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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; 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


Dear Colleague

16th April, 2010 Friday

The pros and cons of PSA screening: Should I screen for PSA or not (Excrpts from The Health Beat)

A PSA test measures the level of a protein prostate–specific antigen, made by cells in the prostate. It is used to detect prostate cancer in its earliest, most curable stage. It is one of the most important tests, however, many experts now are discouraging the use of widespread PSA screening.

Concerns about PSA screening

There is a growing body of evidence that the benefits of PSA screening may not outweigh the potential harm of unnecessary treatment. PSA alert doctors to the presence of cancer, but there is no precise way to determine, definitively, whether the cancers detected would have ever caused symptoms or harm during a man’s lifetime. One study estimated overdetection to rise with age, from 27% at age 55 to 56% by age 75. To be on the safe side, most men with elevated PSA levels will opt for treatment, frequently suffering side effects such as incontinence and impotence.

What the research says

The trials, published in the New England Journal of Medicine in March 2009, had pposite conclusions. The Prostate, Lung, Colorectal, and Ovarian (PLCO) Cancer Screening Trial reported no survival benefit with PSA screening and digital rectal examination, but the European Randomized Study of Screening for Prostate Cancer (ERSPC) found a 20% reduction in prostate cancer deaths. The ERSPC study estimated that for every life saved, 48 men are treated and 1,068 men are screened.

However there is widespread agreement on two major points: overdiagnosis and overtreatment rates are far too high, and there is an urgent need to refine PSA testing to be a more effective screening tool.

The principal investigator of the Prostate Cancer Prevention Trial wrote an editorial in The Journal of the American Medical Association in October 2009 and pointed out that while the amount of prostate cancer diagnosed has risen dramatically since PSA testing began, there has not been a proportional decrease in the number of men with metastatic tumors. Screening may be detecting a disproportionate number of lower–risk cancers, while missing many of the most aggressive tumors, which may advance too rapidly to be found with periodic testing.

What you should know about PSA screening

Screening doesn’t lower your risk of having prostate cancer; it increases the chance you’ll find out you have it.

PSA testing can detect early–stage cancers that a digital rectal examination (DRE) would miss.

A "normal" PSA level of 4 ng/ml or below doesn’t guarantee that you are cancer–free; in about 15% of men with a PSA below 4 ng/ml, a biopsy will reveal prostate cancer. A high PSA level may prompt you to seek treatment, resulting in possible urinary and sexual side effects.

Conditions other than cancer–BPH and prostatitis, for example–can elevate your PSA level.

In the past few years, more and more men who undergo PSA screening and later learn that they have cancer have opted to pursue active surveillance. This strategy involves frequent monitoring of the disease through PSA tests and biopsies–and postponing treatment until the cancer shows signs of increasing its activity. In short, these men choose to live with prostate cancer until it advances, sometimes avoiding potentially life–altering side effects for several years

Dr KK Aggarwal
Padma Shri Awardee and Chief Editor


Photo feature

Padma Shri and Dr B C Roy Awardee, Dr KK Aggarwal and Dr NN Khanna, Chairman of the Asia Pacific Vascular Society and Advisor, Apollo Group of Hospitals releasing a CD featuring excerpts of the 2nd Asia Pacific Vascular Interventional Course held in New Delhi from April 3–5, 2010.

Dr k k Aggarwal

News and views

Approach to Leg Edema of Unclear Etiology (Dr N P Singh- Nanoo)

A common challenge for GPs is to determine the cause and find an effective treatment for leg edema of unclear etiology.

1. The most common cause of leg edema in older adults is venous insufficiency. It is treated with leg elevation, compressive stockings, and sometimes diuretics.

2. The most common cause in women between menarche and menopause is idiopathic edema, formerly known as "cyclic" edema. The initial treatment of idiopathic edema is spironolactone.

3. A common but under–recognized cause of edema is pulmonary hypertension, which is often associated with sleep apnea. Patients who have findings consistent with sleep apnea, such as daytime somnolence, loud snoring, or neck circumference >17 inches, should be evaluated for pulmonary hypertension with an echocardiogram.

The GP may watch an asymptomatic patient with chronic bilateral edema but not ignore a patient with dyspnea or a patient with acute edema (<72 hours).

If the full evaluation could wait for a subsequent visit, the patient should be examined briefly to rule out an obvious systemic cause and basic laboratory tests should be ordered for later review (complete blood count, urinalysis, electrolytes, creatinine, blood sugar, thyroid stimulating hormone, and albumin). (J Am Board Fam Med 2006;19:148–60.)

No pregnancy issues in early natalizumab review

An early check of registry data from women with multiple sclerosis who became pregnant while taking natalizumab does not appear to raise concerns of miscarriages or abnormalities. (Dr Lynda Cristiano, medical director of drug safety at Biogen Idec, Cambridge, Mass at Annual Meeting of American Academy of Neurology).

Heart failure differs in rheumatic arthritis patients

Patients with rheumatoid arthritis had markedly lower left ventricular mass compared with controls. Adjusted mean LV mass by MRI was 119 g in rheumatoid arthritis patients compared with 145 g in controls. (Dr Jon T. Giles, Johns Hopkins University). This represented an 18% difference (April 2010, Arthritis & Rheumatism).

Mnemonic of the Day (Dr Prachi Garg)


Anesthetics (halothane)

Blood transfusions




Foreign travel

Gallstones / Gilbert’s

Homosexual / Hemophilia / Hepatitis

Idiopathic / IVDA (Intravenous drug addicts)

Job – farmers, sewage workers (leptospirosis – Weil’s)

What’s New: Microwave ablation

Two randomized trials found that menstrual flow reduction and patient satisfaction were similar for microwave ablation compared with endometrial resection or thermal balloon ablation. Microwave ablation was associated with a shorter operating time and fewer device failures.

  1. Sambrook AM, Bain C, Parkin DE, et al A randomised comparison of microwave endometrial ablation with transcervical resection of the endometrium: follow up at a minimum of 10 years. BJOG 2009;116:1033.

  2. Sambrook AM, Cooper KG, Campbell MK, et al. Clinical outcomes from a randomised comparison of microwave endometrial ablation with thermal balloon endometrial ablation for the treatment of heavy menstrual bleeding. BJOG 2009;116:1038.

eMedinewS Fact about rheumatoid arthritis

In contrast to RF (rheumatic factor), anti–CCP antibodies are rarely present in the serum of patients with HCV (Hepatitis C virus), infections.

Quote of the day

The gem cannot be polished without friction, nor man perfected without trials. — Chinese proverb

Diabetes Fact

Tumour necrosis factor alpha (TNF–α ) is a potential modulator of adipokines. TNF–α, adiponectin, and insulin form major known regulatory feedback loops that define the long–term glucose uptake control.

Public Forum
(Press Release for use by the newspapers)

15 minutes of sun exposure is a must said Padma Shri and Dr B C Roy Awardee Dr KK Aggarwal, President Heart Care Foundation of India. 

A New research by Dr. Michal Melamed, at Albert Einstein College of Medicine in New York City has discovered that people with low blood levels of vitamin D were found to have a higher incidence of peripheral arterial disease (PAD), potentially dangerous blockages in the leg arteries. The study of nearly 4,900 American adults found more than double the incidence of PAD among those with the lowest levels of vitamin D compared to those with the highest levels. Vitamin D is made when the body is exposed to sunlight. Current guidelines recommend a vitamin D intake of 400 International Units a day for people aged 50 and older. In addition to sunlight, other sources of the vitamin are salmon, sardines, cod liver oil, fortified milk and some fortified cereals. Exposure to sunlight always calls for a balance. Overexposure raises the risk of skin cancer. The recommendation is about 10 to 15 minutes of direct exposure.

Best time to have a heart attack is week days:

Your chances of surviving a cardiac arrest are 13.4 percent worse if you are admitted to the hospital on the weekend versus a weekday, added Dr Aggarwal. Even after taking into account factors such as hospital size and location and the person’s age, gender and other illnesses, the lower survival rate remains the same. A higher death rate among patients admitted on weekends may be due to lack of resources for treating cardiac arrest, according to the study author Richard M. Dubinsky, of the University of Kansas Medical Center in Kansas City. The researchers analyzed a national database containing a 20 percent sampling of all U.S. hospital admissions for cardiac arrest from 1990 to 2004. The analysis included 67,554 admissions. During cardiac arrest, the heart slows or stops working, and brain death can occur in just four to six minutes.

Question of the day

Does hormone therapy cause dementia? (Harvard News Letter)

Q. The Women’s Health Initiative found that hormone therapy (HT) was not helpful for avoiding dementia; there was some suggestion that it might even cause cognitive problems. Am I at risk for dementia by continuing hormone therapy?

Women ages 65 to 79 took HT (estrogen alone or estrogen combined with a progestin) or a placebo. After four to five years, the researchers found that taking HT did not improve cognitive function. Moreover, the women who took combined estrogen and progestin were twice as likely as the placebo takers to develop dementia.

These findings do not square with animal and laboratory studies suggesting a favorable effect of estrogen on cognitive function. And there’s strong biological evidence that estrogen is important for brain function in women. Estrogen receptors are found throughout the brain, and many interactions take place between the brain and the reproductive endocrine system. Some research suggests that ovary removal during hysterectomy increases the risk of cognitive problems, presumably due to the loss of estrogen.

So what accounts for the WHIMS results? Some researchers think the problem is in the timing; they suggest that HT is more likely to benefit the brain if it’s started in early menopause.

We do know that taking HT increases the risk for several serious conditions, including blood clots, stroke, heart attack, and breast cancer (when estrogen is combined with a progestin). Unless you have burdensome hot flashes or vaginal atrophy that can’t be controlled any other way, I suggest that you taper off HT, which is recommended only for the short–term relief of such symptoms. There are several non–hormonal, risk–free strategies that may help your memory and thinking, including these: get regular exercise; keep learning — through work, hobbies, or pursuits such as reading; get enough sleep; and review your medications, to make sure you’re not taking anything that could interfere with your thinking. (Celeste Robb–Nicholson, M.D; Editor in Chief, Harvard Women’s Health Watch)

eMedinewS Try this it Works

Removing corneal foreign bodies

For removing foreign bodies from the cornea, use a sterile plastic 20–or 22–gauge catheter tip instead of a traditional needle or eye burr.

Dr Good Dr Bad

Situation: A highly emotional diabetic female was not getting her diabetes under control.

Dr Bad: You need to shift to insulin.

Dr Good: Try emotional control measures.

Lesson: A study evaluating the gender–related psychological effects on metabolic control concluded that lower quality of life, internal control and socioeconomic status, and higher prevalence of negative emotions probably prevented woman patients from achieving improved glucose control despite their better knowledge of and greater efforts to cope with diabetes. Women patients would benefit from individualized diabetes care offering social support. (Diabetologia 2009;52(5):781–8.)

Make Sure

Situation: A 36–year–old truck driver has severe allergic rhinitis and seeks treatment.

Reaction: Oh my God, why was he not prescribed azelastine nasal spray?

Lesson: Make sure to avoid oral antihistamines in persons who perform tasks like driving and instead advise azelastine nasal spary which is effective and non–sedating.


Laughter the best medicine

Patient: (to cosmetic surgeon): Will it hurt me, doctor?

Surgeon: Only when you get my bill.

Formulae in Critical Care

Transtubular potassium gradient (TTKG)

Formula: TTKG = (UK × Posm)/(PK × Uosm)

PK – Plasma potassium, UK – Urine potassium, Uosm – Urine osmolality, Posm – Plasma osmolality.

Comment: Calculation of TTKG is helpful in patients with persistent hyperkalemia, a value <7 and particularly <5 is highly suggestive of hypoaldosteronism.

Milestones in Medicine

1960 – First ever intensive care unit for newborns

Lab Test (Dr Arpan Gandhi and Navin Dang)

Platelet Count

Do not ignore a high platelet count. It signifis immuno inflammation. 

List of Approved drug from 1.01.2009 to 31.10.2009

Drug Name


Approval Date

Exemestane 25mg Tablet (Addl. Indication)

Indicated for adjuvant treatment of post menopausal women with estrogen receptor positive early breast cancer who have received two–three year of tamoxifen and are switched to exemestane for completion of total of five years of adjuvant hormonal therapy.


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Contact: drkk@ijcp.com or emedinews@gmail.com

eMedinewS–PadmaCon 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.

NATIONAL SEMINAR ON STRESS PREVENTION (17 – 18 April) Over 500 registrations already done.

A Stress Prevention Residential Seminar cum spiritual retreat with Dr KK Aggarwal and Experts from Brahma Kumaris will be organized from April 17–18, 2010.

Co–organizers: eMedinews, Brahma Kumaris, Heart Care Foundation of India, IMA New Delhi Branch and IMA Janak Puri Branch, IMSA (Delhi Chapter)

Venue: Om Shanti Retreat Centre, National Highway 8, Bilaspur Chowk, Pataudi Road, Near Manesar.

Timings: On Saturday 17th April (2 pm onwards) and Sunday 18th April (7 am–4 pm). There will be no registration charges, limited rooms, kindly book in advance; stay and food (satvik) will be provided. Voluntary contributions welcome. For booking e–mail and SMS to Dr KK Aggarwal: 9811090206, emedinews@gmail.com BK Sapna: 9811796962, bksapna@hotmail.com

Also, if you like emedinews you can FORWARD it to your colleagues and friends. Please send us a copy of your forwards

Readers Responses

  1. Dear K K Bhai: At the outset let me congratulate you for the most wonderful job you have done in the history of Medicine by bringing A DAILY UPDATE by emedinews. It is really commendable. I shall be obliged if you kindly write me an update on low levels of serum testosterone (after the age of 65 years) and endothelial dysfunction: Dr Gaurav Garg : Wil do that (Dr KK)

  2. Thank u sir the effort is worth lauding: Deepak Bhardwaj

  3. Dear Dr KK Aggarwal, Many thanks for mailing me emedinews regularly. I try to peruse through it whenever I get time. I wish to share following information with fellow colleagues through your esteemed newsletter: Constipation as a precipitating factor for Hepatic encephalopathy is often underestimated/overlooked. In any patient of hepatitis, constipation needs to be prevented at all costs. Such patients are particularly prone to get constipated as their fluid and food intake is less. Hepatitis patients should not be given drugs that can cause constipation e.g. oral iron; codeine/dextroproxyphene; calcium tabs; anticholinergics etc. If constipation develops in these patients, it should be promptly treated with oral lactulose or lactitol or glycerine enema: Dr Ramnik K Duggal. Sr Specialist in Medicine, (Nephrology division), ESI Hospital

  4. Dear Sir, Thank you very much for the daily dose of e–medinews that is so informative and enriching. We all benefit from your immense experience and efforts at bringing it out. One thing I wanted to have your expert opinion about after reading today’s section on aortic aneurysm repair was that–in light of the large randomized controlled trials done in the UK* showing that endovascular aneurysm repair was not much better than conventional open repair for aortic aneurysm in terms of all cause mortality and health related quality of life, what is your stand on the issue? They found that initial benefit of low mortality with EVAR was not persisting after 2 years and some complications were more common besides having higher cost. In India, what is the cost difference and is either of the method preferred by patients or doctors? What is advocated by experts in the field?

    *1. EVAR Trial Investigators. Endovascular versus Open Repair of Abdominal Aortic Aneurysm. This article (10.1056/NEJMoa0909305) was published on April 11, 2010, at NEJM.org.

    *2. EVAR Trial Participants. Endovascular aneurysm repair versus open repair in patients with abdominal aortic aneurysm (EVAR trial 1): randomised controlled trial.Lancet 2005;365:2179–86.

    Thank you very much for your expert opinion. Yours sincerely: Dr. SH Subba, Associate Professor, Department of Community Medicine, Kasturba Medical College, Hampankatta, Mangalore, Karnataka–575001 Phone:9886456225

    eMedinewS Answers: The third generation grafts used today have comparable 5 years data. In India most hospitals use third–generation grafts.