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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,

19th January, Tuesday, 2010

Health Advisory: Revised Rabies Postexposure Prophylaxis Protocol - Fifth Dose of Vaccine No Longer Necessary for Most Persons

On June 24, 2009, the ACIP approved new recommendations on the use of rabies vaccine for post-exposure prophylaxis in unvaccinated persons for the prevention of human rabies.

The Advisory Committee on Immunization Practices has advised that the 5-dose schedule be changed to four doses, eliminating the last dose administered on day 28.

A regimen of 4 one-mL vaccine doses of rabies vaccine (HDCV or PCECV) should be administered intramuscularly to previously unvaccinated persons with no immunosuppression. The first dose of the 4-dose course should be administered as soon as possible after exposure. This date is considered day 0 of the post-exposure prophylaxis series. Additional doses should then be administered on days 3, 7, and 14 after the first vaccination. Considerations for the site of the intramuscular vaccination remain unchanged. For immunocompromised patients, five doses of vaccine should still be given as previously recommended. The recommendations for use of immune globulin remain unchanged. 

For persons who previously received a complete vaccination series (pre-or postexposure) with a cell culture vaccine or who have previously had a documented rabies virus neutralizing antibody titer following vaccination with non-cell-culture vaccine, the recommendation for a 2-dose postexposure vaccination series has not changed at this time.

Rabies post-exposure prophylaxis protocol
All Rabies Rabies post-exposure prophylaxis should begin with immediate thorough wound cleansing with soap and water and irrigation of the wound with a viridical agent such as povidone-iodine solution when available. RPEP includes administration of both HRIG and vaccine, except in previously vaccinated persons.

PEP for previously unvaccinated persons
1. A single 20 IU/kg body weight dose of HRIG, infiltrated into and around the wound, should be given when PEP is initiated (day 0). If it is not possible to infiltrate the entire dose, the remainder should be administered intramuscularly at a site distant from the site of rabies vaccination.

2. Four doses of vaccine (1 ml administered IM) in the deltoid area or, for small children, in the anterolateral aspect of the thigh. Rabies vaccine should never be given in the gluteal area. The first vaccine dose is given when PEP is initiated on day 0 (the same day as HRIG is administered) and three additional doses are given 3, 7, and 14 days after the first vaccination.

3. Persons with immunodeficiencies (either due to illness, medication, or therapy for the illness or condition) should continue to receive a fifth dose of rabies vaccine 28 days after the first vaccination. When administered to an immunosuppressed person, one or more serum samples should be tested for rabies virus neutralizing antibody to ensure that an acceptable antibody response has developed after completing the series. A patient who fails to seroconvert with an acceptable antibody response after the fifth and last dose should be managed in consultation with their physician and appropriate public health officials.

4. Previously vaccinated persons are those individuals who have received either: A complete rabies pre-exposure or post-exposure prophylaxis regimen in accordance with ACIP recommendations with a modern, cell culture-derived rabies vaccine or Rabies vaccination following another protocol or with another vaccine with a documented rabies virus neutralizing antibody titer.

5. PEP for previously vaccinated persons consists of two doses of rabies vaccine (1 ml administered IM) given on day 0 and day 3. HRIG is not given to previously vaccinated persons receiving PEP.

6. Persons having previously received a 4-dose PEP regimen will be managed as 'reviously vaccinated' individuals in the event of a subsequent exposure.

Dr KK Aggarwal
Chief Editor

Breaking news
Low dose aspirin in the primary prevention of cardiovascular events in healthy individuals with asymptomatic atherosclerosis is not warranted, as per  Dr Gerry Fowkes (University of Edinburgh, Scotland) researchers of Aspirin for Asymptomatic Atherosclerosis (AAA) trial presented at the European Society of Cardiology (ESC) 2009 Congress.In the randomized trial of 3350 subjects deemed at high risk for cardiovascular and cerebrovascular events because of a low ankle-brachial index (ABI) (<0.95), aspirin had absolutely no effect on reducing events compared with placebo. However, aspirin did increase the risk of major hemorrhage.

American Heart Association, Orlando, FL ( November 14 - 18, 2009)
1. The FDA has issued a public health advisory warning patients and physicians that concomitant use of clopidogrel and omeprazole  blunts the antiplatelet effect of clopidogrel, so the combination should be avoided.

2. An early repolarization pattern in the inferior leads of a standard electrocardiogram is associated with an increased risk of cardiac death in middle-age individuals. A J-point elevation of at least 0.1 mV in the inferior leads was associated with a 28% higher risk of cardiac death in the general population of Finland (RR 1.28, 95% CI 1.04 to 1.59) (Jani Tikkanen, BS, University of Oulu, Finland).

3. Maximizing the dose of the angiotensin receptor blocker losartan for heart failure patients may reduce mortality and heart failure hospitalization. Use of a 150 mg dose instead of a 50 mg dose would prevent one death from any cause or admission for heart failure for every 31 patients treated over four years (P=0.027) (Marvin A. Konstam, Tufts University, Boston)

4. Treating iron deficiency in heart failure patients makes patients feel better even in the absence of anemia. Intravenous iron increased the odds for at least a moderate improvement in patient-reported heart failure symptoms (50% versus placebo 28%, p<0.001). (Dr Stefan D. Anker,Charité Universitatsmedizin, Berlin)

5. Pacing both ventricles of the heart, rather than just the right ventricle, may prevent declines in left ventricular function for patients with bradycardia but initially normal ejection fraction. Left ventricular ejection fraction was maintained with biventricular pacing but fell with right ventricular pacing for an absolute difference of 7.4 percentage points at 12 months (p<0.001) (Dr Cheuk-Man Yu,Chinese University, Hong Kong)

6.  People who play active video games such as Wii Sports or Wii Fit may actually be breaking a sweat: researchers say that the same provide the equivalent of a moderate-intensity workout.
Gamers expended energy equal to walking on a treadmill at three miles an hour or more (3 metabolic equivalents, or METs) during a third of the games tested in a Nintendo-funded study. (Motohiko  Miyachi, National Institute of Health and Nutrition,Tokyo.)

7. Heart failure patients with a normal left ventricular ejection fraction have an impaired heart rate response to exercise compared with healthy individuals. They also have abnormal heart rate recovery after they've finished exercising. (Thanh Phan, University of Birmingham,England)

8. For infants with single ventricle congenital heart defects, ACE inhibition does not improve growth or heart remodeling. No height or weight measurements increased significantly in infants treated with enalapril compared with placebo. (Daphne T. Hsu, Children's Hospital, Montefiore, New York City).

Coference Information
RGCON-2010 has DMC 20.15 CME credit hours. Conference would be beneficial to all the medical professionals registered with DMC. They can have access to the details of the Conference from our website www.rgci.org/rgcon2010. Prof. N. R. Datta, Organizing Secretary, RGCON-2010, Department of Radiation Oncology, Rajiv Gandhi Cancer Institute & Research Centre, Telefax:  11- 47022621, Fax: 11-27051037

ZENIMMUNE FACT: Zenimmune shield is a strong immunity booster, helps in prevention of various allergic disorders and recurrent infections.


Our HIP's

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.

Dr Good Dr Bad
Situation: A 45-yr-old male came with chest pain and normal ECG
Dr Bad: Take antacids.
Dr Good: It seems to be a cardiac pain.
Lesson: ECG can be normal in the first six hours of acute heart attack

Make sure
Situation: A patient with antibiotic-associated diarrhea was not responding to IV vancomycin.
Reaction: Oh My God! Why was IV dose prescribed?
Make sure that only oral vancomycin is used in the dose of 125 mg four times daily (or 500 mg TDS). Oral vancomycin is not absorbed systemically and achieves predictably high levels in the colon. IV vancomycin has no effect on C. difficile-colitis since the antibiotic is not excreted appreciably into the colon. (Source: Am J Med 1989;86:15)

Formulae Imaging
A minimum of 175 mL of pleural fluid is necessary to obscure the lateral costophrenic sulcus on an upright chest radiograph.

Mistakes in clinical practice
Clinicians under-prescribe medications, such as statins, that could provide benefit for older adults.

ENT Facts
Acute mastoiditis, inflammation of the petrous bone adjacent to the middle ear, is infrequently clinically significant, but may be severe in the elderly.

SMS Anemia
A hemoglobin(Hb) <13.5 g/dL or a hematocrit HCT <41.0 percent represents anemia in men.

Emedinews-Try This : It Works
Cotton swabs can prevent eye injury
Treatment of verruca vulgaris, papules, minor cysts, or verruca plana in the eyelid area with cryotherapy or electrodesiccation carries the risk of damaging the globe of the eye. Thermal damage to the eye during such procedures can be prevented by inserting the cotton tip of an applicator (thickened by an additional layer of cotton swab) between the inner surface of the eyelid and the sclera. Patients who wear contact lenses may want to remove them before the procedure to avoid contact between the lens and the applicator.

Milestones in Neurology
Edgar Douglas Adrian, 1st Baron Adrian OM PRS London was a British electrophysiologist and recipient of the 1932 Nobel Prize for Physiology, won jointly with Sir Charles Sherrington for work on the function of neurons.

Mnemonic to Know
SITTT : Causes of hematuria
S: Stone
I: Infection
T: Trauma
T: Tumor
T: Tuberculosis

Laughter The best Medicine
Anatomy - something that everybody has but somehow looks better on a girl.
Practical prayer is harder on the soles of your shoes than on the knees of your trousers.  ~Austin O'Malley

Can the Income of a trust which is created for the benefit of any particular religious community or caste, be allowed as exemption? 
Any income of a trust which is created for benefit of any particular religious community or caste is not allowed as exemption.

Is a Doctor duty bound to obtain consent?
One of the duties of a doctor towards his patients is to obtain consent before any medical examination or procedure. Any examination without prior consent amounts to an assault on the patient. 


Docconnect milestones
Docconnect is officially endorsed by several medical associations including Indian Academy of pediatrics (IAP) (Hyderabad), Association of Obstetrics and Gynecologists of Delhi (AOG) (Delhi), EDPA (Delhi) and AMC (Noida)

(Dr Vivek Chhabra)
1. Telegraph: Mothers who opt for caesarean risk health: Mothers-to-be should only give birth by caesarean when strictly necessary, according to a new study. Figures suggest caesareans carried out during labor without pressing medical reasons were 14 times more risky than a normal birth. Data from the World Health Organization’s global maternal survey - published in the Lancet medical journal - found pregnant women who had C-sections were more likely to die in childbirth or suffer serious complications, such as needing intensive care treatment, blood transfusion or hysterectomy.

Letters to the editor

1. Dr Narendra has summed up opthalmology in just a few words for all to recapitulate it. I hope others do the same, while still maintaining that it is all basically to the efforts of KK.

2. Dear News Mag Med Ijcp, I strongly recommend this website www.justdial.com. It's a world class local search service & I've always found anything I've ever wanted.You can find info on any company, product, or service in over 240 cities in India. You can also call them up 24x7, on phone (69999999), a local call in 240 Indian cities.Ask for anything, you'll get the info on the phone and/or by SMS within 30 secs, and this service is at no cost!Krishan Kumar Arora


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