eMedinews
Address: 39 Daryacha, Hauz Khas Village, New Delhi, India. e-Mail: drkk@ijcp.com, Website: www.ijcpgroup.com

Dr K K Aggarwal

Dr KK Aggarwal
Dr BC Roy Awardee
Sr Physician and Cardiologist,
Moolchand Medcity
President, Heart Care
Foundation of India
Gp Editor-in-Chief,
IJCP Group
Member,
Delhi Medical Council
Director, IMA AKN Sinha Institute
(08-09)

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 16th January Saturday 2010

Dear Colleague,

Rotate antibiotics

Serious infections with multidrug-resistant organisms are associated with significant morbidity, mortality, and healthcare-related costs, especially in the ICUs.

Interventions to control spread of these resistant bacteria include optimizing antibiotic selection and dosing, strict adherence to infection control practices, and use of antimicrobial combinations.
Restricting or eliminating the use of an antibiotic or antibiotic class to which selected organisms demonstrate increasing bacterial resistance can lead to recovery of in vitro activity.

Restricted use of antibiotics prevents development of resistance and the antibiotic can be reintroduced at a later time. This is called 'antibiotic cycling or rotation'.

The practice involves withdrawal of an antibiotic or antibiotic class from general use for a defined period of time. They are then substituted with antibiotics from a different class possessing comparable spectrum of activity but (ideally) different mechanisms of antimicrobial resistance (e.g. exchange between select beta-lactams, fluoroquinolones, and aminoglycosides). Two or more antibiotics may be targeted at one time. The period of rotation should occur on a scheduled basis and the original agent(s) must be reintroduced.


Dr KK Aggarwal
Chief Editor


News: American Heart Association, Orlando, FL  November 14-18.
1. Over the long term, diuretics fight hypertension as well as newer, more expensive blood pressure drugs. A 10-year analysis of the ALLHAT study confirmed continued lack of superiority of calcium channel blockers and ACE inhibitors over thiazide-type diuretics. Any differences between groups for mortality and major cardiovascular and renal outcomes initially seen in the main five-year analysis were lost by 10 years. The only exception was a persistent 34% elevated heart failure risk with amlodipine. (Dr William Cushman, VA Medical Center, Memphis, Tenn).

2. Percutaneous coronary intervention (PCI) may be worse for the brain than coronary artery bypass grafting (CABG) without the heart-lung machine. Although the safety profiles were similar overall, 7.5 years after revascularization off-pump CABG patients showed neurocognitive performance at least 25% better than stent patients. The findings are from a post-hoc analysis of the randomized Octopus trial. (Dr Jakub J. Regieli, MD, University Medical Center Utrecht, The Netherlands).

3. One year of daily gym class increased fat-free mass by 2.6% among children in a poorer neighborhood compared with youngsters who got twice-weekly classes. That brought them close to the baseline level of children in a more affluent area in a randomized trial. A second analysis of the same trial revealed an increase in endothelial progenitor cells overall with daily exercise, along with a trend for reduced body mass index. Primary prevention by means of increasing physical activity should start in childhood. (Dr Claudia Walther, University of Leipzig, Germany).

4. Ancient Egyptians had atherosclerosis too. Of the 16 mummies housed in the Egyptian National Museum of Antiquities in Cairo that had vascular tissue available for CT examination, nine had probable or definite evidence of calcification in the arteries.The calcification in these arteries looks just like it does in modern humans. (Dr Randall Thompson,of the Mid America Heart Institute in Kansas City, Nov. 18 issue of JAMA)

5. Patients with ST elevation myocardial infarction (STEMI) appear to have similar outcomes regardless of whether they undergo a first percutaneous coronary intervention (PCI) at a center with onsite surgical backup or not.
At one year, those who underwent PCI at a center without onsite surgical capabilities had a mortality rate that was similar to those who had the procedure done at a center with backup (8.58% versus 9.41%,) (Dr Ather Anis, Winchester Cardiology & Vascular Medicine in Winchester, Va).

Dr Good Dr Bad
Situation: A child on penicillin for rheumatic fever prophylaxis undergoing an invasive dental procedure required infective endocarditis prophylaxis.
Dr Bad: Give amoxicillin.
Dr Good: You need clindamycin, cephalexin, or azithromycin.
Lesson: If patients are receiving antibiotics for other indications at the time that dental or invasive procedures are being undertaken, an alternate antibiotic of a different class is often chosen.

Make Sure
Situation: In a hospital setting gentamycin resistance was becoming a problem.
Reaction! Oh My God, you should have done an antibiotic switch.
Make sure: Antibiotic switch policy is adapted in such settings where selected antibiotics are withdrawn for six months and switched to similar but antibiotics with different mechanisms of resistance. (Pharmacotherapy 2004;24:224S.)

Mistakes in critical care
The possibility of an adverse drug event should always be borne in mind when evaluating an elderly individual; any new symptom should be considered drug-related until proven otherwise.

Milestones in Neurology
Edward Flatau was a Polish neurologist. He published a human brain atlas in 1894, wrote a fundamental book on migraines (1912), established the localization principle of long fibers in the spinal cord (1893), and with Sterling (1911) published an early paper on progressive torsion spasm in children and suggested that the disease has a genetic component.

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 mock up 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."

SMS of the day: Anemia
Initial tests for anemia are TLC, DLC, platelet count and reticulocyte count.

Question of the day
Can IBD occur in children or the elderly?
Most cases of ulcerative colitis and Crohn's disease have their onset between ages 15 and 40. Some suggest a bimodal age distribution for both disorders with a second peak between age 50 and 80.It is not clear whether this second peak relates to greater susceptibility to disease with increased age, the late expression of an earlier environmental exposure or to confusion with underlying vascular disease. Approximately 20% of patients with IBD develop symptoms as children or teenagers (younger than age 18). The development of IBD early in life has implications that are not encountered in adults. (
Source: Gastroenterology 1991;100:350.)

Formula to Practice
Nitrogen balance (g) = Protein intake in g/6.25 - urine urea nitrogen (g) +2.5

Mnemonic to Know
Hyperthyroidism
Remember the following mnemonic when evaluating patients for hyperthyroidism:

S: Sweating
T: Tremor or Tachycardia
I: Intolerance to heat, Irregular menstruation, and Irritability
N: Nervousness
G: Goiter and Gastrointestinal (loose stools/diarrhea)

Quote
Prayer is when you talk to God; meditation is when you listen to God. Diana Robinson

Medilaw
What are the main issues involved in a medical negligence claim?
There are many issues which are related to medical negligence claims, the most common of which are, failed sterilization operations and unsuccessful surgeries amongst others. However, there is a varied field of other issues which the courts deal with; some of them are given in the cases below.

The Complainant had undergone an operation from the defending doctor after an accident. The after effects of the operation were not as desired and after repeated consultation with other doctors; the Complainant filed this complaint against the treating doctor. The court held that the defending doctor had followed all proper medical principles and had not done any wrong. Merely having some bad after-effects or side-effects isn't enough to constitute a claim, there has to be a definite instance of negligence on the part of the doctor in question due to which injury was directly caused.

A Complainant's wife had discovered that she had a boil on her vagina after she had given birth to a child. The wife was a gynecologist herself. The Respondent doctor in this case performed a surgery and then left for some other work with the instructions to be called if anything went wrong. There were some complications which arose when the doctor was called and despite everything he tried, the wife died. The Complainant who was the deceased' husband, filed for medical negligence on part of the doctor, saying that he just wanted to make money and hence ordered for a needless operation due to which the patient's condition worsened. After hearing the contentions of both sides and examining the documents on record, the court held that there was no evidence of any foul play by the doctor and he did everything as per established procedure.
This is another case which shows that mere failure of a procedure does not entail medical negligence.

eMedinewS try this it works: Golden 1 hour
A road traffic accident victim must receive first aid within the first hour and that should involve stoppage of bleeding and fluid resuscitation.
 

Letters to the editor

1. Respected Dr KK, Regards: It is high time, I agree, that Indian Interventional Cardiologist ,in fact every doctor ,should wake up and start fighting against unwarrented angioplasties.Every Cardiology conference should have a debate on this .(Very very few conferences have a debate on this ,this is really SURPRISING). Every angioplasty should have a clear cut lable as to which ACC Guideline  Class Indication this  patient belongs.It is really shameful how this procedure is being misused.Yes ,there are many doctors who do ethical practice and are not fond of simply increasing their counts (of angioplasties.).They should be duly praised and encouraged.Dr.Varesh Nagrath   M.D. Guru -kripa  Clinic, Raghav Nagar, Deoria Sadar, U.P.

2. Dear Dr.Aggarwal, Please accept my heartiest congratulations for the T.P.Junjhanwala National Excellence Award.You thoroughly deserve it for you contribution in teaching to medical fraternity and your amazing energy. Dr.S.K. Parashar

3. Dear Sir,Please accept my heartfelt congratulations for being confered the prestigious T P JUNJHANWALA FOUNDATION 22 NATIONAL EXCELLENCE AWARD for your outstanding contribution to Healthcare services.It is really appreciable to see your affort to educate our fraternity.I would be happy to see you more award in form of Dornacharya  very soon. Dr.Lalit Mohan Joshi. Consultant Cardiac , Delhi Heart and Lung Institute

Humor
A pipe burst in a doctor's house. He called a plumber. The plumber arrived, unpacked his tools, did mysterious plumber type things for a while, and handed the doctor a bill for Rs 12000/-.
The doctor exclaimed, "This is ridiculous! I don't even make that much as a doctor!."
The plumber quietly answered, "Neither did I when I was a doctor." (Send by Dr Arun Jian)

Punjab & Sind
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Aviva
 
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nestle
 
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