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
Delhi Medical Council
Director, IMA AKN Sinha Institute


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 18th  January Monday 2010

 Dear Colleague,

Healthcare associated-pneumonia: A new term

The 2005 American Thoracic Society/Infectious Diseases Society of America (ATS/IDSA) guidelines on the management of adults with hospital-acquired, ventilator-associated, and healthcare-associated pneumonia used the following definitions:

1. Hospital-acquired (or nosocomial) pneumonia (HAP): is pneumonia that occurs 48 hours or more after admission and did not appear to be incubating at the time of admission.

2. Ventilator associated pneumonia (VAP): is a type of HAP that develops more than 48 to 72 hours after endotracheal intubation.

3. Healthcare-associated pneumonia (HCAP): is pneumonia that occurs in a non hospitalized patient with extensive healthcare contact, as defined by one or more of the following:
a. Intravenous therapy, wound care, or intravenous chemotherapy within the prior 30 days
b. Residence in a nursing home or other long-term care facility
c. Hospitalization in an acute care hospital for two or more days within the prior 90 days
d. Attendance at a hospital or hemodialysis clinic within the prior 30 days

HCAP should change the way we treat infections. The term may also be used for healthcare-associated UTIs, sinusitis or any other infections. Until now HAP were treated by specialists and in the hospitals, but now even a GP needs to know about HCAP as they are treated or similar lines as HAP.

Dr KK Aggarwal
Chief Editorial

News: American Heart Association, Orlando, FL November 14 - 18, 2009.
1. A 60 mg loading dose of prasugrel is now a recommended alternative to clopidogrel for patients with ST-elevation myocardial infarction (STEMI) who undergo primary percutaneous coronary intervention. The authors of guidelines, from the American College of Cardiology, American Heart Association, and Society for Cardiovascular Angiography and Interventions, determined that the benefits of prasugrel outweighed its risk for bleeding and incorporated the drug into their recommendations.

2. By a margin of 0.014 mm in carotid intimae-media thickness (CIMT), extended-release niacin demonstrated superiority over ezetimibe as an add-on for high risk patients on long-term statin therapy. The niacin versus ezetimibe findings come from the ARBITER 6-HALTS trial, a late-breaker reported at the American Heart Association and simultaneously published in the New England Journal of Medicine.

3. Boosting HDL cholesterol with extended-release niacin is a more effective way of slowing atherosclerosis in high-risk patients on long-term statin therapy than seeking additional LDL cholesterol reductions by adding ezetimibe. Compared with ezetimibe, 2 grams of niacin led to significant reductions in both the mean and maximal carotid intima-media thickness (CIMT) (P=0.001 for all comparisons). (Dr Allen J. Taylor, Walter Reed Army Medical Center, USA)
4. Overweight smokers have the greatest risk of a venous thrombotic event, according to a review of data from the Copenhagen City Heart Study.(Dr Anders Holst, University Hospital Rigshospitalet, Copenhagen, Denmark)

5. Acute myocardial infarction patients pretreated with anticoagulants before percutaneous coronary interventions appear to fare better with fondaparinux or enoxaparin than unfractionated heparin. In fact, there was no apparent difference between unfractionated heparin and no pretreatment at all -- one year survival without experiencing a clinical endpoint (death, recurrent infarction, stroke, or severe bleeding) was about 80% in these two groups (Dr Francois Schiele, University Hospital Jean Minjoz, Besancon, France).

6.  The oral anticoagulant dabigatran did not appear to markedly increase major bleeding rates among post-MI patients who were already being treated with aspirin and clopidogrel. Acute coronary syndrome patients continue to have recurrent ischemic events despite evidence based treatment, including dual antiplatelet therapy (Dr Jonas Oldgren, Uppsala University Hospital, Sweden

Dr Good Dr Bad
Situation: A female with mitral valve prolapse and grade 1 MR was scheduled for LSCS.
Dr Bad: You need endocarditis prophylaxis.
Dr Good: No prophylaxis is required.
Lesson: Vaginal or cesarean delivery is not an indication for routine antibiotic prophylaxis as the rate of bacteremia with these procedures is low. (BJOG 2008;115:1601-4).

Make Sure
Situation: A patient with antibiotic-associated diarrhea did not respond to seven days treatment with Metronidazole
Reaction: Oh my God! Why metronidazole not given for 14 days?
Make sure that Metronidazole 500 mg oral or IV TDS is given for minimum 14 days for initial treatment of non-severe CDAD. (c-difficle-associated diarrhea)

ENT Facts
Otitis media with effusion (OME) is the presence of middle ear fluid without inflammation, and usually results from barotraumas or allergy.
Mistakes in critical care
Clinicians must be alert to the use of herbal and dietary supplements by elderly patients as they, may not volunteer this information, and are prone to drug-drug interactions related to these supplements.

Milestones in Neurology
Marie Jean Pierre Flourens was a French physiologist, the founder of experimental brain science and a pioneer in anesthesia.

Laughter the Best Medicine
Gynecologist - at your cervix, madam.

Question Of the Day
What is the symptomatic treatment for diarrhea in ulcerative colitis?
Symptomatic treatment for diarrhea is necessary while anti-inflammatory medications take effect or as an adjunctive therapy in patients in whom more aggressive therapy is not desirable. Dietary counseling is also helpful.
In patients who have mild intermittent diarrhea, antidiarrheal agents, such as loperamide or diphenoxylate are beneficial, particularly at night when they can aid in obtaining good quality sleep. However, antidiarrheal agents should be avoided in severely ill patients, since they may precipitate toxic megacolon.
Bulk agents such as psyllium or methylcellulose or pectin may also be helpful while avoiding the risk of precipitating toxic megacolon.

Emotional stress frequently accompanies inflammatory bowel disease. Judicious use of anti-anxiety agents may be helpful. Tricyclic antidepressants (such as amitriptyline) given in low dose before bedtime can improve sleep quality while decreasing cramping and diarrhea due to their anticholinergic effects.
(Source: Ann Intern Med 1991; 114:381.; Scand J Gastroenterol 1996;31:792.; Eur J Gastroenterol Hepatol 1998;10:783.

Formula to Practice
Fecal osmolal gap= (290 - 2 X (stool Na + stool K))

Mnemonic to know
Causes of acute and reversible forms of urinary incontinence –

D:   Delirium
R:   Restricted mobility, retention
I:   Infection, Inflammation, Impaction (fecal)
P:   Polyuria, Pharmaceuticals

Prayer may not change things for you, but it for sure changes you for things. … Samuel M. Shoemaker

What are the types of consent?
Consent may be: Implied, Expressed, Informed depending upon the circumstances.
Consent is not required in situation like medical emergency, for vaccination etc.
If the patient is not medically or legally competent to give consent then the consent of the parents or guardians or any person present at the time with the patient can be taken.
Any research on a potential subject, removal of organs for transplantation, publication of information obtained during medical examination also requires consent of the concerned person.

eMedinewS try this it works
Simpler eyedrop administration
Putting eyedrops in an uncooperative or frightened child. Have the child lie supine, with eyes closed. Place one or two drops of medication in the pocket by the medial canthus. When the eyes are opened, the drops flow in.

 Letters to the editor
1. Respected Sir,    A very gud aftrnoon to u!! Many Congratulations for receiving the T.P. Junjhunwala National Excellence Award!! It is ur sheer hard work, sincerity & dedication towards the profession that has made u achieve all of this fame. U SURELY DESRERVE IT!! Thnx for imparting such valuable knowledge to all of us. Dr. Mayank Mawar

2. The concept of "golden hour" emphasizes the urgency necessary for successful treatment of injured patients and is not intended to represent a "fixed" time period of 60 minutes. Rather, it is the window of opportunity during which doctors can have a positive impact on the morbidity and mortality associated with injury. (So: Advanced Trauma Life Support - ATLS - Manual - 8th Edition - 2008); Dr Vivek Chhabra, Faculty, ATLS, American College of Surgeons Committee on Trauma.

3.Respected Dr. Aggarwal, Heartiest congratulations for being conferred the T.P.Junjhanwala National Excellence Award for your outstanding contribution to Healthcare services. You thoroughly deserve this award, not only for you contribution in clinical practice but also for the teaching to medical fraternity. Hats off for your amazing energy. Hope you get lots of such award in future.  Dr Rajiv Bhatt, M.B.B.S., D.T.C.D., D.H.A., M.D.

4.  Respected Dr. Aggarwal, Please accept my heartiest congratulations on receiving T. P. Junjhanwala National Excellence Award. Dr. Neeraj Gupta

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Psychoneuroimmunological research has shown that psychosocial factors, including stress, social support, and emotion may affect susceptibility to infectious disease by influencing the immune system . Because the immune system is a part of a complex and interactive network formed by the brain, neurotransmitters and neuropeptides, secretory glands, and various types of immune cells, no single measure of 'immune functioning' can fully express
immune competence. In several studies, secretory immunoglobulin A (slgA) has been chosen as a measure of resistance to infectious disease, because it plays an important role in the defense mechanism of mucosal membranes. Measuring the Levels of sIgA could also be used in making an Assesment about the Possible Positive Effects of Immunity Booster Health Supplements on our Body.

Eye care snippets by Dr. Narendra Kumar (OptometryToday@gmail.com):

 Ocular pathology detection makes timely referral to the ophthalmologist easier. Recognition of common ocular diseases is made easy once the practitioner becomes familiar with the etiology, general appearance and symptomatology of the various affections. Let us consider some of the common diseases of the eye:

This is a drooping of the upper eyelid which is due to faulty development, weakness or absence of levator palpabrae muscle. The eye appears partially covered. The defect may be present since birth or may develop afterwards. Trauma or injury is also a common cause of ptosis. The patient complains of the cosmetic effect or also of reduced visual acuity.

Blepharitis is characterised by inflammation of the eyelid margins. The condition is often chronic and difficult to manage because it may recur. There is crusting of the eyelids, irritation, burning, foreign body sensation, watering and photophobia, usually worse in the morning. There may be foamy meibomian gland secretions, inferior corneal punctuate keratitis, with a poor tear film and short tear break-up time. There may be eyelash abnormalities like madarosis (loss of lashes), poliosis (whitening of lashes) and trichiasis (misdirection of lashes). Complications of blepharitis include epiphora, dry eyes, conjunctivitis, chalazion, trichiasis, ectropion, entropion, and corneal disease in the form of pannus, keratitis or interference with contact lens wear.

A hordeolum, or stye, is a localised infection/inflammation of the eyelid margin with a yellow point of pus, which is painful. Sometimes a secondary conjunctivitis may also be present. It occurs at all ages. Recurrence of the condition is very common.

It is a small, painless swelling of a meibomian gland following the obstruction of its duct. It appears as a small firm pea in the eyelid. There is a small spot of discolouration of conjunctival lining at the site of the chalazion. Chalazion may be present in the eyelid for a long period without causing any trouble.

This is bending inwards of the eyelashes which rub against cornea, and this results in pain, watering, foreign body sensation and ulceration of cornea. The eyelid margins in this condition are in their normal position. Chronic trachoma, blepharitis, chemical burns and injuries are the common causes. The cause may also be involutional (due to ageing) change.

Entropion is the inversion of the eyelid with the lid margin turned inwards toward the globe. The patient complains of excessive tearing, irritation, redness end eye discomfort or pain. The discomfort is due to the lashes rubbing against the conjunctiva and cornea.

This condition is an abnormal eversion of the lid from the globe, resulting in corneal exposure, tearing and visual loss. Ectropion usually involves the lower lid, and there may be horizontal lid laxity. The condition may be congenital or acquired. Congenital cases are rare. Acquired types include involutional, paralytic and mechanical.

Conjunctivitis is inflammation of the conjunctiva, characterised by hyperemia (injection of blood vessels), chemosis (oedema) and mucus discharge; may or may not be infectious. There may be discomfort, foreign body sensation, photophobia, and lacrimation. Eyes or eyelids are itchy in allergic conjunctivitis. Conjunctivitis may be primary, with no associated disease. It may also be secondary to, say, a local spreading of inflammation from dacryocystitis (an inflammed lacrimal sac), or may even be contact lens-induced. It can be either acute or chronic. Common causes of conjunctivitis are bacteria, viruses and allergy.

Vitamin A deficiency
Our bodies need vitamin A for the maintenance of epithelial surfaces, for immune competence, for the normal functioning of the retina, and for growth, development, and reproduction. We obtain vitamin A from two sources: firstly, from fat soluble vitamin A present in milk, eggs, butter, and fish liver oils; secondly as provitamin A carotenoids in dark green leafy vegetables, red palm oil, and in red or orange coloured fruits and vegetables such as mango, papaya, sweet potato, and carrots. Inadequate intake of vitamin A over a prolonged period can result in clinical vitamin A deficiency, called xerophthalmia, and characterized by the ocular features of night blindness, keratomalacia (lower part of the cornea becomes soft, turns white, and bulges out), Bitot’s spots (foamy white patches on the conjunctiva), corneal drying (xerosis), and corneal ulceration, softening and necrosis, and a generalised impaired resistance to infection. A child with inadequate liver stores of vitamin A is susceptible to blinding xerophthalmia and respiratory infection that can lead to death from febrile illnesses. Periodic supplementation with a large dose of vitamin A in capsule form for children at high risk of vitamin A deficiency has been shown to reduce mortality.

This disease is characterized by the presence of typical follicles particularly on palpebral conjunctiva and in fornices. There is much conjunctival discharge, itching, irritation and burning sensation, lacrimation and inability to face light. This is an infectious disease.

This is a triangular fold of conjunctiva on to the cornea with its apex directed to cornea and base to sclera. It is usually present on the nasal side and causes little discomfort. If extensive in nature, it may cause vision deterioration.
Sub-conjunctival haemorrhage
Usually confined to a small area, the vessels of conjunctiva rupture due to injury, and in severe coughing and vomiting. There is no pain. In aged persons check up of cardio¬vascular system should be advised as a routine.

Dacryocystitis is infection/inflammation of the lacrimal sac. This is due to the obstruction of the naso-lacrimal duct. In acute dacryocystitis, there is sudden onset of pain and there is oedema in the lacrimal sac region. Tenderness is localized in the medial canthus region but may extend to nose, cheek, teeth and face. There is excessive watering. Pus exudes from the lower punctum on pressure over the sac. If the condition remains untreated for long, this may lead to an abscess.

This is a conical bulging outwards of the centre of cornea, resulting in myopic astigmatism which cannot be corrected with glasses. It is not very common. It can be helped with the use of rigid gas-permeable contact lenses. This is a non-inflammatory condition.

Corneal opacity
Corneal opacities result from inflammation, ulcers or injury. A faint opacity is called 'nebula'. A more pronounced scar is known as 'macula'. And a dense white scar is called 'leucoma'. These interfere with vision when involving pupillary area.

Corneal ulcer
There is photophobia characterised by inability of the patient to keep the eyes open even in average light. Also present are pain, defective vision, watering and redness. Staining with fluorescein turns the affected portion of the cornea green, because of the destruction of epithelium.

Corneal foreign body
A foreign body on corneal surface, if superficial, can usually be seen with a simple torch. A recent, superficial foreign body can be lifted off the cornea with a disposable hypodermic needle after putting local anaesthetic drops. Antibiotic drops are then prescribed by the ophthalmologist to take care of the abraised corneal surface. Corneal foreign body results in acute pain, redness, and watering, and its removal brings about dramatic relief.

This is a red spot at scleral surface away from limbus. There is pain but no discharge. In superficial scleritis, there is no effect on vision. But vision may become seriously affected if glaucoma follows as a complication. This is an inflammatory condition. Inflammation of the uveal tract (involving choroid, iris and ciliary body) is also commonly present along with this disease.

Pain is the most common symptom of the inflammation of the iris, which may radiate to the forehead, to the temple, or to the upper jaw. Iris becomes swollen and lusterless. Pupil becomes constricted. Vision is usually adversely affected. Inflammation of the ciliary body and that of choroid may accompany or follow this disease and aggravate the condition.

Uveitis in an inflammation of the uveal tract (the continuous layer of iris, ciliary body and choroid). It may be acute, chronic, or recurrent depending on its onset and the subsequent course. Uveitis may be caused by trauma or by the invasion of the eye with micro organisms from the outside or from within the patient (due to underlying systemic disease like ankylosing spondylitis, tuberculosis). In uveitis, vision is blurred and the eye becomes red and painful with watering and photophobia. Redness is especially marked in circum-corneal zone. Iris oedema results in somewhat constricted pupil. If not treated in time and adequately, there may be complications like synechiae (adhesions), secondary glaucoma, vitreous opacities, corneal changes (keratitis), and cataract.

Glaucoma - commonly known in vernacular as 'kala pani' or 'kala motia' if allowed to remain untreated
even for a short period, can actually make the world dark for the affected eye. Glaucoma is the rise in
pressure inside the eyeball because of the above-normal manufacture of aqueous humour and/or its poor circulation. The sufferer gets sudden severe pain in temples accompanied by redness and blurring of vision with or without vomiting. There is no discharge. Sudden loss of sight in one eye on waking up in the morning is also not uncommon. The disease affects persons of both sexes usually above the age of 40 years, and is bilateral in nature. The cornea is steamy, pupil dilated and non-reacting to light, and intra ocular pressure elevated. Fundus shows changes of degeneration of the optic disc and of the retina. Prompt medical attention is aimed at bringing down the tension of the eyeball. Miotics (e.g. Pilocarpine eye drops) are instilled in eyes at frequent intervals till tension comes down to a safer level. Systemically administered drugs (e.g. Diamox tablets) act by inhibiting the secretion of aqueous. Surgical intervention may be necessary sometimes to drain out excessive aqueous humour.

The condition of lenticular opacity is known as cataract, the most commonly prevalent diseases resulting in curable blindness. Cataract may be senile when it appears as a sign of ageing process, it may be traumatic when it results from perforating injury, or it may be complicated with the presence of associated ocular pathology. The patient complains of gradually diminishing vision in the affected eye. Inability to read in bright light is a common complaint in central lens opacity. The patient often discards reading glasses because of the development of myopia. There is no inflammation. Lenticular area shows opacity especially on dilated pupil. When cataract is mature the ophthalmoscope cannot reveal fundus details. Intraocular tension should always be noted at regular intervals in all cataract cases as a safeguard against glaucoma. Urine and blood sugar estimation should be advised to rule out diabetes. When cataract interferes with daily activities of a person the opacified lens is removed and an intra-ocular lens (IOL) is implanted.

(charitable trust Eye Care India kumars@vsnl.com)