18th February 2010, Thursday
Aortic valve replacement: the right time
Aortic valve replacement should be performed in all patients with symptomatic aortic stenosis (AS) (heart failure, syncope or angina). The life span is less than 4 years without surgery. Surgery is associated with marked reductions in symptoms and mortality.
Valve replacement should not be done for isolated severe AS in asymptomatic patients unless not doing so may be risky to life. [Remember the formula: your own 'nalayak' son is better than the 'layak' adopted son unless he is a risk to your life).
High–risk situations are enlisted in the ACC / AHA guidelines. Such patients require careful monitoring as most will develop symptoms after a brief period.
ACC / AHA Guidelines
Class I – There is evidence and/or general agreement that AVR is indicated in patients with AS in the following settings
Symptomatic severe AS.
Severe AS in patients undergoing coronary artery bypass graft surgery or surgery on the aorta or other heart valves.
Severe AS with a left ventricular ejection fraction less than 50 percent.
Class IIa – The weight of evidence or opinion is in favor of the usefulness of AVR in patients with AS in the following setting
Moderate AS in patients undergoing coronary artery bypass graft surgery or surgery on the aorta or other heart valves.
Class IIa – The weight of evidence or opinion is less well established for the usefulness of AVR in patients with AS in the following settings
Severe AS in asymptomatic patients who have an abnormal response to exercise such as the development of symptoms or hypotension.
Severe AS in asymptomatic patients with a high likelihood of rapid progression (as determined by age, valve calcification, and coronary heart disease).
Severe AS in asymptomatic patients in whom surgery might be delayed at the time of symptom onset.
Mild AS in patients undergoing coronary artery bypass graft surgery in whom there is evidence, such as moderate to severe valve calcification, that progression may be rapid.
Extremely severe AS (aortic valve area less than 0.6 cm2, mean gradient greater than 60 mmHg, and aortic jet velocity greater than 5.0 m/sec) in asymptomatic patients in whom the expected operative mortality is 1 percent or less.
Class III – There is evidence and/or general agreement that AVR for AS is not useful in the following settings
For the prevention of sudden cardiac death in asymptomatic patients who have none of the class IIa or IIb findings.
Source: J Am Coll Cardiol 2006;48:e1. and excerpts from a symposium held at Medanta: The Medcity.
Dr KK Aggarwal
News and Views
Blood test for Alzheimer’s disease
OPKO Health is developing a simple diagnostic blood test for Alzheimer’s disease. The test which has been designed to detect elevated levels of antibodies unique to the disease,. had 95 percent accuracy in early testing.
Consuming chocolate may reduce stroke risk
A new analysis, which involved a review of three prior studies, suggests eating about a bar of chocolate a week can help cut the risk of stroke and lower the risk of death after a stroke. Researchers in Canada has shown that 44,489 people who ate one serving of chocolate per week were 22% less likely to have a stroke than people who ate no chocolate. The second study showed that 1,169 people who ate 50 grams of chocolate once a week were 46% less likely to die following a stroke. The third study, however, "found no association between chocolate consumption and risk of death from stroke.
Depression during pregnancy
According to a study published in the Feb. 5 issue of the journal Child Development, children born to women who were depressed during pregnancy were four times as likely to be arrested for violent crimes by age 16 than children of nondepressed mothers.
Predicting Prognosis and Treatment Response in a Subset of Pancreatic Cancer Patients Specific chemical modifications to proteins called histones, which are found in the nucleus of cells and act as spools around which DNA is wound, can be used to predict prognosis and response to treatment in subsets patients with pancreatic cancer, a study by researchers at UCLA’s Jonsson Comprehensive Cancer Center has found.
Prepregnancy, Obesity and Gestational Weight Gain Influence Risk of Preterm Birth Researchers at Boston University School of Medicine’s Slone Epidemiology Center and Boston University School of Public Health have shown that pre–pregnancy obesity and gestational weight gain are associated with an increased risk of preterm birth in African American participants from the Black Women’s Health Study. This study is published on–line in Epidemiology.
Suture better than staples (Dr G M Singh)
Women who’ve had a cesarean delivery are less likely to suffer complications if their wound is closed using sutures rather than staples. The researchers at the Lehigh Valley Health Network in Allentown, Pa., found that wound separation rates were 16.8 percent for staples and 4.6 percent for sutures; composite wound complication rates were 21.8 percent for staples and 9.1 percent for sutures; and that 36 percent of women who received staples required post-surgery physicians visits, compared with 10.6 percent of women who received sutures. Median surgery time for women who received staples was 49 minutes, compared with 57 minutes for those who received sutures. (Annual meeting of the Society for Maternal–Fetal Medicine in Chicago).
Basic Life Support (BLS) Provider Course
Target Audience – All Healthcare Personnel & General Public
Date: February 20, 2010
Venue: 142, Bharathiyar Road, Papanayakanpalayam, Coimbatore, Tamil Nadu.
Normal fasting sugar should be < 100 mg%. As above this level the process of atherosclerosis starts.
Ibuprofen May Increase Heart Problems
Ibuprofen, the popular over–the–counter painkiller, may increase
the odds of heart problems in patients who have osteoarthritis and are taking daily low dose aspirin to help lower their cardiovascular risk, said Dr. K K Aggarwal, President, Heart Care Foundation of India and Editor eMedinewS.
Quoting a study published in the Annals of the Rheumatic Diseases, Dr. Aggarwal said that ibuprofen may cancel out the cardio–protective effects of daily low–dose aspirin.
In the study, use of ibuprofen and aspirin boosted arthritis patients’ one–year heart attack and stroke risk nine–fold.
Previous studies have suggested that drugs known as cox–2 inhibitors, as well as non–selective nonsteroidal anti–inflammatory drugs (NSAIDs), increase the risk of cardiovascular events. Many cox–2 inhibitors have been withdrawn from the market.
In the study investigators revisited data on more than 18,000 individuals over the age of 50 with osteoarthritis, comparing the cox–2 inhibitor lumiracoxib with either ibuprofen or naproxen. Ibuprofen and naproxen are both traditional NSAIDs.
In the study, high–risk patients taking aspirin and ibuprofen were about nine times more likely to have heart attacks and strokes over one year as those taking lumiracoxib. People taking ibuprofen were also more likely to develop congestive heart failure than those taking the cox–2 inhibitor.
The findings, are important as ibuprofen is easily available and if cardiac patients take this over–the–counter pills it may be dangerous. It can block the effect of aspirin, so there can be more heart failures, more heart attacks and more hypertension.
This is an important public health message.
Question of the day
What is refractory ulcerative colitis?
Regardless of the extent of colonic involvement, some patients remain symptomatic despite optimal doses of oral 5–aminosalicylic acid (5–ASA) drugs, topical therapy with either 5–ASA or steroids and systemic corticosteroids. In these patients, additional medical therapy should be considered.
Mistakes in Clinical Practice
"U" and "IU" – The "U" can easily be mistaken as the number "0", particularly when the "U" is written too closely after the number. This can lead to tenfold overdoses. And "IU" can be mistaken for "IV" or the number "10". So instead of using "U" and "IU", use the terms "unit" and "international unit".
eMedinewS Try this it Works
Arm drop test for parkinsonian rigidity
In patients who have muscle rigidity associated with parkinsonism, a simple arm drop test can help confirm the diagnosis. To test arm drop, have the patients hold their arms straight out to the sides, parallel to the ground. Tell them to drop the arms to their sides. In patients with rigidity, the arms descend slowly and do not make the slapping sound against the thighs that this maneuver normally makes.
Dr Good Dr Bad
A patient with acute heart attack was not fit for reperfusion therapy.
Dr Bad: Start 60 mg prasugrel.
Dr Good: Chew 300 mg aspirin and 300 mg clopidogrel.
Lesson: For patients receiving no reperfusion therapy, start clopidogrel 300 mg as opposed to prasugrel. (Prasugrel is soon being marketed in India)
Thought for the day
People are tired of words. However we still need to use words, so how could words become a means of giving an experience? For this we need to pay attention to the alignment of thoughts, words, and actions. Words are such they could either ‘make’ or ‘break’. Words have broken relationships into so many pieces. Now I am staying in a peace palace and my job is to put back together all the broken pieces. Ask yourself, who is inside the temple of my heart? Who is the one who has made my heart into a temple? Make the temple of your heart such that others can take rest and comfort with your pure feelings. God is looking for instruments who can do such service to others. Now, look at the time, the fortune of being an instrument for world service, and transform yourself. Do not get stuck in the thought that others should transform, but transform yourself and be free from bondages. This time of transformation will not come again. Keep the determination that it is now or never. [Dadi Jankiji]
Situation: A patient with hypertension developed bleeding at the puncture site while on intergrilin therapy.
Reaction: Oh My God! Why was the Anti–Platelet Agent Started?
Make Sure the BP is checked before starting intergrilin. Severe hypertension (systolic blood pressure>/ 200 mmHg or diastolic blood pressure >110 mmHg not adequately controlled on antihypertensive therapy is a contraindication for intergrilin therapy.)
Message of the day ( Dr G M Singh)
If couples lead an overall healthy lifestyle, they could reduce their sub fecundity by more than 50%. In turn, they could create a healthier environment for their future child.
Laughter the best medicine
Patient: My hair keeps falling out. What can you give me to keep it in?
Doctor: A shoebox.
Quote of the Day
Any concern too small to be turned into a prayer is too small to be made into a burden. (Corrie ten Boom)
Formulae in Critical Care
Inspiratory capacity (IC) Formula: IC = IRV + TV
IRV : Inspiratory reserve volume
TV: Tidal volume
Iron–deficiency anemia has been associated with increased risk of death from circulatory disease.
Milestones in Neurology
Vladimir Mikhailovich Bekhterev (1857 – 1927) was a Russian Neurologist and the Father of Objective Psychology. He is best known for noting the role of the hippocampus in memory, his study of reflexes, and Bekhterev's Disease. Moreover, he is known for his competition with Ivan Pavlov regarding the study of conditioned reflexes.
LIST OF APPROVED DRUG FROM 1.01.2009 to 31.10.2009
Cetirizine 5/10mg + Ambroxol 30mg per 5ml syrup
For the symptomatic relief of productive cough associated with allergic rhinitis, when both anti–histamine and mucolytic agents are desired
Silicic Acid and Herbs: A New Approach.
Various clinical studies have proved that silicic acid as sodium metasilicate, has a synergistic effect with concomitant use of relevant herbal extracts when both are used in conjunction. Silicic acid and herbs compliment each other and in fact, the Herbs potentiate the absorption, assimilation and response to sodium metasilicate. Herbal extracts are known to enhance the Bio-availability of Sodium Metasilicate at the cellular Level and thus play a significant role to be a part of silicic acid supplementation. Interestingly, The most popular brands of silicic acid health Supplements, Available in the USA Market contain Herbal Extracts along with the Silicic acid as a major Ingredient. Sodium Metasilicate is NOW available in India as ZENIMMUNE Range of Products.
Advertising in emedinews
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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.
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 cum Retreat
A stress management workshop cum retreat 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 email@example.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 firstname.lastname@example.org
International Symposium on ‘Yogism for Healthy & Happy Living and Aging’
The International Symposium on ‘Yogism for Healthy & Happy Living and Aging’ will be organised on December 6–7, 2010. Contact BC Harinath, Director, JBTDRC & Coordinator, BIC & Arogyadham Mahatma Gandhi Institute of Medical Sciences, Sevagram – 442102, Wardha, Maharashtra, India, E-mail: email@example.com, firstname.lastname@example.org
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Respected Sir, I am Dr. Priyank Jain, Ur CME student, I heartily congratulate u for Padmshri award, may god give u happy & long life. Sir i requesting u, please mail me all formulae of Dr.KK like, formula of 80,etc because i was not able to write them all in the class. This will help me for exams & practice. Thank u sir: Dr.Priyank Jain.
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Respected Dr Aggarwal, We are really Proud of the great pride, done to medical fraternity, for being honored with The prestigious Padam Shri: Mrs Veena, Dr V K Bhatia, Panipat
Congrats for the great achievement which you truly deserved. Keep your philanthropic spirits and always remember you are a national asset now. Cheers: Lion Girish Chaudhry
My heartiest congratulations to you and family on getting prestigious Padmashri award. May God bless you: Sanjay Kumar Aggarwal, Addl. Dist. & Session Judge
Mubarak to bahut ayi hongi par yeh dil ke core se hai: Dr. Avtar Krishan