emedinews
Head Office: E–219, Greater Kailash, Part 1, New Delhi–110 048, India. e–mail: emedinews@gmail.com, Website: www.ijcpgroup.com
FIRST NATIONAL eMEDICAL NEWSPAPER OF INDIA

eMedinewS is now available online on www.emedinews.in or www.emedinews.org

  From the Desk of Editor–in–Chief
Dr KK Aggarwal

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; Chairman Ethical Committee 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

 
  Editorial …

19th April, 2011, Tuesday                                eMedinewS Present Audio News of the Day

View Photos and Videos of 2nd eMedinewS – Revisiting 2010

For regular emedinews updates follow at www.twitter.com/DrKKAggarwal

Stop commission and increase the fees

Today pathologists are giving upto 70% and imaging centers upto 60% as referral fee. For angioplasty with a stent, referral fee can be upto Rs. 40000/–. As per Medical Council of India Act, any referral fee, fee splitting, paying commissions or refund is unethical. But, unfortunately, most of the corporate hospitals are not governed by MCI but comes under Directorate of Health Services and the Nursing Home Act does not have punishment for unethical acts.

Doctors invariably get a bad name because they are the ones who are treating or referring the patients. It is well known that that by charging a fee of Rs. 50/– or Rs. 100/–, one cannot run his or her household and one ends up in accepting commissions. So, then why not actually increase the fee and stop this business of commissions or referral fees. A blood test which can be available for a patient @ Rs.30/–, why does one allow a patient to pay Rs. 100/–?

Stopping acceptance of referral fee will enhance the image of doctors in the society and make the treatment cheaper to the patient and still allow doctors to make enough money by charging more consultation fees.

Dr KK Aggarwal
Editor in Chief
drkkaggarwal Dr K K Aggarwal on Twitter
Krishan Kumar Aggarwal Dr k k Aggarwal on Facebook
 
    Changing Practice – Evidence which has changed practice in last one year

Revised HIV treatment guidelines

For patients with a CD4 cell count between 350 and 500 cells/mm3 who are motivated to be treated, start ART. A revised version of the HIV treatment guidelines from the International AIDS Society–USA panel has several major changes, including recommendations to initiate antiretroviral therapy (ART) for patients with a CD4 count less than 500 cells. This recommendation is based upon observational data supporting a mortality benefit in reducing AIDS– and non–AIDS–related complications. Patients should be advised of the potential risks and benefits of early treatment interventions.

References

  1. Thompson MA, Aberg JA, Cahn P, et al. Antiretroviral treatment of adult HIV infection: 2010 recommendations of the International AIDS Society–USA panel. JAMA 2010;304:321.
  2. HIV–CAUSAL Collaboration, Ray M, Logan R, et al. The effect of combined antiretroviral therapy on the overall mortality of HIV–infected individuals. AIDS 2010;24:123.
  3. Kitahata MM, Gange SJ, Abraham AG, et al. Effect of early versus deferred antiretroviral therapy for HIV on survival. N Engl J Med 2009;360:1815.
 
  eMedinewS Audio PostCard

CKD Update

Dr KK Aggarwal Speaks on
‘Key points in diagnosis of CKD’
 

Audio PostCard
 
    Photo Feature (from the HCFI Photo Gallery)

1st National Conference on Gynae Endocrinology 2011

Releasing the Souvenir of The 1st Conference of Gyne Endocrinology Society of India. In the Photo: Prof PC Mahapatra, Dr Behram Anklesaria, Dr KK Aggarwal, Prof. Dr Alka Kriplani, Dr Neerja Goel and Dr Nutan Aggarwal.

 
Dr K K Aggarwal
 
    National News

Who will be in the next MCI team?

Last year when Medical Council of India was reconstituted as per a President Ordinance, The council was supposed to have seven members but only six were appointed. 7th seat was kept vacant. There were rumours that then Health Secretary, Govt. of India will take over that 7th seat after her retirement and even become the Chairperson of the council. But the same did not happen. She is retired now. The one year term is going to be over soon. One year extension has been done. Will the government continue with the same old team of six people or appoint a new group of seven or replace a few of them is a matter of debate. If media reports are to be believed, then many of the existing members have shown their inability to continue on the ground of paucity of time. Lobbying has already started in the medical circles to gain entry into the new team. There are also media reports that the new team may have more representation from the government sector or a balance of both the government and the private sector.

Cities should have rainfall gauges every four sq km

GANDHINAGAR: The National Disaster Management Authority (NDMA) has proposed that cities across the country should set up an automatic rainfall gauge every four sq km area. Vice–chairman of NDMA M Shashidhar Reddy released the guidelines for management of urban flooding on Thursday at the opening of the 3–day international conference on "Post–Earthquake Reconstruction: Lessons Learnt and Way Forward," at the Pandit Deendayal Petroleum University (PDPU). Reddy said that the task to formulate the guidelines was taken up by the NDMA after the 2005 Mumbai floods. The guidelines also mandate an urban flood cell under the urban development ministries at the centre and state which will not only monitor floods but also create an early warning system. The NDMA guidelines also make it mandatory for all the 2325 cities in the country to map on Global Information System (GIS) platform. The guidelines also made it mandatory for the urban bodies to complete the pre–monsoon desilting of drainages before March 31 every year. Also while granting permission for new buildings or laying storm water drainage system, the guidelines say storm water drains should be designed on the basis of the catchment of that particular area. The guidelines states that the local residents’ welfare association and community based organisations should also be involved in monitoring these guidelines and also be made a part of the disaster management programmes and also chalking out the same for the local area. (Source: The Times of India, Apr 15, 2011)

Certificate courses in 2D and 3D Echocardiography/Fellowship Diploma in non invasive cardiology Contact Dr KK Aggarwal, Moolchand Medcity, email: emedinews@gmail.com

 
    International News

(Contributed by Rajat Bhatnagar, International Sports & Fitness Distribution, LLC)

Medicaid to offer rewards for healthy behavior

The Los Angeles Times recently reported that a federal grant program authorized in the health overhaul law is offering states $100 million to reward Medicaid recipients who make an effort to quit smoking or keep their weight, blood pressure or cholesterol levels in check. The grant program is meant to encourage states, many of which are under pressure to cut Medicaid costs, to experiment with an uncertain approach to wellness: offering incentives for healthy behavior. Idaho, which launched an incentive program in 2007, offers $200 in vouchers to Medicaid enrollees who consult with a doctor about losing weight or quitting smoking. Recipients can use the vouchers for gym memberships, weight management programs, nutrition counseling and tobacco cessation products.

(Dr Monica and Brahm Vasudev)

Study supports watchful waiting for low–risk prostate cancer

Active surveillance for low–risk prostate cancer offers a safe alternative to immediate curative intervention and may reduce overtreatment and adverse events, investigators in a large clinical study concluded. A third of 769 patients eventually had surgery or radiation therapy, but delaying intervention for as long as 10 years caused no apparent harm.

Three–biomarker panel may improve risk prediction for kidney failure or death in patients with CKD

Use of a three–biomarker panel significantly improved risk prediction for kidney failure or death in patients with chronic kidney disease, according to a study published online in the Journal of the American Medical Association. Researchers found that adding cystatin C to creatinine and albumin–creatinine ratio (ACR) increased the accuracy for predicting mortality by 13.3% and end–stage renal disease (ESRD) by 6.4%, as compared with use of just one or two markers. Furthermore, assessment by all three biomarkers revealed CKD in 16% of patients who did not have CKD by creatinine alone.

Some physicians arguing HIV infection should not disqualify transplant organs for HIV–positive recipients

United States has a huge need for kidneys, livers and other organs for transplant, but federal law has one absolute rule for donors: no HIV infections. Now, some physicians are arguing that HIV should not disqualify the organs from transplant into recipients who also are already infected with the virus. Since HIV has become a chronic treatable disease rather than a death sentence, there appears to be growing consensus in the medical field that infected organs should be considered.

 
    IJCP Special

Dr Good Dr Bad

Situation: A patient with postpartum fever was not responding to broad–spectrum antibiotics.
Dr Bad: Change the antibiotic.
Dr Good: Get a CT scan done.
Lesson: Non–responding postpartum fever could either be due to a pelvic abscess or pelvic thrombophlebitis. A CT scan can detect the abscess.

Make Sure

Situation: A patient on 10 units of insulin developed hypoglycemia with 11 units of insulin.
Reaction: Oh My God! Why was additional insulin given?
Lesson: Make sure that insulin dose is calculated correctly. The formula is 1500/total daily dose. The value will be the amount of sugar fluctuation with one unit of insulin.

 
    An Inspirational Story

(Dr Prachi Garg)

This widely used story is often told as if it’s a true story. It is most certainly not. It is an urban legend, but even as such, the story contains great lessons and is very inspirational.

Fleming was a poor Scottish farmer. One day at work in a field he heard a cry for help. Following the sound, Fleming came to a deep bog, in which a boy was stuck up to his chest, screaming and sinking. Farmer Fleming tied a rope around his own waist and the other end to a tree, and waded into the bog. After a mighty struggle in which it seemed they would both perish, the exhausted farmer pulled himself and the boy to safety. He took the lad back to the farmhouse, where Mrs Fleming fed him, dried his clothes, and when satisfied he had recovered, sent him on his way home.

The next day a carriage arrived at the Fleming’s humble farmhouse. An well–dressed man stepped out and introduced himself as the father of the boy whom Fleming had saved. "You saved my son’s life," said the man to Fleming, "How can I repay you?"

"I don’t want payment," Fleming replied, "Anyone would have done the same."

At that moment, Fleming’s own young son appeared at the farmhouse door.

"Is he your son?" the man asked.

"Yes," said Fleming proudly.

"I have an idea. Let me pay for his education. If he’s like his father, he’ll grow to be a man we’ll both be proud of."

And so he did. The farmer’s son attended the very best schools, graduated medical college, and later became the world–renowned nobel prize–winning scientist and discoverer of penicillin, Sir Alexander Fleming.

It is said that many years later, the grown man who’d been saved from the bog as a boy, was stricken with pneumonia.

Penicillin saved his life. His name? Sir Winston Churchill.

 
    Infertility Update

(Dr. Kaberi Banerjee, Director Precious Baby Foundation)

A young couple married for last 4 months has visited an infertility specialist for treatment. They are very stressed. How should we counsel them?

Firstly we have to ascertain that there are no gross medical problems in the couple. We have to ensure that there is no problem in performing regular intercourse. The lady’s menstrual cycle should be regular. Once this is ascertained the couple should be reassured that the chances of getting pregnant per month in a healthy couple is about 15–20%. The fertile period should be explained which is usually between day 12 and day 18 of a regular menstrual cycle. Infertility will only be defined once they are unable to conceive after trying for more than a year. The couple should be able to return in 6 months if conception does not occur. A basic semen analysis may also be done.

ijcpgroup
Docconnect
Docconnect
 
    Pediatric Update

(Dr. Neelam Mohan, Director Pediatric Gastroenterology, Hepatology and Liver Transplantation, Medanta – The Medicity)

Clinical presentation of croup

Mild croup (the commonest presentation)

  • The child is happy, playful and is feeding well.
  • A barking cough, change in voice and stridor on coughing and crying and absent at rest.
  • There may be mild chest–wall retractions and tachycardia.

Moderate croup

  • Audible stridor at rest, which worsens with agitation
  • Barky cough, and increased work of breathing (retractions, increased RR and HR)
  • Child may be fussy but is alert, interactive.

Severe croup

  • The child appears increasingly tired and exhausted due to labored breathing and stridor.
  • Marked tachycardia and tachypnea persists.
  • Restlessness, agitation, irrational behavior, decreased level of consciousness, hypotonia, cyanosis and marked pallor are late signs of life–threatening airway obstruction.
 
    Medicolegal Update

(Dr Sudhir Gupta, Additional Prof, Forensic Medicine & Toxicology, AIIMS)

Do not misrepresent the document/medical literatures in the court of law

One paragraph or even one part of a paragraph may be all that is necessary to substantiate the point a doctor wants to make in a court room. Reading the remainder of the document, even if it establishes a context for the evidence, is unnecessary and time consuming. The document must potentially be available to any debater researching the topic or lawyer/interested party of cross examination side.

  • The portion of a document read as evidence cannot be taken out of context. When a document is cut in a manner which lends the quoted passage a meaning other than what would be derived from a more complete reading, you are misrepresenting the document. This does not mean, however, that you are responsible for drawing the same conclusions from information as the author of the document.
  • Drawing a contrary conclusion from passages accurately interpreted does not constitute misrepresentation. The fact that the author of the document reached a different conclusion from the information argues – perhaps persuasively – against your conclusion. However, you have not misused the evidence.
  • Read the used evidence literature verbatim in the court of law. Documents must be presented in the words of the author. When you paraphrase evidence, you argue in a circle. A document obviously will seem to support your point if you are allowed to read into the record only what you think it says.
  • The advent of the Internet has created a new form of publication – electronic documents like this emedinews. Electronic documents are accepted as published if they are accessible by the general public. Thus, electronic files to which other debaters would be denied access are not published. However, files and documents which other debaters may access, even if they have no subscribe to a commercial service to do so, satisfy the publication rule.
 
    Legal Question of the Day

(Dr. M C Gupta)

How to promote low priced, indigenously developed medical appliances?

Q. Many equipments developed in India, though costing a fraction of the imported equivalents, are not being used by hospitals in India. Some examples are: Low weight caliper for polio cases, Kalam–Raju stent, Ophthalmic laser, Slit lamp, Hydroxypatite eyeball, Intraocular lens implant, Titanium dental and bone implants, Cavitron scalars, Critical care ventilator, Cochlear implant, Vrtual reality laparoscopic surgery simulator, Micro–sensor for intracranial pressure, High Altitude Pulmonary Oedema (HAPO) bags, and Light weight stretchers. What should be done?

Ans. One has to take an analytical look as follows:

  • Identify those items that have been permitted for use by the concerned authorities. Let us confine here to those items that need the permission of the Drug Controller General of India. Such items would include all implants including the stent.
  • The next point to check is whether the items are available in the market. If they are available, the only step left is for the government to take a policy decision to encourage or enforce their use in government health facilities and issue necessary orders/directions for this purpose. Deviation from such usage should be permitted only when the decision is taken at the level of the in–charge of the hospital for reasons to be recorded in writing.
  • If the government does not act on its own, a proper (legally drafted) representation should be made to it on the above lines, followed by a PIL if necessary.
  • Action may also be possible under provisions of the Consumer protection Act, 1986, and the MCI’s Ethics Regulations, 2002.
  • Once the problem has been tackled in case of implants, attention may be focused towards non–implant items also.

The above action can be initiated by anybody. Preferably it should be done by an association such as: Residents’ association; specialists’ association or IMA. It can also be done by a consumer organization.

 
    Obesity Update

Dr. Parveen Bhatia and Dr. Pulkit Nandwani

What are the calorie reductions for an Obesity Diet Plan?

The average diet for obesity cuts 500 to 1,000 calories a day. Cutting 500 calories a day from a diet should result in weight loss of about one pound a week. However, eliminating too many calories can actually endanger your health — the U.S. National Library of Medicine (2010) recommends that a woman’s lowest calorie intake be 1,200 calories per day, and that males should not eat less than 1,500 calories each day. In spite of this, a severely restricted diet is sometimes recommended for people who are morbidly obese. Such diets, characterized by caloric counts as low as 500 to 800 calories, should only be attempted if approved and supervised by a qualified medical professional. Attempting extremely low–calorie diets alone is not recommended, and can be dangerous. Always doctor and dietician should be consulted before beginning a diet plan.

 
    Mind Teaser

Read this…………………

ICUR

Yesterday’s eQuiz: YYUB

Answer for Yesterday’s Mind Teaser: Too wise you be

Correct answers received from: Dr Sudipto Samaddar, Dr Rakesh Bhasin, Dr K.Raju, Dr Muthumperumal Thirumalpillai, Dr Rashmi Chhibber, Dr Chandresh Jardosh

Answer for 17th April eQuiz: Too wise you are
Correct answers received from: Dr Rakesh Bhasin, Dr Raju Kuppusamy, Dr Neelam Nath, Dr Amit Kochar

Send your answer to ijcp12@gmail.com

 
    Laugh a While

(Dr. GM Singh)

It was out anniversary and I asked my wife where she wanted to go, she said: "Please take me somewhere I’ve never been before" So, I took her to the kitchen !!!

 
    Lab Update

(Dr Arpan Gandhi and Dr Navin Dang)

Stool Examination

O & P (Ova and Parasite) testing: A microscopic evaluation of stool for parasites and the ova (eggs, cysts) of parasites. A basic test but very important!!

 
    Medi Finance Update

(Prof. Dr. S. Arulrhaj, MD., FRCP (Glasg)

In India Health Expenditure has not gone beyond 1.05% of GDP. The UPA Government had promised to take this spending to 2–3% of GDP. Despite India’s rapid economic growth, the Health Indices are world’s worst. Almost half of India’s Children suffer from level of malnutrition which is in some places worse than sub–Saharan Africa.

 
    Drug Update

List of approved drugs from 01.01.2010 to 31.8.2010

Drug Name
Indication
DCI Approval Date
Ramosetron Dispersible Tablet 0.1 mg
For the prevention and treatment of gastrointestinal symptoms (nausea and vomiting) associated with ematogenic cancer chemotherapy.
12/06/2010
 
    IMSA Update

International Medical Science Academy (IMSA) Update

Polio vaccination

The Advisory Committee on Immunization Practices has issued updated recommendations regarding routine poliovirus vaccination. The final dose in the series should be administered when the child is at least four years old.

(Dr Vinay Sakhuja)

Latin Quotes

Ad poenitendum properat, cito qui judicat.

He who comes too speedily to a decision (and acts on the impulse of the moment) is not long ere he repents of it.

 
  Quote of the Day

(Dr GM Singh)

Blessed is the season which engages the whole world in a conspiracy of love. Hamilton Wright Mabi.

 
    Readers Responses
  1. Bharat Ratna should be conferred on a person whose major part of life has been spent in the service of humanity through scientific, social, political or spiritual activities without any expectation of monetary or material reward, whose time and energy are spent solely on such service often involving considerable discomfort even extending to families and dependents. Such persons have in the past given back their material and other inputs for the benefit of society, either whole or most of it, leaving very little behind. Cricketers of today are a pampered lot whose earnings are disproportionate to their talent or work – example Dhoni – 26 crores from Vijay Mallya apart from crores from other brand ambassadorships. Sachin Tendulkar has become a billionaire through cricket, which has extended to him a life of luxury and comfort. One would like to hear more of his ‘outputs’ to society through charity, donations, scholarships etc. Let him be admired for his batsmanship and for being an all rounder and awarded a Khel Ratna of a ‘higher degree’ with the prefix Bharat, ‘Bharat Khel Ratna’, since his ‘service’ to society has been in a very limited sphere of human activity, giving him almost unlimited benefits. I was very happy to see the list of Bharat Ratna awardees. Sachin has to do much, much more to deserve the award. I entirely agree with the views expressed on this subject in eMedinews: Dr. S Ramaswamy, 26 (125) Chamiers Road, Nandanam Extension, Chennai 600 035 Mobile 9444140829, 044–2435 1714.
 
    Public Forum

(Press Release for use by the newspapers)

Pregnant ladies should wear seat belts

Pregnant women should wear seat belts, not only to save themselves in the event of a car accident but also to save their unborn baby.

Quoting a study from American Journal of Obstetrics & Gynecology, Padma Shri & Dr. B.C. Roy National Awardee Dr. KK Aggarwal and President, Heart Care Foundation of India said that over half of all fetal losses in motor–vehicle crashes could be saved if pregnant women buckled up properly.

Even if a fetus survives, premature delivery as a result of the crash can lead to low birth weight, respiratory problems and long–term physical or neurological problems.

According to researchers, the survival of the fetus is most strongly associated with the severity of the crash and how badly the mother is injured. Fetuses were 4.5 times more likely to survive if the mother was wearing the proper seat belt restraint (with or without air bag deployment).

Amongst the other findings were:

  • Regular use of seat belts by pregnant women will prevent 84 percent of fetal injuries and deaths as a result of car accidents.
  • Women in car crashes where the fetus is injured or dies are unbelted 62 percent of the time.
  • 79 percent of pregnant women who properly wore a three–point belt, with or without air bag deployment, had "acceptable" fetal outcomes in less severe crashes.
  • Air bags do not seem to adversely affect fetal outcomes.
  • For pregnant women, the lap–belt portion needs to be worn low over the pelvis so if there is a crash, basically, the bony pelvis is what the seat belt is restraining rather than (having the force) transmitted to the uterus or the abdomen.
  • The shoulder belt should simply come up from the side, go between the woman’s breasts, and over the shoulder.
 
    eMedinewS Special

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

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

HCFI
Activities eBooks


  HCFI

  Playing Cards

  Dadi Ma ke Nuskhe

  Personal Cleanliness

  Mental Diseases

  Perfect Health Mela

  FAQs Good Eating

  Towards Well Being

  First Aid Basics

  Dil Ki Batein

  How to Use

 
Pesticides Safely

  Towards Well Being

 

 
    Forthcoming Events

May 7–8, 2011, National Seminar On Stress Prevention
A Stress Prevention Residential Seminar cum spiritual retreat with Dr KK Aggarwal and Experts from Brahma Kumaris.
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: Saturday 7th May (2 pm onwards) and Sunday 8th May (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: 9899974439, emedinews@gmail.com, rekhapapola@gmail.com; BK Sapna: 9811796962, bksapna@hotmail.com

………………………………………………………………

September 30 – October 02, 2011; XVIth World Congress on Cardiology, Echocardiography & Allied Imaging Techniques Venue: The Leela Kempinski, Delhi (NCR), September 29, 2011: A unique & highly educative Pre–Conference CME, International & national icons in the field of cardiology & echocardiography will form the teaching faculty.
Highlights of Pre – Conference CME: Case based learning experience & audience interaction, Maximum 250 delegates for CME will be accepted, who will be divided in 5 batches and will rotate to different halls every 90 minutes. The topics are:(A) Right heart pressures & functions (From basics to newer methods (RV anatomy, echo views, echo assessment of RV function, prognostic impact of RV function) (B) Carotid Doppler: How do i assess and interpret in my daily practice.: Technical tips (Anatomy of the vessel, views of ultrasound scanning, Normal & abnormal Doppler hemodynamics, how to measure IMT) (C) Valvular stenosis: Assessment, limitations and their solution: (Anatomy of the valves, 2–D findings of stenotic lesions, quantitation of lesion, limitations) (D) How do I assess and report ventricular dyssynchrony in my lab. (What is ventricular dyssynchrony, what are the types of dyssynchrony, in whom, when & why do we assess it, various echo methods to assess it) (E) Live 3–D Echo: Protocol for acquisition. How to slice and get full information. Aim is that by end of the day, every participant is well conversant with all the topics
Dr (Col) S.K. Parashar, President, e–mail: drparashar@yahoo.com, Mob:09810146231/Dr Rakesh Gupta, Secretary General, email:jrop2001@yahoo.com, Mob:09811013246
worldcon2011@in.kyoni.com, www.worldcon2011.org

………………………………………………………………

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    Our Contributors

Dr Veena Aggarwal, Dr Arpan Gandhi, Dr Aru Handa, Dr Ashish Verma, Dr A K Gupta, Dr Brahm Vasudev, Dr GM Singh, Dr Jitendra Ingole, Dr Kaberi Banerjee (banerjee.kaberi@gmail.com), Dr Monica Vasudev, Dr MC Gupta, Dr Neelam Mohan (drneelam@yahoo.com), Dr Naveen Dang, Dr Prabha Sanghi, Dr Prachi Garg, Rajat Bhatnagar (http://www.isfdistribution.com), Dr. Rajiv Parakh, Dr Sudhir Gupta