emedinews
Head Office: 39 Daryacha, Hauz Khas Village, New Delhi, India. e-mail: emedinews@gmail.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; 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


19th August, 2010, Thursday

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

Women’s cholesterol levels vary with phase of menstrual cycle

As per US National Institutes of Health researchers, women’s cholesterol levels change with monthly changes in estrogen levels. One should take into account the phases of a woman’s monthly cycle before evaluating cholesterol measures. On average, the total cholesterol level of the women varies 19 % over the course of the menstrual cycle.

Estrogen levels steadily increase as the egg cell matures, peaking just before ovulation. It is known that taking formulations which contain estrogen can affect cholesterol levels and high blood cholesterol levels raise the risk for heart disease. The NIH study showed that as the level of estrogen rises the protective good or high–density lipoprotein (HDL) cholesterol also rises peaking at the time of ovulation. On the other hand the total cholesterol, bad or the low–density lipoprotein (LDL) cholesterol levels as well as triglycerides declined beginning a couple of days after the estrogen peak at ovulation reaching their lowest just before menstruation began. The findings were published online in the Journal of Clinical Endocrinology and Metabolism by Sunni L. Mumford, Ph.D. and Enrique F. Schisterman, Ph.D. at the University of North Carolina, Chapel Hill; the State University of New York, Buffalo; and the University of Nevada Health Sciences System.

The study also found that women's total cholesterol levels rise as estrogen levels increase during the monthly menstrual cycle, drop shortly before ovulation, then decrease more rapidly after ovulation occurs. Cholesterol levels will be thus elevated in women before ovulation, which could have a particular impact on women whose cholesterol levels are already high. Also, testing at the end of a woman’s cycle when cholesterol levels are low might give a false feeling of a normal cholesterol levels.

The study compared estrogen with cholesterol and triglyceride levels among 259 healthy women between 18 and 44 years old. For 94 % of the volunteers, researchers took 14 or more measurements over two menstrual cycles. Most of the women were physically active and did not smoke. Only
5 % consistently had total cholesterol levels greater than 200 mg/dL. Cholesterol levels among 19.7 percent of the women reached 200 mg/dL at least once.

A small subset of obese women over 40 showed greater fluctuation in cholesterol levels during their cycles than did the rest of the group.

Further research may help clarify the optimal point in the cycle for doctors to measure women’s cholesterol levels.

Dr KK Aggarwal
Editor in Chief
drkkaggarwal Dr K K Aggarwal on Twitter
Krishan Kumar Aggarwal Dr k k Aggarwal on Facebook  

 

Photo Feature

Every member in a Team, has times when they need support….

Teamwork is the ability to work together toward a common vision.  The ability to direct individual accomplishment toward organizational objectives.  It is the fuel that allows common people to attain uncommon results.
~Andrew Carnegie

(Contributed by Dr Chandresh Jardosh)

Dr K K Aggarwal

 

News and Views

National

Pay more for fancy hospitals, says IRDA

The  mediclaim policy premiums may go up for treatment at major hospital chains as insurance companies are devising new products to break the current cashless deadlock said IRDA chairman J Hari Narayan.  His remarks came a day after the Delhi High Court asked the insurance regulator to sort out the cashless facility to policyholders in major hospitals across the country. (TOI)

Cashless cover for trauma, emergency cases

New India Assurance Company chairman M Ramadoss said a patient who requires emergency and trauma services will be attended to through the cashless scheme in all TPA-empanelled hospitals. (TOI)

 Insurers to pay more for road deaths: SC

The next of kin of motor accident victims can now expect a much higher compensation from insurers. The Supreme Court has ruled that only the income tax component can be deducted from a victim's salary to arrive at his net income for the purpose of calculating the claim amount.  Till now, the monthly income of the victim was calculated after deducting from the gross salary loan repayment premiums, contribution to provident fund and even life insurance payments. This helped insurance companies greatly reduce the victim's `income' on which the compensation is based. (TOI)

 Cashless claims: Hospitals set to sign on package deal

Cashless hospitalization facility may soon be restored at most corporate hospitals in Delhi, Mumbai, Bangalore and Chennai, with the impasse between insurers and big hospital chains on the verge of a resolution reports TOI. A three-tier package has been worked out for 42 standard medical procedures, covering almost all common ailments requiring hospitalization.

Hospitals have been divided into three groups based on infrastructure capabilities. In Delhi, Gangaram, Medicity, Apollo, Fortis, Max (Saket); In Mumbai, Breach Candy, Hiranandani, Jaslok, Leelavati and Hinduja. Manipal in Bangalore and Apollo and Fortis in Chennai: are the hospitals  that have been found eligible to charge the highest rates include may also make the top grade.  

Other  450 hospitals across these cities had already joined the cashless network. Corporate hospitals had been taken off the preferred network after July 1 when they refused to standardize their treatment procedures, and agree to a package deal with insurers. The package rates have been worked out by a committee headed by Raksha TPA CEO Pawan Bhalla. The rates have been segmented into three categories because high-end hospitals cannot be pushed to accept tariffs applicable for smaller ones. The packaged rates, when implemented across the country, are expected to result in 20-25% savings for insurance companies.

International

(Dr Monica and Dr Brahm Vasudev)

Bisphosphonates not associated with increased risk of cancer of the esophagus or stomach

The combined incidence of cancer of esophagus or stomach was the same for osteoporosis patients who were given bisphosphonates, vs those not treated with these drugs, according to a study in the New England Journal of Medicine. The study comes out about a year and a half after the US FDA reported 23 cases of esophageal cancer between 1995 and 2008 in patients using alendronate and another 31 cases in patients using a variety of bisphosphonates in Europe and Japan.

Finasteride’s use for the prevention of prostate cancer appears to be limited

Researchers have urged doctors to discuss the benefits of finasteride for preventing prostate cancer with their patients, after a study found that prescribing of the product did not increase when a 2003 trial showed the drug to wards off tumors. The drug was shown to reduce some men's risk of developing prostate cancer, to 18 percent from 24 percent, according to the 2003 paper in the New England Journal of Medicine. The American Society of Clinical Oncology and the American Urological Association issued a joint guideline in 2009 recommending that 5–alpha reductase inhibitors be considered for prostate cancer prevention in healthy asymptomatic men with a prostate–specific antigen (PSA) level of 3.0 ng/mL or less who receive regular screening for prostate cancer.

New DNA test could allow earlier detection of colon cancer

A new generation of DNA tests for colon cancer seems likely to improve the detection both of cancers and of the precancerous polyps that precede them. Exact Sciences, a company based in Madison, Wis., is developing a colon cancer test based on highly methylated DNA, reported that by testing for methylated DNA at four markers, pieces of DNA drawn from specific genes, they could detect colon tumors and polyps, distinguishing them from normal tissue with 100 %t sensitivity and with no false positives.

Spinal fluid proteins can help diagnose Alzheimer’s

The findings of a study state that measuring certain proteins in spinal fluid, beta amyloid and tau, can accurately diagnose Alzheimer’s, predict which patients with memory problems will develop the fatal brain–wasting disease and help identify early signs of the disease in healthy people. The study headed by Belgian researcher Geert De Meyer of Ghent University in Belgium is published in the Archives of Neurology

 

Legal Column

Forensic Column (Dr Sudhir Gupta, Associate Professor, Forensic Medicine & Toxicology, AIIMS)

WMA declaration of Malta on hunger strikers – Guidelines for medical management

The doctor must assess the mental capacity of the individual. This involves verifying that an individual intending to fast does not have a mental impairment that would seriously undermine the person's ability to make health care decisions. Individuals with seriously impaired mental capacity cannot be considered to be hunger strikers. They need to be given treatment for their mental health problems rather than allowed to fast in a manner that risks their health.

As early as possible, physicians should acquire a detailed and accurate medical history of the person who is intending to fast. The medical implications of any existing condition should be explained to the individual. Physicians should verify that hunger strikers understand the potential health consequences of fasting and forewarn them in plain language of the disadvantages. Physicians should also explain how damage to health can be minimized or delayed by, for example, increasing fluid intake. Since the person’s decisions regarding a hunger strike can be momentous, ensuring full patient understanding of the medical consequences is critical. Consistent with best practices for informed consent in health care, the physician should ensure that the patient understands the information conveyed by asking the patient to repeat back what they understand.

 

Experts’ Views

Interesting Tips in Hepatology & Gastroenterology

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

Chronic Pancreatitis

Aetiological factors associated with chronic pancreatitis (TIGAR–O Classification System Modified from Etemad et al)

Toxic – Metabolic
Hypercalcemia, Hyperlipidemia, Chronic renal failure, Drugs, Toxins ( e.g. DBTC) (alcohol and smoking)
Recurrent acute pancreatitis RAP, Post necrotic, Vasculitis, Post irradiation

Idiopathic
Early–onset, Late–onset, Tropical

Obstructive
Pancreas divisum, Sphincter of Oddi dysfunction, Duct obstruction (e.g. stones, post–inflammatory, posttraumatic)

Genetic
PRSS1 mutations, SPINK1 mutations, ABCC7 (CFTR) mutations

Autoimmune
Isolated autoimmune CP, Syndromic autoimmune CP in association with: Sjogren’s syndrome /IBD/PBC

Question of the day

What are the benefits of weight loss in diabetes mellitus and its related complications? (Dr HB Chandalia, Mumbai)

Weight loss is indeed desirable in a person with family history of diabetes and who is also overweight/obese. It has been well–documented that a 5–10% of weight loss (˜7%) from the present weight by lifestyle intervention (diet and exercise) can decrease the risk of diabetes by 58% which surpasses that seen even with medications.

Obesity is a co–morbid condition in diabetes. Both obesity and diabetes form part of the multi–metabolic syndrome. The effort made towards weight reduction are effective, even if targets of full normalization of weight is not achieved. In fact, losing and maintaining weight successfully is a very difficult proposition.

Weight loss prevents vascular complications of diabetes by its effect on various components of the multi-metabolic syndrome. For example, weight loss has a salutary effect in the control of diabetes, hypertension, high triglycerides and high LDL cholesterol.

Evidence–Based Medicine

Characterization of a new metallo–beta–lactamase gene, bla(NDM–1), and a novel erythromycin esterase gene carried on a unique genetic structure in Klebsiella pneumoniae sequence type 14 from India

A Swedish patient of Indian origin traveled to New Delhi, India, and acquired a urinary tract infection caused by a carbapenem–resistant Klebsiella pneumoniae strain that typed to the sequence type 14 complex.

The isolate, Klebsiella pneumoniae 05-506, was shown to possess a metallo–beta–lactamase (MBL) but was negative for previously known MBL genes. Gene libraries and amplification of class 1 integrons revealed three resistance–conferring regions; the first contained bla(CMY–4) flanked by ISEcP1 and blc. The second region of 4.8 kb contained a complex class 1 integron with the gene cassettes arr–2, a new erythromycin esterase gene; ereC; aadA1; and cmlA7. An intact ISCR1 element was shown to be downstream from the qac/sul genes. The third region consisted of a new MBL gene, designated bla(NDM–1), flanked on one side by K. pneumoniae DNA and a truncated IS26 element on its other side. The last two regions lie adjacent to one another, and all three regions are found on a 180–kb region that is easily transferable to recipient strains and that confers resistance to all antibiotics except fluoroquinolones and colistin.

NDM–1 shares very little identity with other MBLs, with the most similar MBLs being VIM–1/VIM–2, with which it has only 32.4% identity.

As well as possessing unique residues near the active site, NDM–1 also has an additional insert between positions 162 and 166 not present in other MBLs. NDM–1 has a molecular mass of 28 kDa, is monomeric, and can hydrolyze all beta–lactams except aztreonam. Compared to VIM–2, NDM–1 displays tighter binding to most cephalosporins, in particular, cefuroxime, cefotaxime, and cephalothin (cefalotin), and also to the penicillins. NDM–1 does not bind to the carbapenems as tightly as IMP–1 or VIM-2 and turns over the carbapenems at a rate similar to that of VIM–2. In addition to K. pneumoniae 05-506, bla(NDM–1) was found on a 140–kb plasmid in an Escherichia coli strain isolated from the patient's feces, inferring the possibility of in vivo conjugation.

The broad resistance carried on these plasmids is a further worrying development for India, which already has high levels of antibiotic resistance.

Reference
1. Yong D, Toleman MA, Giske CG, et al. Antimicrob Agents Chemother 2009 Dec;53(12):5046–54. Epub 2009 Sep 21.

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Public Forum (Press Release for use by the newspapers)

Relieve Stress by Changing the Interpretation

Stress is the reaction of the body or the mind to the interpretation of a known situation. Stress management, therefore, involves either changing the situation, changing the interpretation or taming the body the yogic way in such a way that stress does not affect the body said Padma Shri and Dr B C Roy National Awardee Dr K K Aggarwal, President Heart Care Foundation of India, BSNL Dil ka Darbar & MTNL Perfect Health.

Dr. Aggarwal said that every situation has two sides. Change of interpretation means looking at the other side of the situation. It is something like half glass of water, which can be interpreted as half empty or half full.

He said that studies have shown that anger, hostility and aggression are the new risk factors for heart disease. It has been shown that even recall of anger can precipitate a heart attack.

Talking about prayer, Dr. Aggarwal said that many studies have shown that when doctors talk positive in front of unconscious patients in ICU, their outcome is better than those in whose presence if doctors talk negative.

The best way to practice spiritual medicine is to experience silence in the thoughts, speech and action. Simply walking in the nature with silence in the mind and experiencing the sounds of nature can be as effective as 20 minutes of meditation. He said that 20 minutes of meditation provides the same physiological parameters as that of seven hours of deep sleep.

 

Conference Calendar

Voice Update 2010
Sri Ramachandra Voice Update 2010

Date: August 28 – 29, 2010
Venue: Seminar Hall, 2nd Floor, College Block, SRMC & RI, Sri Ramachandra University, Porur, Chennai, Tamil Nadu.

 

An Inspirational Story

Look Within To Find Happiness

A close friend said’ "If I could only figure this out, I think I could find happiness." I have heard this before and will hear it again I am sure.

Many people want to believe that finding happiness is all about finding something else they want. Not many have ever found long term happiness by achieving another goal. The answer to finding happiness is to look within.

In other words, happiness is completely an inside job. The most important piece to finding happiness is to comprehend that happiness is a choice and not the result of an experience. If all happiness could be found as the result of an acquisition, meeting a goal, or having anything, then a person’s happiness would always be subject to something else.

Remember this: one definition of happiness is simply the absence of an opposite emotion whether it is pain, sadness or something else. If the opposite emotions are never experienced then happiness can never be experienced either. Think about it like this: bad times allow you to appreciate good times; hunger allows you to appreciate food; and sadness allows you to appreciate and experience happiness.

The dictionary defines happiness as enjoying, showing, or marked by pleasure, satisfaction or joy.

How often do you hear… "I’ll be happy when"? When I get that job, I’ll be happy. I’ll be happy when I find a life partner. I'd be happy if I had more money.

These, and all the other "if I had", scenarios are following the same reasoning; that happiness is based on external circumstances.

If you base your happiness on external circumstances, you will continuously fail to find happiness. There will always, always be another external circumstance. There will always be another dollar, another job, another house, or another partner. Better, more, else. To break this vicious cycle, we must find our happiness somewhere else.

That somewhere else is within. We have been given everything we need to be happy. Allow yourself to choose happiness.

If life was perfect would you be happy? Life is perfect because we create it with our choices. Since we can create life, we can create happiness - and how much better can it get? When we can accept that life is perfect as it is and that our lives are the sum total of everything that has happened to this instant, only then can we accept the joy and happiness we deserve.

This concept is very difficult for some to accept. However, the alternative to being happy now is to spend the rest of our lives seeking happiness as if happiness was an item to be bought or found. It’s not. Just remember the saying – Don’t worry – be happy!

 

IJCP Special

Dr Good Dr Bad

Situation: A female with rheumatoid arthritis became pregnant while taking leflunomide.
Dr. Bad: Continue it.
Dr. Good: Stop it immediately
Lesson: In women with rheumatoid arthritis who become pregnant while taking leflunomide, healthy pregnancy outcomes usually occur, if the drug is discontinued at the earliest and a cholestyramine drug elimination procedure is done. (Arthritis Rheum 2010;62:1494)

Make Sure

Situation: A 40–year–old male developed acute heart attack after playing squash.
Reaction: Oh My God! Why was a cardiac test not done?
Lesson: Make sure that after the age of 40 anybody going for anaerobic games should first get  a cardiac clearance.

Quote of the Day

Abraham Lincoln …
"If friendship is your weakest point then you are the strongest person in the world."

Asthma Alert

Severity of an attack of asthma

Asthma attacks can occur in both intermittent and persistent asthma category and can be mild, moderate of severe attack.

 If a person can speak a sentence, its mild asthma attack and can be managed as OPD. 
 • If a person is breaking sentences, its moderate asthma attack and needs observation. 
 • If the person is speaking in words, its severe asthma attack and needs ICU care.

 

International Medical Science Academy (IMSA) Update

A new American Academy of Neurology guideline suggests an algorithm for evaluating driving safety in patients with dementia based upon the clinical dementia rating (CDR). Patients with a CDR of 2 should not drive. Patients with a CDR of 0.5 or 1 should undergo further risk assessment and/or an on–road driving evaluation.

Reference
Iverson DJ, Gronseth GS, Reger MA, et al. Practice Parameter update: Evaluation and management of driving risk in dementia. Report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology 2010;74:1316–1324

 

Drug Update

List of Approved drugs from 01.01.2010 TO 30.4.2010

Drug Name

Indication

DCI Approval Date

Lornoxicam 4mg/4mg + Thiocolchicoside 4mg/8mg tablets

For the treatment of patients with acute painful musculoskeletal conditions.

12–Feb–10

 

Medi Finance

Q. Who is required to file the income tax return?

Ans. Any person, whose total income exceeds Rs. 50,000 in a financial year is liable to furnish income tax return

 

Lab Test

Calculative Values

VLDL Cholesterol = Triglycerides / 5

 

Lateral thinking

Read this………………

T.O……C.H =
……U

The answer for yesterday’s puzzle "broken promise"

Correct answers received from: Dr Singh Simran, Dr Ashok Wasan, Dr kamlesh Kanodia, Dr Anurag Jain, Dr Chandresh Jardosh, Dr D.K.GUPTA, Dr.Asim Sen, Dr.K.V.Sarma, Dr.Susheela Gupta, Dr.R.K.Goel, Dr Yogesh Saxena, Dr Suparna Khera, Er Anuj Sinha, Dr Girish Cally, Dr.Alok Deb, Dr. Rohini, Dr. Anupam Sethi Malhotra, Dr Shashi Chhabra, Dr Bajaj, Dr Sunita Kalra, Dr Ashok Kumar,

Correct answer received for 17h August Puzzle from: Dr.Akshat Bhargava

Send your answer to ijcp12@gmail.com

 

Humor Section

Testing Sons–in–law

An old woman had 3 daughters. One day she decided to test her three Sons–in–law. One a fine day, she was walking along a lake shore with the first son–in–law. Purposefully, she fell down in the lake and started yelling for help. The first son–in–law jumped into the water and dragged her out into the shore. The next day he found a brand new E Class Mercedes at his door step with the wordings "Thank you! Your Mother–in–law who loves you very much!!"

Another day she went out with her second son–in–law. Purposefully, she fell down in the lake and started yelling for help. The second son–in–law too jumped into the water and dragged her out into the shore. The next day he too found a brand new E Class Mercedes at his doorsteps with the wordings "Thank you! Your Mother-in-law who loves you very much!!"

The third time she was walking with the third son–in–law and she repeated the same. But that guy got scared and ran away without offering any help to her. The poor old lady who wanted to test her sons–in–law drowned and died.

The next day the third son–in–law was suprised to see a new brand new Rolls–Royce waiting at his doorsteps with the following wordings ! ! "Thank you very much! Your Father-in-law! !"

(Contributed by Dr Chandresh Jardosh)

Scenario

Johnny takes apart leftover fireworks from Guy Fawkes, puts them in a model airplane paint bottle, blows up a ants nest.

1957 – Ants die.

2009– Police & Anti–terrorism Squad called. Johnny charged with domestic terrorism, Social workers investigate parents, siblings removed from home, computers confiscated. Johnny’s Dad goes on a terror watch list and is never allowed to fly again.

(Contributed by Dr Chandresh Jardosh)

Funny One Liners

What’s the difference between mother & wife?
A: One woman brings into the world crying & the other ensures you continue to do so.

  Readers Responses
  1. Debate regarding expiry dates of drugs is interesting. Americans can find solutions to their problems based upon their data and the quantum of problems and their results of scientific research. We should not blindly replicate their findings in our settings, as our products are different, our manufacturing, packaging storing, transportation facilities and standards are vastly different and then the patients are different. Potency of the drugs after the expiry date will definitely reduce  and there are no standards indicating the degradation of the product over a period of time as this is also a fact that the drug will not suddenly become unusable after the date on the label. So what do we do? My suggestion is to mention .Best before... date,( like we do for food products).Consult the doctor before use after the date mentioned if it could be used with higher dose and without deleterious effects   Nevertheless we shall need guidelines as there will be indiscriminate use. Spurious drugs is the biggest menace in this country already. Congratulations for bringing up this important issue and classifying the drugs for safe use after the date of expiry. Dr.Prof H.L. Kapoor, President IMA MANDI HP.

  2. Dear Dr KK: Apart from exercise and possibly olive oil, what do you recommend to increase HDL sp. in elderly diabetics? F. R.FAZLUR RAHMAN
    emedinews: The benefits of increasing HDL in patients with low HDL have been suggested by two randomized trials. However, a meta-analysis of studies in which therapies were used to raise HDL-cholesterol failed to show benefit. There is no recommendation of drug treatment directed specifically at low HDL-cholesterol. This is consistent with the 2006 AHA/ACC update on the guidelines for secondary prevention of patients with coronary and other atherosclerotic vascular disease. Exercise, weight loss (in overweight subjects), smoking cessation, and substitution of monounsaturated for saturated fatty acids raise HDL-cholesterol. As health benefits are associated with each of these, one should use them in patients with low HDL-cholesterol.

  3. Dear Editor, Apropos the observation of Dr. Vivek Kumar. In all fairness, practitioners of allopathy, Ayurveda and homoeopathy (the three recognized medical systems), rather than wasting energy in criticizing a system other than their own, should concentrate on highlighting good points of the system they have studied. Dr. Narendra Kumar
 

Forthcoming Events

eMedinewS Events: Register at emedinews@gmail.com

5th September: 3 PM to 5 PM – A dialogue with His Holiness Dalai Lama at C 599 Defence Colony Acharya Sushil Ashram in association with Acharya Sushil Muni Ahimsa Peace Award Trust

26 th September: Sunday- BSNL Dil ka Darbar A day-long interaction with top cardiologists of the city. 8 AM - 5 PM at MAMC Auditorium, Delhi Gate.

17th MTNL Perfect Health Mela 2010 Events: Venue: NDMC Ground Laxmi Bai Nagar, New Delhi

24th October, Sunday: Perfect Health Darbar, Interaction with top Medical experts of the city from 8 AM to 5 PM
30th October, Saturday: eMedinewS Update from 8 AM to 5 PM
29th October, Friday: Divya Jyoti Inter Nursing College/ School Competitions/ Culture Hungama
30th October, Saturday: Medico Masti Inter Medical College Cultural festival from 4 PM to
10 PM
31st October, 2010, Sunday: Perfect Health Darbar, An interaction with top Cardiologists

eMedinews Revisiting 2010

The 2nd 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.

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