headache patients absent specific risk factors for structural disease is not likely to change management or improve outcome. Those patients with a significant likelihood of structural disease requiring immediate attention are detected by clinical screens that have been validated in many settings. Many studies and clinical practice guidelines concur. Also, incidental findings lead to additional medical procedures and expense that do not improve patient well–being.
  • Don’t image for suspected pulmonary embolism (PE) without moderate or high pre–test probability. While deep vein thrombosis (DVT) and PE are relatively common clinically, they are rare in the absence of elevated blood d–Dimer levels and certain specific risk factors. Imaging, particularly computed tomography (CT) pulmonary angiography, is a rapid, accurate and widely available test, but has limited value in patients who are very unlikely, based on serum and clinical criteria, to have significant value. Imaging is helpful to confirm or exclude PE only for such patients, not for patients with low pre–test probability of PE.
  • Avoid admission or preoperative chest x–rays for ambulatory patients with unremarkable history and physical exam. Performing routine admission or preoperative chest x–rays is not recommended for ambulatory patients without specific reasons suggested by the history and/or physical examination findings. Only 2 percent of such images lead to a change in management. Obtaining a chest radiograph is reasonable if acute cardiopulmonary disease is suspected or there is a history of chronic stable cardiopulmonary disease in a patient older than age 70 who has not had chest radiography within six months.
  • Don’t do computed tomography (CT) for the evaluation of suspected appendicitis in children until after ultrasound has been considered as an option. Although CT is accurate in the evaluation of suspected appendicitis in the pediatric population, ultrasound is nearly as good in experienced hands. Since ultrasound will reduce radiation exposure, ultrasound is the preferred initial consideration for imaging examination in children. If the results of the ultrasound exam are equivocal, it may be followed by CT. This approach is cost–effective, reduces potential radiation risks and has excellent accuracy, with reported sensitivity and specificity of 94 percent.
  • Don’t recommend follow-up imaging for clinically inconsequential adnexal cysts. Simple cysts and hemorrhagic cysts in women of reproductive age are almost always physiologic. Small simple cysts in postmenopausal women are common, and clinically inconsequential. Ovarian cancer, while typically cystic, does not arise from these benign–appearing cysts. After a good quality ultrasound in women of reproductive age, don’t recommend follow–up for a classic corpus luteum or simple cyst <5 cm in greatest diameter. Use 1 cm as a threshold for simple cysts in postmenopausal women.

For More editorials…

Dr KK Aggarwal
Group Editor in Chief

  eMedinewS Audio PostCard

Stay Tuned with Padma Shri and Dr BC Roy National Awardee Dr KK Aggarwal

Why BP should be kept

Audio PostCard
    Photo Feature (from the HCFI Photo Gallery)

First Mega Ajmer Health Camp attracts 72,000 patients

For the first time in the history of India, a camp attracted over 72,000 people.

Dr K K Aggarwal
    National News

India one of the top performing clean energy economies: report

With Indian receiving USD 10.2 billion investments in clean energy, the country has emerged as one of the top performing clean energy economies in the 21st century, an eminent American non–profit organisation said in a report. The Pew Charitable Trust, in its report, said India’s clean energy sector continued to flourish in 2011, with private investment increasing 54 per cent to USD 10.2 billion, placing the country at number 6 spot among the G–20 nations. This was the second highest growth rate among the G–20 nations, The Pew Energy said in its research report released here yesterday. "On a number of measures, India has been one of the top performing clean energy economies in the 21st century, registering the fifth highest five–year rate of investment growth and eighth highest in installed renewable energy capacity," said Phyllis Cuttino, director of Pew’s Clean Energy Program. "The country holds great potential in the Asia/Oceana region and will continue to be a top destination for private investment this year," she said. (Source: Deccan Herald, 12 April 2012)

For comments and archives

Certificate courses in 2D and 3D Echocardiography/Fellowship Diploma in non invasive cardiology: Contact Dr KK Aggarwal, Moolchand Medcity, email: emedinews@gmail.com

    International News

FDA announces safety label changes to finasteride

The product labels for finasteride 1 mg and finasteride 5 mg are being revised to note that some sexual adverse effects may continue after the drugs are discontinued; the US Food and Drug Administration (FDA) announced April 11. The new label changes include:

  • a revision to the 1 mg tablet label to include libido disorders, ejaculation disorders, and orgasm disorders that continued after discontinuation of the drug,
  • a revision to the 5 mg tablet label to include decreased libido that continued after discontinuation of the drug, and
  • a revision to both the 1 mg and 5 mg labels to include a description of reports of male infertility and/or poor semen quality that normalized or improved after drug discontinuation.

In 2011, both 1 mg and 5 mg labels were revised to include erectile dysfunction that continued after drug discontinuation. The FDA approved finasteride 5 mg in 1992 to treat benign prostatic hyperplasia and finasteride 1 mg in 1997 to treat androgenic alopecia in men. Finasteride 1 mg is also used off–label to treat unwanted facial hair in women. It has also been studied for chemoprevention of prostate cancer and is used off–label for this.

For comments and archives

FDA: Medtronic CRT–Ds Get NYHA 2 HF indication

The US Food and Drug Administration (FDA) has approved an expanded indication for Medtronic’s cardiac resynchronization therapy with implantable cardioverter–defibrillator (CRT–D) devices. The new labeling permits the devices to be used in patients with mildly symptomatic heart failure (NYHA class 2), with a left ventricular ejection fraction (LVEF) of <30%, left bundle branch block (LBBB), and a QRS duration >130 ms. (Source: Medscape)

For comments and archives

ECG picks up heart trouble in healthy seniors

Abnormal electrocardiography findings in otherwise symptom–free older patients may indicate heightened risk for cardiovascular events, researchers said. (Source: Medpage Today)

For comments and archives

Decision aid leads more patients to skip stress tests

Chest–pain patients at low risk for acute coronary syndrome are more engaged in decisions about their care and less likely to undergo stress testing if they read a decision aid that clearly explains their risk and management options, according to results of a new study published online April 10, 2012 in Circulation: Cardiovascular Quality and Outcomes. (Source: Medscape)

For comments and archives

    Twitter of the Day

@DrKKAggarwal: Earth Eating – PICA Consumption of non food items by children, in medical terms is called pica.

@DeepakChopra: Radiate peace, harmony, love, and laughter from your heart.

    Spiritual Update

(Dr KK Aggarwal, Group Editor in Chief, IJCP Group of Publications and eMedinews)

Baisakhi and Sikh Spirituality

Baisakhi is the day when their 10th Guru, Guru Gobind Singhji started ‘Khalsa Panth’. Khalsa means a baptized Sikh (pure one or GURU’s very own). It is the way of pure living. After the line of corporeal gurus was brought to an end by Guru Gobind Singh, the Khalsa Panth installed its own leader under the abiding guidance of Guru Granth Sahib.

The Sikh Salutation "Wahe Guru Ji ka Khalsa: Wahe Guru Ji Ki Fateh"

For comments and archives

    Infertility Update

(Dr Kaberi Banerjee, IVF expert, New Delhi)

What are the psychological effects of the Multiples on a family?

Many women with a multiple pregnancy do well, their families may experience significant stress. Even if medical problems are overcome and the infants survive without disability, the effect of multiple births on family life is profound and life–altering. The impact of a multiple birth clearly affects the parents, but also the babies, other siblings, and the extended family. Financial stresses may be overwhelming. Obvious additional costs include feeding, clothing, housing, and caring for multiple children.

For comments and archives

    Tat Tvam Asi………and the Life Continues……

(Dr N K Bhatia, Medical Director, Mission Jan Jagriti Blood Bank)

Can a donor do his work after donating blood?

Of course. The donor can resume his routine work after resting for 20–30 minutes. But, he should preferably avoid doing very hard work for a few hours.

For comments and archives

    An Inspirational Story

(Dr. GM Singh)

God wanted me to tell you

"Everything that is going wrong in your life today shall be well with you this year.

You have been destined to make it and you shall surely achieve all your goals this year. For the remaining months of this year (2012), all your agonies will be diverted, and victory and prosperity will be incoming in abundance.

Today, God has confirmed the end of your sufferings, sorrows, and pains, because HE that sits on the throne has remembered you. He has taken away the hardships and given you JOY. He will never let you down.

I knocked at heaven’s door this morning, God asked me… "My child! What can I do for you?" And I said, "Father, please protect and bless the person reading this message"… God smiled and answered… "Request granted."

For comments and archives

    Earthquakes––safety tips

(Dr GM Singh)

Earthquakes are a common occurrence, rumbling below Earth’s surface thousands of times every day. But major earthquakes are less common. Here are some things to do to prepare for an earthquake and what to do once the ground starts shaking.

Safety Tips

Have an earthquake readiness plan.
Consult a professional to learn how to make your home sturdier, such as bolting bookcases to wall studs, installing strong latches on cupboards, and strapping the water heater to wall studs.
Locate a place in each room of the house that you can go to in case of an earthquake. It should be a spot where nothing is likely to fall on you.
Keep a supply of canned food, an up–to–date first aid kit, 3 gallons (11.4 liters) of water per person, dust masks and goggles, and a working battery–operated radio and flashlights.
Know how to turn off your gas and water mains.

If Shaking Begins

Drop down; take cover under a desk or table and hold on.
Stay indoors until the shaking stops and you’re sure it’s safe to exit.
Stay away from bookcases or furniture that can fall on you.
Stay away from windows. In a high–rise building, expect the fire alarms and sprinklers to go off during a quake.
If you are in bed, hold on and stay there, protecting your head with a pillow.
If you are outdoors, find a clear spot away from buildings, trees, and power lines. Drop to the ground.
If you are in a car, slow down and drive to a clear place. Stay in the car until the shaking stops.

    Microbial World: The Good and the Bad They Do

(Dr Usha K Baveja, Prof. and Senior Consultant Microbiology, Medanta – The Medicity)

Modes of transmission of microbes

Oral–fecal transmission

Enteric pathogens like salmonella, Shigella and Cholera vibrio are spread in various ways, including through the ingestion of contaminated food; through direct person–to–person contact; and through contact with infectious waste, usually feces. Bad hand hygiene is the most common cause of transmission of these pathogens amongst health care workers.

For comments and archives

    Cardiology eMedinewS

HbA1c Of 6% or Less Achieved With Bariatric Surgery. Read More

Average Cholesterol Levels May Vary Widely By Country. Read More

Fish Oil May Not Prevent CV Problems In People With Preexisting Heart Disease. Read More

Before Putting A Stent One Should Have One More External Opinion
Read More

    Pediatric eMedinewS

New Reference Norms for Cardiovascular Risk Factors in Children
Read More

Probiotic L Reuteri May Protect Children from Diarrhea Read More

Peptide Vaccine Shows Promise In Childhood Gliomas Read More

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    IJCP Special

Dr Good Dr Bad

Situation: A diabetic patient with uncontrolled diabetes came with cognitive impairment.
Dr Bad: This is dementia and nothing can be done.
Dr Good: Control your blood sugar.
Lesson: An analysis of over 3,000 individuals with established type 2 diabetes demonstrates a clear age–adjusted inverse relationship between cognitive function and the degree of chronic hyperglycemia as measured by A1c level (Diabetes Care 2009;32:221–6).

For comments and archives

Make Sure

Situation: A patient developed dangerous arrhythmias in the immediate post CABG procedure.
Reaction: Oh my God! Why did you not correct his K+ value of 3.4 pre–operatively?
Lesson: Make Sure that pre–operative K+ value of <3.5 is corrected. Cardiac surgery patients who have serum potassium levels below 3.5 mmol/L are at high risk for perioperative arrhythmia.

For comments and archives

    Legal Question of the day

(Prof. M C Gupta Advocate & Medico–legal Consultant)

Q. Does the SDM have power to waive off the requirement for postmortem examination?


  • With whom the power to waive autopsy lies, can vary from state to state because police is a state subject. It is the duty of the police to make a request for postmortem examination. A doctor cannot perform autopsy unless there is a written request from the police. The police would make a request only as per rules applicable in the state.
  • The rules in Punjab are as follows:

    "The Punjab police rules (25:38)7 state that if a body is unidentified, the officer making the investigation shall record a careful description of it, giving all marks, peculiarities, deformities, other distinctive features and shall take the finger impressions. In addition to taking all other reasonable steps to secure identification he shall, if possible, have it photographed. In cases where such action appears desirable, a description should be published in the criminal intelligence Gazette. Unidentified body should be handed over to any charitable society willing to accept them, and if no such society comes forward, they should then be buried or burnt. In Delhi, the police sends telegram message called "Hue and cry notice’ to various police head–quarters of the country. The "Hue and cry notice’ contained brief description of the identification features of the deceased. The body is preserved in the mortuary for 72 hours from the time telegram message is sent. If the body is not claimed even after 72 hours, the police is then legally authorized to dispose of the body. But if the police think that the body maybe identified by the relatives, it should be preserved for longer time till relatives come and claim the body. The expenditure on the disposal of body in unidentified cases are borne by the police department. This is applicable in medicolegal cases who have died outside hospital or inside the hospital.

    Again as per Punjab police rule (25:36)7 an investigating officer is empowered by the law to waive off the postmortem in case he thinks that there is no foul play and death is due to natural cause.”

    In: Procedure for Preservation and Disposal of Dead Bodies in Hospital

    T. Millo, Arun Agnihotri, Shakti Gupta, T.D. Dogra

    http://cyberlectures.indmedica.com/show/125/3/Procedure_for_Preservation_ and_Disposal_of_Dead_Bodies_in_Hospital
  • The rules in Delhi are as follows:

    "In Delhi, the Assistant commissioner of police is authorized to waive off the postmortem on the recommendation of the investigating officer. However, the autopsy surgeon can recommend to the investigating officer for waiving off the case if he think it is a case of natural death, but the final authority rests with the Assistant commissioner of police."

    Ref: Millo et al., as above.
  • The legal principles involved are as follows:
    • There may be situations when performing an autopsy may not be necessary or practical and the requirement for autopsy may have to be waived off. The role of police is to maintain law and order and to investigate crime as per rules and, after investigation, to file the charge sheet or the closure report before the appropriate judicial authority for passing appropriate judicial orders.
    • Police is bound to get a post mortem examination done as per departmental rules and has little or no discretion in the matter.
    • When death occurs and a body is likely to be disposed/cremated, the judicial authority has powers to grant a request for post mortem and to issue necessary orders to the police to get an autopsy done.
    • It stands to reason that if the judicial authority has power to order an autopsy, it should also have power to waive the requirement for autopsy when the circumstances so demand.

For comments and archives

    Quote of the Day

(Dr GM Singh)

When you find yourself stressed, ask yourself one question: Will this matter in 5 years from now? If yes, then do something about the situation. If no, then let it go. Catherine Pulsifer

    Lab Update

(Dr Arpan Gandhi and Dr Navin Dang)

Tumor marker tests

Tumor markers are chemicals made by tumor cells that can be detected in your blood. But tumor makers are also produced by some normal cells in the body and levels may be significantly elevated in noncancerous conditions. This limits the potential for tumor marker tests to help in diagnosing cancer. The best ways to use tumor markers in diagnosing cancer has not been determined. And the use of some tumor marker tests is controversial.

Examples of tumor markers include prostate–specific antigen (PSA) for prostate cancer, cancer antigen 125 (CA 125) for ovarian cancer, calcitonin for medullary thyroid cancer, alpha–fetoprotein (AFP) for liver cancer and human chorionic gonadotropin (hCG) for germ cell tumors, such as testicular cancer and ovarian cancer.

    Mind Teaser

Read this…………………

What’s the leading cause of death for women?

A. Cancer
B. Heart disease
C. Stroke
D. Accidental injuries
E. Diabetes

Yesterday’s Mind Teaser: Which of the following is not fermented by colonic bacteria?

a. Lignin
b. Pectin
c. Cellulose
d. None of above

Answer for Yesterday’s Mind Teaser: Lignin

Correct answers received from: Raju Kuppusamy, Dr Deepali chatterjee, Yogindra Vasavada,
Dr Thakor Hitendrsinh G, Dr Chandresh Jardosh, Dr Jainendra Upadhyay, Dr U Gaur, Rameshwar prasad.

Answer for 13th April Mind Teaser: a) Complete proctocolectomy and Brook’s ileostomy
Correct answers received from: Dr K V Sarma.

Send your answer to ijcp12@gmail.com

   Laugh a While

(Dr GM Singh)

Expensive Operation

A woman was having a medical problem – her husband’s snoring. So she called the doctor one morning and asked him if there was anything he could do to relieve her "suffering." "Well, there is one operation I can perform that will cure your husband, but it is really rather expensive. It will cost $1000 down and payments of $450 for 24 months, plus payments for extras."

"My goodness!" the woman exclaimed, "it sounds like leasing a new sports car!"

"Hmm," the doctor murmured, "too obvious, huh?"

    Medicolegal Update

(Dr Sudhir Gupta, Additional Prof, Forensic Medicine & Toxicology, AIIMS)

What is the right to reject medical interventions?

The Nancy Beth Cruzan automobile accident case

Although mentally incapacitated patients have the same right, the Supreme Court allowed states to impose restrictions on how explicit and specific the patient’s prior wishes had to be. After this court ruling, some of Cruzan’s friends provided evidence that she had previously expressed wishes that she would want artificial feedings discontinued in such a scenario. As a result of this testimony, her feedings were terminated. Mentally competent patients need not be terminally ill to exercise this right to refuse interventions; they have the right regardless of health status. In addition, the right applies equally to withholding proposed treatments and to discontinuing initiated treatments. Of note, this right to refuse medical care does not imply a correlative right to demand treatment.

For comments and archives

    Public Forum

(Press Release for use by the newspapers)

S. moorei responsible for bad breath

Solobacterium moorei, a gram–positive anaerobic bacillus originally isolated from human feces has been shown to be responsible for chronic bad breath, or halitosis. Persistent bad breath, is often caused by the breakdown of bacteria in the mouth, producing foul–smelling sulfur compounds that reside on the surface of the tongue.

According to Betsy Clark, at the State University of New York at Buffalo School of Dental Medicine in a study of 21 people with chronic bad breath and 36 subjects without this problem, S. moorei was found in every patient who had halitosis compared with only four control subjects. Brushing twice a day with antibacterial toothpaste and using a toothbrush with a built–in tongue scraper can eliminate chronic bad breath. Bad oral hygiene is also associated with increased risk of heart disease said Dr KK Aggarwal, Padma Shri and Dr BC Roy National Awardee and President, Heart Care Foundation of India.

Identifiable cause of bad breath is periodontal disease, gingivitis, postnasal drip, systemic illness. The oral sources of bad breath may be alleviated by:

  1. Proper dental care and oral hygiene.
  2. Gentle cleaning of the posterior portion of the dorsum tongue with a plastic tongue cleaner.
  3. Rinsing and deep gargling with an effective mouthwash. One should extend the tongue while gargling.
  4. Eating fibrous foods especially at the breakfast.
  5. Brief gum chewing for 5 minutes if the mouth is dry, or after meals, especially with high protein intake.
  6. Sufficient water intake.
  7. Antibiotics, if bacteria are present for temporary relief.

One should floss their teeth properly, smell the floss between each passage, and clean the malodorous sites carefully. Flossing should include cleaning the posterior surface of the back teeth as well.

Effective tongue brushing requires access to the deep posterior part of the dorsal tongue; odors often lurk for 10 cm or more from the tip of the tongue. The basic idea is to sweep away the mucus, desquamated cells and other debris.

Some mouthwashes contain components that may harm soft oral tissues (e.g., alcohol, sodium dodecyl sulfate, strong oxidizing agents). The most efficacious mouthrinses for short–term use are probably those that contain 0.2 percent chlorhexidine gluconate.

The best time to use a mouthwash is before bedtime since the residue of the mouthrinse may remain in the mouth for a longer period of time and have a greater effect. Bacterial activity leading to bad breath is greatest during the nighttime, when saliva flow is practically zero and microbial activity is highest.

    Readers Responses
  1. Dear Sir, Thnaks for the useful information. Regards: Dr Priya
    Forthcoming Events
Dr K K Aggarwal

Dil Ka Darbar

September 23, 2012 at 9:00 AM – 6:00 PM
Tal Katora Indoor Stadium, Connaught Place, New Delhi, 110001

A non stop question answer session between all the top cardiologists of the NCR region and the mass public. Event will be promoted through hoardings, our publications and the press. Public health discussions

    eMedinewS Special

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