17th December 2014, Wednesday

Dr K K AggarwalPadma Shri, Dr B C Roy National Awardee and National Science Communication Awardee. Limca Book of Record Holder (CPR). Gold Medalist

Dr KK Aggarwal

President, Heart Care Foundation of India; Senior Consultant Physician, Cardiologist & Dean Medical Education Moolchand Medcity; Editor in Chief IJCP Group, Senior National Vice President, Indian Medical Association; Member Ethics Committee Medical Council of India, Chairman Ethical Committee Delhi Medical Council, Hony. Visiting Professor (Clinical Research) DIPSAR; Limca Book of Record Holder in CPR, Chairman (Delhi Chapter) International Medical Sciences Academy (March 10–13); 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);
For updates follow at :  www.twitter.com/DrKKAggarwal, www.facebook.com/Dr KKAggarwal

Stroke prevention guidelines

  • Risk calculators, such as that endorsed by the American Heart Association (AHA) and the American College of Cardiology (ACC), can be useful in assessing patients’ risk for stroke in a holistic context. However, these tools should not absolutely dictate treatment decisions for each individual patient.
  • Not all strokes are ischemic. Clinicians should consider noninvasive screening of the cerebral vasculature for patients with at least two first-degree relatives with a history of subarachnoid hemorrhage or intracranial aneurysms.
  • The minimal amount of exercise recommended to prevent stroke is 40 min/day at 3 to 4 days/week.
  • Statins should be first-line agents for stroke prevention among patients who meet the 10-year risk criteria for use of these drugs.
  • Niacin can raise high-density lipoprotein cholesterol levels, but it is unproven in preventing stroke. Similarly, fibric acid derivatives may not actually prevent stroke.
  • Hypertension should be treated to a goal blood pressure (BP) of less than 140/90 mm Hg to prevent stroke. Achieving target blood pressure is, in itself, more important than the types of medications used to treat hypertension.
  • However, evidence exists that reducing systolic BP to a target of less than 130 mm Hg may prevent more strokes.
  • Self-measured BP monitoring helps to reduce overall BP values and is recommended.
  • A graded positive relationship appears to exist between the degree of obesity and the risk for stroke, regardless of other cardiovascular risk factors. Weight loss reduces BP and blood glucose levels and has been demonstrated to reduce the risk for stroke in long-term research protocols.
  • Comorbid diabetes should not alter BP targets to prevent stroke, but these patients should preferentially receive a statin. The 10-year overall cardiovascular risk profile should be used to decide on aspirin prophylaxis for these patients; the presence of diabetes alone is less appropriate as an indication for aspirin therapy.
  • Dabigatran has been associated with lower risks for stroke and embolic events compared with warfarin, as well as a lower risk for intracranial hemorrhage, among patients with AF. However, dabigatran was associated with a higher risk of gastrointestinal bleeding vs warfarin. Dabigatran may also slightly increase the risk for myocardial infarction.
  • Rivaroxaban is more similar to warfarin in risk reduction for stroke or embolism among patients with AF, with a lower risk of serious bleeding.
  • Similarly, the benefit of apixaban vs warfarin in cases of AF is more marked for intracranial hemorrhage vs stroke prevention.
  • Economic analyses of the three new oral anticoagulants have generally been favorable.
  • The three new anticoagulants and warfarin can be considered for patients with AF and a CHA2DS2-VASc score of 2 or more. Treatment choice should be individualized based on patients' risks of bleeding, tolerability, cost, and patient preference.
  • Patients with AF and a CHA2DS2-VASc score of 0 should not receive anticoagulant or aspirin therapy, and treatment may also be withheld among patients with a score of 1.
  • Patients with mitral stenosis and a previous embolic event should receive anticoagulant therapy. Even severe mitral stenosis with left atrial enlargement might serve as an indication for anticoagulants.
  • For patients who receive an aortic or mitral bioprosthesis, aspirin is sufficient in stroke prevention.
  • Patients with asymptomatic carotid stenosis should receive aspirin and a statin. Carotid endarterectomy may be considered if the level of stenosis exceeds 70% and the risk for serious perioperative morbidity and mortality is less than 3%, but the efficacy of endarterectomy vs modern medical therapy is not well established.
  • Risk stratification using transcranial Doppler ultrasound screening should be initiated at age 2 years for patients with sickle cell disease, and these patients should receive annual screening through age 16 years.
  • Migraine with aura has been associated with a higher risk for stroke among women. Women with migraine should be urged not to smoke and should consider other methods of contraception besides oral contraceptives.
  • Chronic inflammatory diseases, such as rheumatoid arthritis, should be considered risk factors for stroke.
  • Annual influenza vaccination may reduce the risk for stroke among high-risk adults.
  • Aspirin at a dose of 81 mg per day or 100 mg every other day remains recommended for patients at high risk for stroke, including those with chronic kidney disease. Aspirin should not be used to prevent stroke among patients whose sole risk factor is diabetes or asymptomatic peripheral artery disease.
  • According to the new guidelines on primary stroke prevention, aspirin at a dose of 81 mg per day or 100 mg every other day remains recommended for patients at high risk for stroke, including those with chronic kidney disease. Aspirin should not be used to prevent stroke among patients whose sole risk factor is diabetes or asymptomatic peripheral artery disease.
  • The new guidelines on primary stroke prevention state that warfarin, dabigatran, rivaroxaban, and apixaban may be recommended to prevent stroke among high-risk patients with AF. The main benefit of newer agents compared with warfarin is a reduction in the risk for intracranial hemorrhage.

(Medscape Cardiology)

News Around The Globe

  • Patients with type 1 or type 2 diabetes have a higher incidence of cancer and death from cancer, with risks highest for certain specific tumors, compared with the general population, suggests a new study published online in Diabetes Care.
  • A landmark study published online December 11 in Arthritis & Rheumatism confirmed the widely held assumption that gout is more likely to flare at night and challenged the common impression that attacks are more likely after alcohol or purine dietary indulgence.
  • Thyroidectomy or long-term statin use may reduce the risk for thyroid-associated ophthalmopathy (TAO) in patients with Graves' disease, report the results from a large, observational study published online in JAMA Ophthalmology.
  • Although posttraumatic stress disorder (PTSD) has been approved as a qualifying condition for medical marijuana use, new research shows that the drug may actually worsen symptoms and increase violent behavior. The data were presented at the American Academy of Addiction Psychiatry (AAAP) 25th Annual Meeting.
  • Taking a low dose of the antidepressant fluoxetine immediately before a premenstrual cycle could prevent the symptoms of premenstrual syndrome, according to results of two new studies published in European Neuropsychopharmacology and the British Journal of Pharmacology.

Dr KK Spiritual Blog

The Vedic Will – as I understand it

Sometimes back, I used to think that a ‘will’ simply meant how my finances would be controlled by my wife and my children after my death.

As I started acquiring Vedic knowledge, my interpretation changed. Following is the gist for writing a Will, as I understand it the Vedic way.

Of course, writing a will requires a sound state of mind, two witnesses, signed registered paper with accompanying, if possible audio-visual link.

  • The first step is to calculate your life earnings. Your earnings are not only your finances earned but also the respect, dignity and image that you have earned in the society.
  • Now the next step is to pay off your unpaid debts (Hrins). Apart from actual loans we have taken from banks, friends and others, there are three more debts (Hrins) which we need to pay before we die and define in our Will to be paid from our earning if we die unexpectedly. These as per mythology are Pitra Hrin, Dev Hrin and Rishi Hrin and mean that we have not been able to fulfill the committed desires of our ancestors and commitments made to our GOD and teachers respectively. All these debts, if unpaid, need to be paid out of the finances you are leaving at the time of death. A percentage of your finances, therefore, should be kept to pay these debts. These commitments are usually fulfilled by the eldest son and eldest daughter if there is no son or wife till she is alive.
  • Rest of the finances need to be divided to fulfill your Dharma, Artha, Kama and Moksha or purpose for which you were born.
    • Artha: A percentage of your finances should go and be equally divided within your immediate family. A percentage of this amount should be converted into a family trust account to be used for the minus 18 years of age children in future.
    • Dharma: Dharma in literal meaning is to hold. A percentage of your finances should be kept into a reserve account and this account interest can be used by the family only if they stick to the code of family conduct (includes rituals, religious activities etc) you have created in your life and mentioned in the will or this amount may be given for charity as defined in your will.
    • Kama and Moksha: Kama means the unfulfilled desires at the level of intellect and ego and Moksha the same at the level of our soul.

We must enlist both our desires at the level of mind and at the level of soul and a percentage of our finances should be converted into a trust or defined to fulfill these desires.

The examples of desires at the level of soul are to do some charitable work without any publicity. The same at the level of ego are to open some dispensary, dharamshala etc. in our own name.

You also need to fulfill and document your desired rituals at the time of death. These rituals must answer the following questions:

  • Should my death be celebrated (band, lunch) as I have completed all my purposes of life?
  • How should my death anniversary be celebrated or observed?
  • How should my last rites be done?

Final Note: If my children and wife are not willing to take care of the finances other than Artha, I nominate the following persons to manage my finance to look after my other desires

Inspirational Story

The Carpenter

Once there was an elderly carpenter who was ready to retire. He told his employer-contractor of his plans. To leave the house building business and live a more leisurely life with his wife enjoying his extended family.

He would miss the paycheck, but he needed to retire. They could get by. The contractor was sorry to see his good worker go and asked if he could build just one more house as a personal favor.

The carpenter said yes, but in time it was easy to see that his heart was not in his work. He resorted to shoddy workmanship and used inferior materials. It was an unfortunate way to end his career.

When the carpenter finished his work and the builder came to inspect the house. The contractor handed the front-door key to the carpenter. "This is your house," he said, "my gift for your retirement as a token of my appreciation."

What a shock! What a shame! If he had only known he was building his own house. He would have done it all so differently. Now he had to live in the home he had built none too well.

So it is with us. We build our lives in a distracted way, reacting rather than acting, willing to put up less than the best. At important points we do not give the job our best effort. Then with a shock we look at the situation we have created and find that we are now living in the house we have built. If we had realized that we would have done it differently.

Think of yourself as the carpenter. Think about your house. Each day you hammer a nail, place a board, or erect a wall. Build wisely. It is the only life you will ever build. Even if you live it for only one day more, that day deserves to be lived graciously and with dignity.

The plaque on the wall says, "Life is a do-it-yourself project." Your life tomorrow will be the result of your attitudes and the choices you make today.

Rabies News (Dr A K Gupta)

What precautions should be taken while vaccinating by the ID route?

  • The ID injections must be administered by staff trained in this technique.
  • The Vaccine vials must be stored at +2°C to + 8°C after reconstitution.
  • The total content should be used as soon as possible, but at least within 8 hours.
  • The 0.1 ml. ID administration of cell–culture vaccine should create a wheal of at least 5 mm diameter with "peau de orange" appearance.
  • If ID dose is given subcutaneously then there is a possibility of poor immune response due to low antigen load. This may be life–threatening.

Cardiology eMedinewS

  • The US Food and Drug Administration (FDA) has approved a screening test that measures serum lipoprotein-associated phospholipase A2 (Lp-PLA2) for the assessment of coronary heart disease (CHD) risk in patients without existing disease. The approval is based on a substudy of the Reasons for Geographic and Racial Differences in Stroke study.
  • Women in their 60s and 70s who had their first menstrual period either when they were much younger or older than the average age of 13 have an independently increased risk of cardiovascular events, suggests an analysis based on the UK Million Women Study. The study is published online December 15 in Circulation.

Pediatrics eMedinewS

  • Off-label medications continue to be prescribed by general practitioners to children in significant numbers, despite campaigns to discourage the practice, suggests a new study. Possible adverse reactions make prescribing drugs for unapproved uses in children problematic, reported the study, published online December 15 in Pediatrics.
  • The first study to follow intelligence quotient (IQ) in type 1 diabetes patients from diagnosis in childhood into young adulthood has shown that the condition can affect some aspects of IQ. The findings, published online in Diabetes Care, show evidence of a selective impact of specific disease risk factors on IQ. Researchers noted that diagnosis with type 1 diabetes at an earlier age was associated with a decline in visuospatial (performance) aspects of IQ, while hypoglycemic seizures affected verbal IQ (word knowledge and abstract verbal conceptual reasoning).

Quote of the Day

Champions keep playing until they get it right Billie Jean King

Wellness Blog

Tips on family history of high cholesterol

Premature heart disease is when heart disease occurs before 55 years in men and 65 years in women. In premature heart disease, the prevalence of dyslipidemia (high cholesterol levels without symptoms) is 75-85%.

Fifty-four percent of all patients with premature heart disease and 70% of those with a lipid abnormality have a familial disorder. Hence, a screening test for lipids is recommended for first-degree relatives of patients with myocardial infarction, particularly if premature. Screening should begin with a standard lipid profile and if normal, further testing should be done for Lp(a) and apolipoproteins B and A-I.

About 25% patients with premature heart disease and a normal standard lipid profile will have an abnormality in Lp(a) or apo B. Elevated apo A-1 and HDL are likewise associated with reduced CHD risk.

First-degree relatives are brothers, sisters, father, mother; second-degree relatives refer to aunts, uncles, grandparents, nieces, or nephews and third-degree relatives refer to first cousins, siblings, or siblings of grandparents.

Familial hypercholesterolemia (FH) is a genetic disorder, characterized by high cholesterol, specifically very high LDL "bad cholesterol") levels and premature heart disease. Patients may develop premature cardiovascular disease at the age of 30 to 40.

Heterozygous FH is a common genetic disorder, occurring in 1:500 people in most countries. Homozygous FH is much rarer, occurring in 1 in a million births. Heterozygous FH is normally treated with drugs. Homozygous FH often does not respond to medical therapy and may require apheresis or liver transplant.

To detect familial high cholesterol levels, a universal screening must be done at age 16. The cholesterol levels in heterozygous patients are between 350 to 500 mg/dL, and in homozygous, the levels are between 700 to 1,200 mg/dL.

emedipicstoday emedipics

Health Check Up and CPR 10 Camp at GB S School, Khan Pur, New Delhi, on 27th November 2014

video of day
press release

Obesity reduces life expectancy

Sameer Malik Heart Care Foundation Fund

The Sameer Malik Heart Care Foundation Fund is a one of its kind initiative by the Heart Care Foundation of India instituted in memory of Sameer Malik to ensure that no person dies of a heart disease because they cannot afford treatment. Any person can apply for the financial and technical assistance provided by the fund by calling on its helpline number +91 9958771177 or by filling the online form.

Madan Singh, SM Heart Care Foundation Fund, Post CAG

Kishan, SM Heart Care Foundation Fund, Post CHD Repair

Deepak, SM Heart Care Foundation Fund, CHD TOF

Total CPR since 1st November 2012 – 101090 trained

cpr10 Mantra The CPR 10 Mantra is – "within 10 minutes of death, earlier the better; at least for the next 10 minutes, longer the better; compress the centre of the chest of the dead person continuously and effectively with a speed of 10×10 i.e. 100 per minute."

CPR 10 Success Stories

Ms Geetanjali, SD Public School
Success story Ms Sudha Malik
BVN School girl Harshita
Elderly man saved by Anuja

CPR 10 Videos

cpr 10 mantra
VIP’s on CPR 10 Mantra Video

Hands–only CPR 10 English
Hands–only CPR 10 (Hindi)


IJCP Book of Medical Records

IJCP Book of Medical Records Is the First and the Only Credible Site with Indian Medical Records.

If you feel any time that you have created something which should be certified so that you can put it in your profile, you can submit your claim to us on :


Dr Good and Dr Bad

Situation: A patient came with classical benign postural vertigo.
Dr Bad: Take these drugs
Dr Good: Do Epley maneuver.
Lesson: Epley maneuver in most situations can cure benign postural vertigo.

Make Sure

Situation: A patient with acute heart attack died on the way to the hospital.
Reaction: Oh my God! Why was the patient not accompanied by the doctor?
Lesson: Make sure that all heart attack patients are accompanied by the doctor to the hospital so that chest compression (CPR) can be given if the heart stops on the way.

eMedinewS Humor

Sales Practice

The out–of–work newlywed took a temporary job as a vacuum cleaner salesman to make ends meet. After 3 days of intensive training, the sales manager told him to go home and practice his pitch on his wife.

The next morning, the manager asked the novice how he made out.

"Well," the man began, "I did what you said, and after I finished, I asked her if she would buy the vacuum cleaner from me. She said ‘Yes.’ Then I asked her ‘Why?’ She replied, ‘Because I love you.’"

Twitter of the Day

Dr KK Aggarwal: Stress can increase your blood sugar
Dr Deepak Chopra: How do you know that a dream is your true calling and not an indulgence of the ego mind?

ePress Release

Cold Weather and Heart Disease

It is important to know how cold weather can affect your heart, especially if you have heart disease, said Padma Shri, National Science Communication and Dr B C Roy National Awardee Dr KK Aggarwal President Heart Care Foundation of India and Senior National Vice President IMA.

People who stay outdoors in cold weather should avoid sudden exertion to prevent accidental hypothermia. Hypothermia occurs when the body temperature drops below 950F. This means that the body does not produce enough energy to keep the internal body temperature warm enough. Hypothermia can be life-threatening.

The most common cause of death in hypothermia is heart failure. Symptoms include lack of coordination, mental confusion, slowed reactions, shivering and sleepiness.

Children, the elderly and those with heart disease are especially at risk of developing hypothermia. With advancing age, the ability of the body to maintain a normal internal body temperature often declines. The elderly seem to be relatively insensitive to moderately cold conditions, so they can develop hypothermia without them being aware that they are in danger.

People with coronary heart disease often suffer angina pectoris (chest pain or discomfort) during winters. The cold weather may increase the risk of heart attack due to overexertion.

Besides cold temperatures, high winds, snow and rain also can cause loss of body heat. High winds remove the layer of heated air from around your body. Even at 300F in a 30-mile wind, the cooling effect is equal to 150F. In the same way, dampness causes the body to lose heat faster than it would at the same temperature in drier conditions.

  • To keep warm, wear layers of clothing. This traps air between layers, forming a protective insulation.
  • Also, wear a hat or head scarf.
  • Heat can be lost through your head.
  • Ears are especially prone to frostbite.
  • Keep hands and feet warm, too, as they tend to lose heat rapidly.
  • Don't drink alcoholic beverages before going outdoors or when outside. Alcohol gives an initial feeling of warmth, because blood vessels in the skin expand. Heat is then drawn away from the body's vital organs.
  • If you have a medical condition, don’t exercise on a regular basis or if you are middle aged or older, meet with your doctor prior to exercising in cold weather.
  • Learn CPR 10: Effective bystander CPR, provided immediately after sudden cardiac arrest, can double or triple a victim’s chance of survival. Hands-only CPR makes it easier than ever to save a life.

eMedi Quiz

A 30 year old man came to the outpatient department because he had suddenly developed double vision. On examination it was found that his right eye, when at rest, was turned medially. The most likely anatomical structures involved are:

1. Medial rectus and superior division of oculomotor nerve.
2. Inferior oblique and inferior division of oculomotor nerve.
3. Lateral rectus and abducent nerve.
4. Superior rectus and trochlear nerve.

Yesterday’s Mind Teaser: A lesion of ventrolateral part of spinal cord will lead to loss (below the level of lesion) of:

1.Pain sensation on the ipsilateral side.
2.Proprioception on the contralateral side.
3.Pain sensation on the contralateral side.
4.Propriception on the ipsilateral side.

Answer for yesterday’s Mind Teaser: 3.Pain sensation on the contralateral side.

Correct answers received from: Raju Kuppusamy, Dr Avtar Krishan, Dr Rakesh Sharma Nohar, R Krishnamoorthy.

Answer for 15th December Mind Teaser: 2.Hypovolemia.

Correct answers received from: Raju Kuppusamy, Dr Rakesh Sharma Nohar, Dr Avtar Krishan, Dr Poonam Chablani.

Send your answer to email

medicolegal update

(Contributed by Dr MC Gupta, Advocate)

Q: I had a query and then I saw you who knows about the law. Would you mind telling me few rules about govt jobs? I have applied for job in medical college. But I am confused if I can resign from it easily if I don’t feel like continuing with it. Few of my colleagues have told me that it’s tough to get into govt job and even tougher to get out of it as the Govt does not let you go even if you want to resign. Can you tell me how far this is true?

A: Rules about government jobs are as follows:

  • Just as "God helps those who help themselves", government tends to give jobs to those who can write good English.
  • Getting in is difficult. Many people would gain by preventing the entry. Getting out is easy. Many people would gain by facilitating the exit.
  • Bonded labour is unconstitutional. Nobody can be made to work forcibly. I have resigned five jobs, including that of an army officer.
  • It is better (and more sensible) to get a job and then resign rather than not get a job because it would be difficult to resign. Of course, the more sensible thing would be to seek a job that one likes and to not think of resigning even before getting the job.
medicolegal update
  1. Thanx for enriching us scientifically, spiritually, medico–legally… Som Datt Bherwal

eMedinewS Special

1. IJCP’s ejournals (This may take a few minues to open)

2. eMedinewS audio PPT (This may take a few minutes to download)

3. eMedinewS audio lectures (This may take a few minutes to open)

4. eMedinewS ebooks (This may take a few minutes to open)