emedinews
Head Office: 39 Daryacha, Hauz Khas Village, New Delhi, India. e-Mail: drkk@ijcp.com, Website: www.ijcpgroup.com
FIRST NATIONAL DAILY eMEDICAL NEWSPAPER OF INDIA
emedinews is now available online on www.emedinews.in or www.emedinews.org
Dr KK Aggarwal

From the Desk of Editor in Chief
Padma Shri and Dr B C Roy National Awardee

Dr KK Aggarwal
President, Heart Care Foundation of India; Sr Consultant Physician, Cardiologist and Dean Medical Education Moolchand Medcity; Member Delhi Medical Council; Chairman (Delhi Chapter) International Medical Sciences Academy; 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); Editor in Chief IJCP Group of Publications & Hony. Visiting Professor (Clinical Research) DIPSAR


YOU CAN DOWNLOAD EMEDINEWS AT www.emedinews.in

Dear Colleague

19th March 2010, Friday

Oculo stenotic reflex

If a coronary lesion measures 50% on angiogram on an asymptomatic pateint the cardiologist (and patient) may be tempted to stent the lesion. "If you see a blockage you must open it and stent it" is the reaction referred to in the medical literature as the oculo–stenotic reflex.

Fractional Flow Reserve, or FFR, is a guide wire–based procedure that can accurately measure blood pressure and flow through a specific part of the coronary artery. The procedure is carried out through a standard diagnostic catheter at the time of a coronary angiogram. Measurement of Fractional Flow Reserve has been shown to be useful in assessing whether or not to perform angioplasty or stenting on ‘intermediate’ blockages.

The objective of opening up blockages in the coronary arteries is to increase blood flow to the heart. But several studies have shown that if a functional measurement, such as FFR shows that the flow is not significantly obstructed, the blockage or lesion need not be opened and the patient can be safely managed with drugs.

A few minutes of measurement with a special guide wire may reveal that an intervention won’t have a significant impact on this particular blockage. Being able to better select cases not only saves  costs, but contributes to more appropriate patient care. (with input from Dr Farooquee)

Dr KK Aggarwal
Chief Editor


News and Views (Dr G M Singh)

Management of the patient with statin intolerance

Strategies for managing statin intolerance include changing statins, intermittent dosing, intensification of lifestyle modifications, and using other LDL–C–lowering agents such as ezetimibe, bile acid sequestrants, and LDL apheresis in suitable patients. More controversial approaches include red yeast rice, coenzyme Q10, and vitamin D supplementation. New therapies to lower LDL–C are in development.

Phototherapy for chronic musculoskeletal pain

Prolotherapy is an injection–based complementary and alternative medical therapy for chronic musculoskeletal pain. Prolotherapy techniques and injected solutions vary by condition, clinical severity, and practitioner preferences; over several treatment sessions, a fairly small volume of an irritant or sclerosing solution is injected at sites on painful ligament and tendon insertions and in adjacent joint space during several treatment sessions. Prolotherapy is becoming increasingly popular in the United States and internationally and is actively used in clinical practice. Prolotherapy has been assessed as a treatment for various painful chronic musculoskeletal conditions that are refractory to ‘standard of care’ therapies. Although anecdotal clinical success guides the use of prolotherapy for many conditions, clinical trial literature supporting evidence–based decision–making for the use of prolotherapy exists for low back pain, several tendinopathies, and osteoarthritis.

Conference Proceedings

Conference on Retroviruses and Opportunistic Infections (as reported by medpage)

  1. Antiretroviral treatment is highly effective at reducing risk of HIV transmission to uninfected partners, prospective data has affirmed. The 92% reduction in risk of transmission dropped the incidence of in–couple transmission from 2.23% to 0.39%, according to Deborah Donnell, PhD, of the Fred Hutchinson Cancer Research Center in Seattle.

  2. Four years of clinical data indicate that patients infected with human immunodeficiency virus and treated with the integrase inhibitor raltegravir fare as well as patients treated with efavirenz. There is no difference between these patients in efficacy after 192 weeks, but the side effects on lipids favor raltegravir, said Eduardo Gotuzzo, MD, director of infectious diseases, Hospital Nacionale Cayetano Heredia, Lima, Peru.

  3. HIV-positive people can markedly reduce their risk of heart attack and forms of cardiovascular disease if they stop smoking. In a large international cohort study, HIV patients who smoked had a significantly elevated risk of cardiac events, according to Kathy Petoumenos, University of New South Wales Sydney, Australia.

  4. Women may be highly vulnerable to HIV during pregnancy, suggesting the need for repeat testing during perinatal care in high prevalence areas. Two studies in sub-Saharan Africa showed that 2.6-4.4% of women who were HIV–negative during prenatal care tested positive at or within weeks after delivery.

  5. Once–daily dosing of the protease inhibitor darunavir appeared to be at least as effective as twice–a–day regimens among treatment–experienced patients with no darunavir-associated resistance mutations. (Dr Pedro Cahn, Medical Director, Fundación Huesped, Buenos Aires.)

  6. For people with both HIV and Hepatitis C, a poor response to hepatitis therapy markedly increased the risk of HIV progression and death. Previous research had shown that such patients were at increased risk of liver–related complications and death, according to Dr Juan Berenguer, Gregorio Marañon University Hospital in Madrid.

  7. Among injection drug users, the type of needle used and the temperature it’s stored at can substantially affect the risk of transmitting hepatitis C virus. Syringes with detachable needles appeared by far to be the most likely to transmit the virus, Dr Elijah Paintsil, of Yale, and colleagues showed in a laboratory study.

  8. HIVV infection did not make the H1N1 pandemic flu more dangerous, and catching the pandemic flu did not worsen the progression of HIV, according to Dr Esteban Martinez, Hospital Clinic, Barcelona.

  9. People with HIV are at increased risk from fragility fractures in the hip or backbone. In a large cohort of more than 119,000 veterans, HIV was associated with a 38% increase in the risk of such fractures, even after adjustment for other risk factors, according to Julie Womack, PhD, VA Connecticut Healthcare System, West Haven, Conn.

  10. A potent capsaicin patch, recently approved to ease neuropathic pain from shingles, burned hopes for similar efficacy in HIV–associated distal sensory polyneuropathy.The patch reduced pain scores by 29.5% to 32.8% in affected HIV patients, Dr David Clifford,of Washington University in St. Louis, Mo., and colleagues found in a nearly 500–patient clinical trial.

Prostate CA prevention affirmed for BPH drug

For men with benign prostatic hyperplasia (BPH), dutasteride both prevents prostate cancer and boosts the predictive power of prostate specific antigen. The drug was associated with 40% lower incidence of prostate cancer diagnosis than the BPH drug tamsulosin in at–risk men, according Dr Leonard G. Gomella, of the Kimmel Cancer Center at Thomas Jefferson University in Philadelphia. There was less frequent biopsy in the dutasteride group. Also, the number of cancers confirmed when biopsy was performed –– largely driven by rising PSA –– tended to be higher on dutasteride. Being on dutasteride or another 5–alpha reductase inhibitor appears to transform PSA into a highly specific tool.

PSA threshhold > 20 ng/ml

Most commonly–used methods to determine when to start prostate cancer treatment for men on watchful waiting have a high ‘false trigger' rate. Only the PSA threshold of 20 ng/mL had a low false trigger rate of 14% among men who didn’t need treatment, Dr D. Andrew Loblaw, a radiation oncologist at the Sunnybrook Health Sciences Centre at the University of Toronto, reported at the Genitourinary Cancers Symposium. PSA doubling time and PSA velocity would have triggered treatment for 39% to 84% of the same cohort of men

Conference Calendar

Basic Life Support (BLS) Provider Course (Target Audience – All Healthcare Personnel & General Public). Date: March 25, 2010 . Venue: V Block, No: 70 (Old No: 89) Fifth Avenue Anna Nagar, Chennai, Tamil Nadu.

What’s New

Psychiatry: weight gain

A systematic review of second–generation antidepressants found that mirtazapine and paroxetine were associated with more weight gain than fluoxetine, sertraline, trazodone, and venlafaxine.

Quote of the Day

I believe in prayer. It’s the best way we have to draw strength from heaven. (Josephine Baker)

Diabetes Fact

Amylin effect: Insulin reduces sugar and glucagon increases sugar. Food leads to secretion of amylin, which reduces glucagon and gastric emptying effect. Pramlinitide (amylin analog) reduces glucagon levels. Newer drug. Inj. form

Public Forum (Press Release)

Diabetic or hypertensive: get your albumin tested

Microalbuminuria or presence of albumin in the urine in micro amounts indicates an early kidney damage, early vascular endothelial dysfunction and/or earely atherosclerosis with risk of major cardio or cerebrovascular events and death.

Current guidelines advocate annual screening in patients with diabetes and wherever possible also in non–diabetic patients with hypertension, said Dr. K K Aggarwal, President, Heart Care Foundation of India and Editor eMedinewS.

Early detection of high–risk patients allows selection of aggressive treatment to slow progression of disease.

Antihypertensive agents that provide angiotensin II blockade are recommended for the treatment of hypertensive patients with microalbuminuria, regardless of diabetes and/or early or overt nephropathy. Treatment with these drugs provides effective reduction of microalbuminuria and blood pressure, and long–term prevention of cardiovascular events beyond blood pressure reduction.

Even very low levels of microalbuminuria strongly correlate with cardiovascular risk. Albumin excretion rates as low as 4.8 µg/min, well below the microalbuminuria thresholds are associated with increased risk of cardiovascular and cerebrovascular disease, independent of the presence of other risk factors.

Question of the day

How do you manage a case of multiple disseminated intra–abdominal hydatidosis with spontaneous intrabiliary rupture?

Echinococcal infection constitutes most of the cystic lesions of liver and only 5–10% are distributed along the peripheral arterial system. The most common complication of hydatid cyst is spontaneous rupture into the biliary tract. Hydatid disease (liquid tumor) is a zoonosis caused by larval or cyst stage of Echinococcus granulosus and humans act as accidental and abortive intermediate hosts. Hydatid cysts occur at all ages, in both sexes and anywhere in the body. In unilocular variety, cysts are usually superficial, grow slowly by expansion and internal pressure of cyst may reach upto 300–900 mm of water. Daughter and even grand daughter cysts develop by restructuring and fragmentation of the germinal layer. Intraperitoneal rupture results in explosive showering of viable reproductive elements, which initiates secondary echinococcosis of the peritoneum. Splenic localization is usually due to retrograde invasion via valveless hepatoportal circulation during bouts of increased intra–abdominal pressure.

Endoscopic sphincterotomy, including removal of daughter cysts and hydatid debris (for rupture cyst in CBD) and PAIR technique (for non–communicating hydatid cysts) with antihelminthic chemoprophylaxis is the mainstay of treatment. During the follow–up period, ultrasonography and laboratory investigations are mandatory to assess effective and complete response to treatment. Ultrasonography and CT are complementary tools for diagnosis of hepatic echinococcosis, with endoscopic retrograde cholangiography being the "gold standard" in confirming rupture into the biliary system. Laboratory results are usually nonspecific. Anti–helminthic treatment,should be continued for 1 year. The traditional treatment of biliary cystic fistula is surgery and recently endoscopic sphincterotomy.

Suggested reading z

  1. McGreevy PB and Nelson GS. Larval cestode infections. In: Hunter’s Tropical Medicine Strickland GT (Ed.), WB Saunders, Toronto, Canada 1984:771. 

  2. Zargar SA, Khuroo MS, Khan BA, et al. Intrabiliary rupture of hepatic hydatid cyst: Sonographic and cholangiographic appearances. Gastrointest Radiol 1922;17(1):41–5.

  3. Akkis H, Akinoglu A, Colakoglu S, et al. Endoscopic management of biliary hydatid disease. Can J Surg 1996;39(4):287–92.

  4. Filice C, Brunetti E. Use of PAIR in human cystic echinococcosis. Acta Tropica1997;64:95–107.

eMedinewS Try this it Works

Home made saline nasal spray

Saline solution sprayed into the nose removes irritants, allergens, and excessive mucus. Patients can avoid the expense of repeatedly purchasing saline solution by putting homemade solution into an empty commercial spray bottle. The solution is made by mixing 1/2 tsp of table salt with 8 oz of warm water.

Dr Good Dr Bad

Situation: An elderly female diabetic on pioglitazone developed fractures

Dr Bad: Its not related.

Dr Good: It may be due to pioglitazone.

Lesson: Patients with diabetes using thiazolidinediones, regardless of type, had higher proportions of distal upper and lower limb fractures compared with those not using thiazolidinediones. Fracture proportions do not differ by thiazolidinedione type. Fracture proportions are higher among women and increased with age. (Source: Am J Manag Care 2009;15(8):491-6.)

Make Sure

A 28–year–old male presents with increased frequency and occasional blood in urine. Examination of urine shows sterile pyuria.
Oh my God! Why didn’t you check for TB?
Make Sure to rule out TB in patients with frequency, dysuria, haematuria. Sterile pyuria is the first clue to diagnosis.

Medi Finance Indirect Tax; Budget 2010

OTHERS

  • Boost to SME Sector, and Infrastructure Sector with special emphasis on Road Infrastructure

  • Scope of cases which may be admitted by the Settlement Commission expanded to include proceedings related to search and seizure cases pending for assessment. Scope of Settlement Commission also expanded in respect of Central Excise and Customs to include certain categories of cases that hitherto fell outside its jurisdiction.
Punjab & Sind Bank
 
action
docconnect
 
Central Bank of India
 
Nestle
 
nuspera
 
Docconnect

Laughter the best medicine

Positive Approach

Father: I want you to marry a girl of my choice.
Son: I will choose my bride
Father: But the girl is Bill Gates’ daughter
Son: Well in that case ‘OK’.

Next day:  Father approaches Bill Gates

Father: I have a husband for your daughter
Bill Gates: But my daughter is too young to marry
Father: But this young man is a Vice–president of the World Bank
Bill Gates: Ah..in that case ‘OK’

Finally father goes to see the President of the World Bank

Father: I have a young man to be recommended as a Vice–president
President: But I already more Vice–presidents than I need.
Father: But this young man is Bill Gates’ son in law.
President: Ah& in that case 'OK'

Moral of the story: Even if you have nothing, you can get anything. But your attitude and approach should be positive.

Formulae in Critical Care

Calculation of VLDL
Formula: VLDL = Triglycerides/5

Mistakes in Clinical Practice

Possible confusion with dose designations that include decimal points: A trailing zero after a decimal point can make a 1.0 mg dose look like a 10 mg dose if the decimal point isn’t seen. Similarly .5 mg can look like 5 mg. So don’t use trailing zeros for doses expressed in whole numbers and be sure to use a leading zero when the dose is less than a whole unit.

Lab test (Dr Navin Dang)

To monitor the response to treatment of invasive Breast Cancer and to watch for recurrence of the disease, the blood test recommended is CA 15.3.

SMS of the Day

Diabetic foot: Deformed foot withgood footwear isalways better than amputed foot with advanced prosthesis.

List of Approved drug from 1.01.2009 to 31.10.2009

Drug Name

Indication

Approval Date

Mecobalamin 750 mg + Pyridoxine hydrochloride 1.5 mg + Nicotinamide 45 mg tablets

For the treatment of diabetic neuropathy

27.10.2009


(Advertorial section)

ZEN IMMUNE–FACT SHEET

Zen Immune Power – a known immunity booster with ability to help reduce absorption of aluminum from the GI tract and enhance excretion through kidneys and is a key to eliminate aluminum toxicity and the related systemic involvement.

Advertising in eMedinewS

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

NATIONAL SEMINAR ON STRESS PREVENTION (17–18 April). Over 400 registrations already done.

A Stress Prevention Residential Seminar cum spiritual retreat with Dr KK Aggarwal and Experts from Brahma Kumaris will be organized from April 17–18, 2010.

Co–organizers: eMedinews, Brahma Kumaris, Heart Care Foundation of India, IMA New Delhi Branch and IMA Janak Puri Branch, IMSA (Delhi Chapter)

Venue: Om Shanti Retreat Centre, National Highway 8, Bilaspur Chowk, Pataudi Road, Near Manesar.

Timings: On Saturday 17th April (2 pm onwards) and Sunday 18th April (7 am–4 pm). There will be no registration charges, limited rooms, kindly book in advance; stay and food (satvik) will be provided. Voluntary contributions welcome. For booking e–mail and SMS to Dr KK Aggarwal: 9811090206, emedinews@gmail.com BK Sapna: 9811796962, bksapna@hotmail.com

Also, if you like emedinews you can FORWARD it to your colleagues and friends. Please send us a copy of your forwards

INVITATION

Heart Care Foundation of India
Jointly with


eMedinewS, World Fellowship of Religions, Delhi Medical Council,
Delhi Medical Association,  IMSA (Delhi chapter) and MAMC takes pleasure to cordially invite you to

A lecture by
World renowned Dr Sanjiv Chopra, M.D., MACP
Dean Faculty Dean for CME, Medical School, Harvard Boston, USA
on
"Leadership for the 21st Century –Ten Tenets of Leadership"
on 
Saturday March 20, 2010

at
MAMC Lecture Hall, Maulana Azad Medical College, Delhi Gate.

RSVP
Dr K K Aggarwal
Padma Shri Awardee 2010

N.B
Dr Sanjiv Chopra is Professor of Medicine and Faculty Dean for Continuing Medical Education at Harvard Medical School, and Senior Consultant in Hepatology at the Beth Israel Deaconess Medical Center, Boston, Massachusetts. He has four books to his credit. His books have been translated into several languages including Portuguese, Japanese, Italian and Czech. He has given a number of Keynote addresses on the topic of Leadership – "Leadership for the 21st Century: The Ten Tenets of Leadership" to wide acclaim in the United States and several countries abroad

Learning Objectives

  • Discuss the qualities of great leaders.
  • Elucidate that often the spark of leadership arises from a negative and somewhat jolting personal experience.
  • Emphasize that we can all lead and can do so at many different levels
  • Explore what made or makes many leaders – historical and contemporary – so effective.

Entry Free by prior registration only
For registration call; 9810301261, 9971994518
e-mail: drkk@ijcp.com, drkakroo@gmail.com

Readers Responses

  1. Dear Dr. Agarwal ji, I congratulate you for introducing e–medinews, which is very informative to all professionals & common public, this is a milestone in medical education. This should be comprehenssive With inclusion of all traditional health care sciences, this will create more impact. with best wishes: Dr. G.S. Lavekar, Former DG, CCRAS

  2. The Guidebook of Immunization IAP, 2009: YK Amdekar, Tanu Singhal & R.K.Agarwal (Jaypee Brothers, Delhi) says under the head, "IAP COI Recommendations for use of Varicella vaccine":
  • The vaccines are licensed for age 12 months and above. However the risk of breakthrough varicella is lower if given 15 months onwards. Hence the IAPCOI recommends administration of varicella vaccine in children aged 15 months or older. For healthy children a single dose of 0.5 ml SC is recommended in children below 13 years and two doses 4-8 weeks apart in children 13 years or older.

  • All high risk children should however receive two doses 4-8 weeks apart irrespective of age. The immunization committee of the USA (ACIP) has recently recommended administration of two doses of varicella vaccine in all children owing to the inability of the single dose regimen to effectively control disease burden and the superior immunogenicity/efficacy of the 2 dose regimen. American children below the age of 13 years receive two doses at 12-15 months and 4-6 years (minimum interval 3 months between doses) and older children two doses 4-8 weeks apart. There is no change in recommendations for healthy Indian children as of date.

  • The IAP COI recommends offering the vaccine to children with no prior history of varicella who can afford the vaccine after one to one discussion with parents (Category 3).

The vaccine is recommended for use in all children belonging to certain high risk groups as enumerated below

  1. Children with humoral immunodeficiencies

  2. Children with HIV infection but with CD4 counts 15% and above the age-related cut off

  3. Leukemia but in remission and off chemotherapy for at least 3-6 months

  4. Children on long term salicylates. Salicylates should be avoided for at least 6 weeks after vaccination.

  5. Children likely to be on long term steroid therapy. The vaccine may be given at any time if the children are on low dose steroids / alternate day steroids but only 4 weeks after stopping steroids if the patients have received high dose steroids ( > 2 mg/kg ) for 14 days or more.

  6. In household contacts of immunocompromised children.

  7. Adolescents who have not had varicella in past and are known to be varicella IgG negative) especially if they are leaving home for studies in a residential school/college.

  8. Children with chronic lung/heart disease.

  9. Seronegative adolescents and adults if they are inmates of or working in the institutional set up e.g. school teachers, day care center workers, military personnel and health care professionals.

  10. For post-exposure prophylaxis in susceptible healthy non pregnant contacts preferably within 3 days of exposure (efficacy 90%) and potentially up to 5 days of exposure (efficacy 70%, against severe disease 100%). With warm regards, Dr.R K Agarwal, Past President Indian Academy of Pediatrics 2008, rk_hospital@hotmail.com