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Dr KK Aggarwal

From the Desk of Editor in Chief
Dr B C Roy National Awardee,

Dr KK Aggarwal
President, Heart Care Foundation of India; Sr Consultant and Dean Medical Education, Moolchand Medcity; Member, Delhi Medical Council; Past President, Delhi Medical Association; Past President, IMA New Delhi Branch; Past Hony Director. IMA AKN Sinha Institute, Chairman IMA Academy of Medical Specialities & Hony Finance Secretary National IMA; Editor in Chief IJCP Group of Publications & Hony Visiting Professor (Clinical Research) DIPSAR

Dear Colleague

17th February 2010, Wednesday

All about Bill Clinton's surgery

The public is shocked that Bill Clinton also needed two stents after a bypass surgery.

A: Former President Bill Clinton, 63, had quadruple bypass surgery in 2004 to free four blocked arteries. Now he has undergone placements of two stents. This is not uncommon after bypass surgery.

What could be the reasons?

A: Even after bypass grafts for coronary artery disease, one is still at risk for another attack. The bypass grafts themselves can develop plaque buildup and narrowing or a new disease can occur in non bypassed arteries.

How early do these blockages occur?

This depends on the type of grafts used for building the ‘flyover’ i.e. venous graft from the leg or arterial grafts from the chest. In Clinton’s case as he had received 4 grafts earlier, one invariably would have been from the leg. The vein graft from the leg develops re–blockage rapidly. Only 65 to 80 percent of venous grafts remain patent five years after the operation, 50 to 60 percent at 7 to 10 years, and 50 percent at 15 years.

At what time after a bypass surgery does a venous graft tend to close?

1. Venous graft occlusion occurs prior to hospital discharge in 10 percent of grafts. This blockage is related to small vessel size (<1.5 mm), severity of bypassed proximal blockage <70 percent, and technical factors, such as kinks from excessive length of the graft or poor distal artery runoff.
2. Another 5 to 10 percent of grafts will close between one month and one year after surgery. The reasons may be platelet aggregation, growth factor secretion, endothelial dysfunction and marked intimal hyperplasia.
3. The late blockages occur after the first year when the areas of intimal hyperplasia develop lipid deposition and finally an atherosclerotic plaque. From the end of year 1 to year 6, venous grafts close at a rate of approximately 2 percent per year; the subsequent closure rate rises to 4 to 5 percent per year. In such grafts, there is no focal compensatory enlargement in the narrowed segments. This is in contrast to what has been seen in native atherosclerotic arteries in which the development of an atherosclerotic plaque is associated with enlargement of the vessel and preservation of the lumen area until plaque progression exceeds the compensatory mechanism of the vessel. Late blockages in vein graft have a worse prognosis than late blockages in the native coronary vessels (this was probably the case with Clinton).

Can the arterial grafts also close?

The early patency of a left internal mammary arterial (IMA) chest graft anastomosed to the LAD (left artery) is almost 99 percent and approximately 94 percent for a right chest IMA anastomosed to major branches of the left circumflex artery. There are infrequent cases in which the IMA graft develops a stenosis or becomes occluded and if this occurs it will happen within three months of surgery. Long–term graft patency is much higher with artery graft than with venous grafts. (Thus, in Clinton’s case, it would be unlikely that an arterial graft might have closed)

Why could Clinton’s doctors not prevent it?

A healthy lifestyle, with rigorous control of blood pressure, cholesterol, sugar, not smoking, and other risk factors, is always advised after bypass surgery. However, even with rigorous control, disease can still occur. There are some factors beyond one’s control.

Why was re–surgery not done in Clinton’s case?

Given the approximately three– to four–old increase in mortality after repeat bypass surgery, this procedure should be reserved for patients with disabling symptoms or a large amount of myocardium at risk and poor candidates for angioplasty. Another limitation to intervention is that the likelihood of prolonging life is less than with first bypass surgery due in part to previous myocardial injury and progressive atherosclerosis in native original vessels. The 2004 American College of Cardiology/American Heart Association guidelines on coronary artery bypass graft (CABG) surgery concluded that bypass surgery can be performed in the following settings in patients with previous bypass surgery.
a) In patients with disabling angina despite optimal medical therapy
b) In patients without patent bypass grafts who have an indication for surgery for native vessel disease (e.g., left main, left main equivalent, three vessel disease).
c) In patients with bypassable distal vessel(s) with a large area of threatened myocardium by noninvasive studies.
d) In patients with atherosclerotic venous grafts with >50 percent stenoses supplying the left anterior descending coronary artery or large areas of myocardium.

When should angioplasty be done after bypass? (This was the case with Clinton and also our PM, Dr Manmohan Singh).

a. Angioplasty is usually done to treat native vessel disease and early (less than five years) venous grafts stenoses. Angioplasty is much less effective for late atherosclerotic venous grafts stenosis.
b. Angioplasty is of choice in patients with early ischemia (usually within 30 days) after bypass.
c. Angioplasty is reasonable with ischemia that occurs one to three years after bypass in patients with discrete lesions in the graft and preserved left ventricular function.
d. Angioplasty can be done in patients with disabling angina secondary to new disease in a native vessel, in patients with venous grafts disease more than three years after bypass surgery, and, if feasible, in patients with a patent left internal mammary artery graft who have clinically significant obstruction in other vessels.
e. Angioplasty is not recommended in patients with total saphenous vein graft (SVG) occlusions and, unless repeat CABG poses excessive risk, in patients with multiple target lesions (native vessels and/or SVGs) and impaired left ventricular function.

How long now will these stents last in Clinton’s case?

Drug coated stents normally stay patent. There is a 90–95% probability that within the next 2 to 3 years they will still be functioning. In Clinton’s case, it will depend on the artery in which angioplasty was done. If it was on the occluded venous graft, he probably will behave like Dr Manmohan Singh and will end up with another bypass surgery within 5–7 years. This is because angioplasty results are poor in venous grafts occlusion occurring after 5 years.

What about our PM, Dr Manmohan Singh?

He had a near similar history; an initial bypass, then stent angioplasty and now a re–bypass. Both bypass and stenting, in his case, lasted for 6-8 years each, which is the average life of such procedures.

Does this mean that bypass and stenting do not cure a blockage?

No. They are only temporary solutions. The best thing is primary prevention of heart blockages and if they do occur, to delay the stent or bypass by effective aggressive medical treatment. If stent or bypass has been done, one should attempt to delay the second procedure as long as possible with aggressive lifestyle management and drugs.

What is the final message?

A bypass surgery is not a cure. You still have to follow a heart–healthy lifestyle and (take) medications to control risk factors.

Dr KK Aggarwal
Chief Editor

News and Views

Glaucoma drugs reduce mortality

Patients with suspected or confirmed glaucoma were 74% less likely to die during a five–year period if they were prescribed any glaucoma medication (HR 0.26, 95% CI 0.16 to 0.40), according to Dr Joshua Stein, of the University of Michigan Kellogg Eye Center in Ann Arbor.

Ban cellphones while driving

A new study analyzing the impact of hand–held cell phone legislation on driving safety concludes that usage–ban laws had more of an impact in densely populated urban areas with a higher number of licensed drivers than in rural areas where there are fewer licensed drivers, according to a University of Illinois researcher.

ART increases chances of pregnancy

A study conducted in a multi–country HIV treatment program in sub–Saharan Africa has found that pregnancy rates increase in HIV–infected women after they start antiretroviral therapy.

Beer for osteoporosis

Beer is a significant source of dietary silicon, a key ingredient for increasing bone mineral density. Researchers from the Department of Food Science & Technology at the University of California, Davis studied commercial beer production to determine the relationship between beer production methods and the resulting silicon content, concluding that beer is a rich source of dietary silicon. The study is published in the Feb issue of the Journal of the Science of Food and Agriculture.

Blueberries for ulcerative colitis

Blueberries are rich in antioxidants and vitamins. A new research from the Lund University Faculty of Engineering in Sweden shows that blueberry fiber can alleviate and protect against intestinal inflammations, such as ulcerative colitis. The protective effect is even better if the blueberries are eaten together with probiotics.

Celastrol for cancer

Celastrol, derived from trees and shrubs called celastracaea, has been used for centuries in China to treat symptoms such as fever, chills, joint pain and inflammation. According to researchers from Georgia, it may also play a role in cancer treatment by inactivating a protein required for cancer growth.

FDA approves heat-stable version of Norvir

Abbott Laboratories has received FDA approval for a heat–stable version of the HIV treatment ritonavir. The approval is for a new formulation of the drug that allows it to be stored at room temperature rather than in a refrigerator.

Taspoglutide may reduce sugar levels when compared with or added to other treatments

Results from five late–stage clinical trials show that the experimental diabetes drug, taspoglutide, reduced blood sugar levels when compared with or added to widely prescribed treatments. The drug met the main goal of studies comparing it to insulin glargine injection, exenatide injection and sitagliptin, as well as trials where it was combined with metformin and against placebo. Smoking

Conference Calendar

IPU 2010 (International Pathology Update 2010)
Date: February 19–21, 2010
Venue: Bhargava Auditorium, PGIMER, Chandigarh.

Diabetes Fact

Normal A1c should < 6%. It represents the average blood sugar level over last three months. The formula is A1c x 25 = average blood sugar

Public Forum

Press Release

Stay away from stress during examination days.

Exam stress can lead to depression and suicide. During exam days prescriptions for anti depressant drugs, so called happy drugs, increase amongst teenagers of 16–18 years in full time education. This figure crosses 20% in school population in the West.

This was stated by Padma Shri and Dr BC Roy awardee Dr. KK Aggarwal, President, Heart Care Foundation of India and Prof. Dr. Aruna Broota, Clinical Psychologist, Dept. of Psychology, University of Delhi and Acharya Sadhvi Dr. Sadhna Ji Maharaj, Chairperson, World Fellowship of Religions during a press conference organized by the Foundation to create awareness about the rising problems of stress in Indian context.

Ms Shibani Kashyap noted singer and music composer was the star attraction of the conference.

The fears of failure, fear of letting down are the two most common factors leading to suicide and depression.

Also, children indulge in drugs to keep awake during exams and end up with addictions like iodex on sandwich, toothpaste, shoe polish, whitener, Vicks and anti fit drugs, cough syrups etc. This is apart from indulgence in smoking, tobacco, alcohol, tea, coffee, and superman drugs like LSD, etc. Some children go to the extent of even eating the tail of the lizards.

Anticipatory anxiety peaks before exams resulting in adverse affects on the body and mind and therefore, a sub optimal performance.

Stress not only causes palpitations and tense muscles but also reduces the ability to make decisions, act or express oneself including organization of thoughts.

Stress during exams can makes it difficult to read and understand questions and even to recall terms and concepts.

A recent study has shown that 45 minutes of afternoon nap improves the declarative memory. Declarative memory is the memory of events learnt and understood earlier during the year.

Not taking afternoon nap or the night sleep may cause the child end up with transient loss of declarative memory.

Free Writing Can Clear Mental Stress: By spending 30 minutes each day for four days to write out your innermost thoughts and feelings, one can significantly boost mental and physical health. In expressive writing therapy, students are encouraged to express whatever is on their mind, letting their hopes and fears flow out in a natural, unrestrained way. It’s akin to keeping a journal, but more focused on the things that might be bothering you or triggering stress.

While writing, the patients need not worry about the punctuations It’s about stepping back and thinking about things in a different way, making linkages. Writing out emotions eases stress and, in turn, boosts the immune system.

Memories of traumatic events are not suppressed by the people who experienced them and can be clearly recalled. In a five year study scientists at Dalhousie University in Halifax found that pleasant events were more difficult to recall than unhappy ones.

Sleeping pills can be dangerous
: Prescription sleeping pills can cause strange and potentially dangerous side effects, including sleep driving, the U.S. Food and Drug Administration has warned. A few years ago the bizarre side effect first made headlines when Rep. Patrick Kennedy crashed his car after taking Ambien (zolpidem).

The side effects can include dangerous allergic reactions and a bizarre behaviour "sleep–driving," in which a person will drive a car while not fully awake and have no memory of doing so. Sleep–driving and other strange behaviours might occur if consumers take a higher–than–recommended dose of the drug, or drink alcohol or consume other similar drugs. All the drugs in the class can produce these effects.

Short walk can help de–addict: Just 5 to 10 minutes of walk can cut cravings for cigarettes among people trying to kick the habit, According to Dr. Adrian H. Taylor of the University of Exeter. Twelve out of fourteen studies reviewed by him found that a bout of physical activity reduced cigarette cravings and withdrawal symptoms compared to staying inactive. Exercise cut craving as much as chewing nicotine gum. Exercise also triples the time it takes for people to reach for their next cigarette.

Effects were seen for vigorous bouts of exercise lasting for up to 40 minutes, but even less intense 15–minute session and even five minutes of isometrics, have a significant effect. Distraction, reducing stress and boosting mood may be the reasons.

Afternoon nap: A study published in the journal Sleep, showed that a 45–minute midday nap can help boost the "declarative memory" which applies to standard textbook learning and knowledge. Sleep appears to help "set" these declarative memories and make them easier to recall.

The other type of memory is "procedural memory," which applies to skills and has no impact with the midday nap.


1. Kids should not be compared: it can lead to anger or depression in the child.
2. One should unconditionally appreciate whatever the child has achieved.
3. One should avoid giving false promises for example if you come first, you will get a bike". When that happens, "You are not yet 18 – so you can’t get a license. This time, settle for a bicycle and later we'll get that bike". Broken promises hurt the child.
4. Avoid anger chain, for example, the father unleashes his anger on the mother (because she does not answer back), and she takes it out on the child (because of the same reason). And the child takes it out on books or studies or younger sibling or hired help at home!
5. Do not force your expectations on the child, for example, you should only become a doctor.
6. Avoid giving the child two conflicting messages like mother asks child to study and father says – "do not force him".
7. Make your child exercise daily, learn pranayama and meditation, 8. Provide your child with balanced and nutritious diet. Avoid overeating or long hunger periods. Restrict caffeine, give more water.
9. Ensure adequate sleep with a consistent schedule to improve concentration, memory and mood, it also reduces irritability.

Punjab & Sind Bank
Central Bank of India

Question of the day

What are the neurological aspects of malaria?

Cerebral malaria may be the most common non–traumatic encephalopathy in the world. The pathogenesis is heterogenous and the neurological complications are often part of a multisystem dysfunction. The clinical presentation and pathophysiology differs between adults and children.
Death from severe malaria in children is most often caused by cerebral malaria, severe malarial anemia, acidosis with accompanying respiratory distress, or a combination of these factors. Cerebral malaria is associated with a particularly high mortality rate. According to the WHO definition, cerebral malaria is present in a patient who:
a) Cannot localize a painful stimulus
b) Has peripheral asexual Plasmodium falciparum parasitemia
c) Has no other identified causes of an encephalopathy.
The WHO definition effectively excludes children who have had a single seizure and children with other causes of cerebral dysfunction, such as bacterial or viral meningitis or toxic or metabolic encephalopathy. Cerebral malaria often develops very rapidly. Children with cerebral malaria may go from having a normal sensorium to being in coma within hours. Parents typically report a history of 2 or 3 days of fever and subsequent abrupt onset of convulsions and/or severely impaired consciousness in their children. Other symptoms include headache, confusion, irritability, and a stuporous state preceding coma. Symptoms seen frequently in uncomplicated malaria, such as weakness, vomiting, diarrhea and cough, are also seen in children with cerebral malaria. Abnormal posturing (decorticate or decerebrate rigidity, opisthotonus), papillary changes, gaze abnormalities (dysconjugate gaze, eyes wide open, nystagmus), and Cheyne-Stokes or Kussmaul respirations may be observed. Abnormal corneal reflexes and reduced muscle tone are more frequent in children than in adults.1 In addition, children with cerebral malaria often have increased intracranial pressure, whereas adults typically do not.2 Hemiparesis, ataxia, and cortical blindness are frequent sequelae of cerebral malaria in children. Other clinical features seen in children with cerebral malaria include hepatosplenomegaly, jaundice, respiratory distress, retinal abnormalities, dehydration and hyponatremia, renal dysfunction, disseminated intravascular coagulation, hypotension, lactic acidosis, hypoglycemia and mild–to–moderate anemia.3–5 Hypotension may be a sign of sepsis from concurrent bacterial infection, but it can be seen with severe malaria alone. Retinal abnormalities in cerebral malaria include retinal hemorrhages and papilledema. Retinal hemorrhages generally resolve without residual visual defects. They are associated with a worse outcome in adults than in children. Papilledema is an independent indicator of poor outcome in children.


  1. Newton CR, et al. Pathophysiology of fatal falciparum malaria in African children. Am J Trop Med Hyg 1998;58:673–83.
  2. Newton CR, et al. Intracranial hypertension in Africans with cerebral malaria. Arch Dis Child 1997;76:219–26.
  3. Waller D, et al. Clinical features and outcome of severe malaria in Gambian children. Clin Infect Dis 1995;21:577–87.
  4. Esamai F, et al. Clinical presentation and diagnosis of cerebral malaria in children in the highlands of western Kenya. East Afr Med J 1999;76:89–92.
  5. Olumese PE, et al. Neurological features of cerebral malaria in Nigerian children. Ann Trop Paediatr 1999;19:321–5.

eMedinewS Try this it Works

Convincing patients to use intranasal steroids

To improve compliance with the use of intranasal steroids for rhinitis, three important issues need to be discussed with the patient:

a) Intranasal steroids are not like over–the–counter nose sprays that people can get ‘hooked on.’
b) They are not the kind of steroids (anabolic) that some athletes and bodybuilders take. Users do not "bulk up," nor do their noses get larger!
c) Improvement is not noticed for 3 to 7 days. The patient should use the medication for a period of 1 to 2 weeks before deciding whether it is effective.

Dr Good Dr Bad

A patient came with acute heart attack.
Dr Bad: Chew 300 mg aspirin.
Dr Good: Chew 300 mg aspirin and 600 mg clopidogrel.
Lesson: For all patients with ST elevation MI, start dual antiplatelet therapy with chewable aspirin (300 mg) and clopidogrel (600 mg) or prasugrel (60mg) as soon as possible after presentation.)

Make Sure

Situation: A patient with acid peptic disease was denied any painkiller for his distressing illness.
Reaction: Oh, my God! Why did not you give him nimesulide?
Make sure to prescribe nimesulide as it is safe in acid peptic disease.

Laughter the best medicine

Late one night the Gynecologists’ wife was home alone, after her husband had been called to the hospital for an emergency. The doorbell rings, and she answers.
"Is the doctor at home?" asks the man at the door, in a very hoarse and quiet voice due to his aching throat.
"No, c’mon in!" whispers the doctor’s wife in return.

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.

SMS Anemia

The mean corpuscular volume (MCV) allows classifying anemia into microcytic, normocytic or macrocytic.

Milestones in Neurology

Jean–Martin Charcot (1825–1893) was a French neurologist and professor of anatomical pathology. He is known as "the founder of modern neurology" and is "associated with at least 15 medical eponyms", including Charcot–Marie–Tooth disease and amyotrophic lateral sclerosis (Charcot's disease). His work greatly influenced the developing fields of neurology and psychology. He was the ‘foremost neurologist of late nineteenth-century France and has been called the Napoleon of the neuroses’.

LIST OF APPROVED DRUG FROM 1.01.2009 to 31.10.2009

Drug Name Indication Approval Date
Ketoconazole 2% + Zinc Pyrithone 1% Lotion
For the treatment of pityriasis and dandruff of the scalp

(Advertorial section)


Studies Indicate that The Immunity Booster Effects of Zen Immune Range of Products can be Measured by Estimation of IgA Immuno Gobulin levels from the Serum, Unstimulated whole Saliva, and Stimulated Parotid Secretions of a normal Individual. This could be a fairly Reliable Indicator to evaluate the Levels of Immuno globulins in the body, Before and After Zen Immune Therapy.

Advertising in emedinews

emedinews is the first daily emedical newspaper of the country. One can advertise with a singe insertion or 30 insertions in a month. Contact: drkk@ijcp.com. 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 hangama and live webcast. Suggestions are invited.

Stress Management Workshop

A stress management workshop with Dr KK Aggarwal and Experts from Brahma Kumaris will be organized on April 17-18, 2010.
Organizers: eMedinews, Brahma Kumaris, Heart Care Foundation of India, In association with IMA New Delhi Branch and IMA Janak Puri Branch
Venue: Om Shanti Retreat Center, National Highway 8, Bilaspur Chowk Pataudi Road, Near Manesar.
Timings: On Saturday (2pm onwards) and Sunday (7am-4pm). There will be no registration charges, limited rooms, kindly book in advance, stay and food (satvik) will be provided. For booking e mail to emedinews@gmail.com or sms to Dr KK Aggarwal 9811090206/ BK Sapna 9811796962

Stroke Update Workshop for GPs

Indian stroke association and International Stroke Conference is organizing a Stroke Update Workshop on March 13–14, 2010 at AIIMS Auditorium. eMedinewS has tied up with the conference for free registration for first 200 GPs of NCR. Organizer: Dr Padma, Prof of Neurology, AIIMS, New Delhi SMS for free registration to 9717298178 or email to isacon2010@gmail.com

International Symposium on ‘Yogism for Healthy & Happy Living and Aging’

The 7th convocation of SVYASA Yoga University was organized on January 12, 2010. The concept Yogism was well received and we now plan to have an International Symposium on ‘Yogism for Healthy & Happy Living and Aging’ on December 6–7, 2010. There is considerable interest abroad to integrate alternate medicine with modern medicine in Medical schools. We feel Yoga, Meditation and Naturopathy should be integrated with modern medicine in promotion of positive health and healing: BC Harinath, Director, JBTDRC & Coordinator, BIC & Arogyadham Mahatma Gandhi Institute of Medical Sciences, Sevagram - 442102, Wardha, Maharashtra, India, TeleFax: +91 7152 284038, Home: +91 7152 260219, E-mail: bch@jbtdrc.org, bc_harinath@yahoo.com.

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Readers Responses

  1. Dear Dr. Aggarwal, Hearty Congratulations on your being bestowed by Padma Shri, a prestigious award. We are proud of your achievement. BC Harinath, Director, JBTDRC & Coordinator, BIC & Arogyadham Mahatma Gandhi Institute of Medical Sciences, Sevagram.

  2. Congratulations on you achieving Padmashree award. May many more laurels crown you: Dr.VT Shah, Mumbai

  3. Dr. KK Aggarwal, heartiest congratulations for Padmashree award for public service: Govardhan Das

  4. Respected Sir, see outside the window, the sun is rising for you, flowers are smiling for you, birds are singing for you because everyone wants to wish you a very special good morning. Please accept our heartiest congratulations. May God be always with you and your family: Dr. Duchan

  5. Congratulations. You achievement gives me a feeling of pride. Shower your blessings on budding doctors like me: Dr. Aditi Sethi