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  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 December, 2010, Sunday

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

Top 10 Medscape Neurology reads in 2010

1. Advances In Stroke Care

  • Dabigatran Approved! Now How Do We Use It?
  • What Does Clopidogrel’s Black Box Warning Mean for Neurologists?
  • Cilostazol Trumps Aspirin in Secondary Stroke Prevention

2. New Guidelines

  • Fibromyalgia: New Diagnostic Criteria
  • New Guidelines on Driving Risk in Dementia Presented
    New Brain Death Guidelines Issued

3. Life Without a Cerebellum
4. Senate Approves Last–Minute Delay for Medicare Pay Cuts
5. FDA Alerts

  • The FDA Alert on Serotonin Syndrome With Use of Triptans and SSRIs
  • FDA Warns of Aseptic Meningitis Risk With Lamotrigine

6. Fingolimod Receives FDA Approval as First Oral MS Treatment
7. House Enacts Historic Healthcare Reform Bill
8. Treating Benign Paroxysmal Positional Vertigo
9. Therapeutic Progress in Neurodegenerative Disease
10. Medscape Great Debate: Should You Treat Radiologically Isolated Syndrome?

Dr KK Aggarwal
Editor in Chief
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  Quote of the Day

(By Dr GM Singh)

"Idleness is an inlet to disorder, and makes way for licentiousness. People that have nothing to do are quickly tired of their own company."

Jeremy Collier

    Photo Feature (from the HCFI Photo Gallery)

Medico Masti in the 17th MTNL Perfect Health Mela 2010

A lively performance of college students during Medico Masti – College and Youth festival 2010.

Dr K K Aggarwal
    National News

Certificate courses in 2D and 3D Echocardiography/Fellowship Diploma in non invasive cardiology

Contact Dr KK Aggarwal, Moolchand Medcity, email: emedinews@gmail.com

Teachers’ decry MCI for diluting norms

NAGPUR: The recent reduction in teaching staff in medical colleges by the Medical Council of India (MCI) is drawing criticism not just from the teachers and students but medical fraternity as well. On the one hand, the council is increasing post graduate seats, while on the other, it is relaxing staff requirement norms which will adversely affect both teaching quality and patient care, especially in government medical colleges. A large section of teachers believes that the change in norms is being done only to suit private medical colleges. Though the Maharashtra State Medical Teachers Association (MSMTA) is taking up the larger issue of reduction in staff with the MCI, forensic science teachers from Indira Gandhi Government Medical College (IGGMC) have already sent a representation to the board of governors of MCI explaining how the latest notification dated September 17, 2010, will lead to poor quality of medico–legal work, teaching and research. (Source: The Times of India, Dec 17, 2010)

    International News

(Contributed by Rajat Bhatnagar, International Sports & Fitness Distribution, LLC http://www.isfdistribution.com)

Michelle obama says obesity is national security issue

The First Lady is not only concerned about the health and economic consequences of obesity, but about national security as well. According to Obama, obesity prevents 25 percent of Americans from serving in the armed forces. "Childhood obesity isn’t just a public health issue, it’s not just an economic threat, it’s a national security threat as well," she said. Mrs. Obama’s statements echo those of several retired generals, who back in September released a report titled, "Too Fat To Fight," that highlighted the obesity epidemic’s negative impact on the availability of military recruits.

(Dr GM Singh)

Warning Signs & Symptoms of Cardiac Rehabilitation

  1. Dyspnea
  2. Pulse rate: Should come back to resting level in 2–3 minutes after ending the exercise.
  3. Pulse ratio: Pulse is taken before the exercise then on completion. Pulse is counted for 2 consecutive minutes. The pulse after exercise is divided by resting pulse to give pulse ratio e.g. pulse before exercise = 80.
  4. Chest pain: Patients must be educated to report chest pain and to rest immediately on any onset of retrosternal sensation or tightness in chest.
  5. Fatigue: If patient is doing the exercise every day, and at same point, patient feels tired before completion of exercise, he should stop exercise at that point and rest.
  6. Dizziness: Any onset of dizziness or faintness must be reported and the patient should rest.
  7. Cramps: If patient is developing cramps in any of the muscles during the exercise, exercise should be stopped for the day.
  8. Abnormal ECG recording: If any abnormality presents, exercise should be stopped on that day and progressed slowly.
  9. Abnormal BP
  10. Decreased urinary output
  11. Signs of CV insufficiency

(Dr Monica and Brahm Vasudev)

Drug combination helps women with breast cancer

A new study finds that using two drugs, Herceptin (her–SEPT–in) and Tykerb (TIE–curb), more than doubles the number of women with early breast cancer whose tumors disappear before they are scheduled to have surgery to remove them.

Roche’s bevacizumab failed in comparison to chemotherapy in early–stage breast cancer

Roche Holding AG’s Avastin (bevacizumab) failed to eradicate tumor cells better than standard chemotherapy in women with early stage breast cancer, a finding that could limit the efforts to expand use of the oncology drug.

    Infertility Update

Dr. Kaberi Banerjee, Infertility and IVF Specialist Max Hospital; Director Precious Baby Foundation

Q: Is infertility more common in any particular group? For example, IT industry, BPO sector, highly competitive and career minded people or any other group.

A. People in the cities are definitely more prone to it as the stressful life style and long working hours do not allow them to have contact at the right time with the desired frequency. Most cases are from people working in the BPO industry.

For queries contact: banerjee.kaberi@gmail.com

    Medicine Update

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

Common causes of hematuria

  • Urinary tract infection with bacterial species, viruses, other sexually transmitted diseases
  • IgA nephropathy (Berger’s disease)
  • Trauma
  • Benign familial hematuria
  • Ureteropelvic junction obstruction
  • Kidney stones or ureter stones
  • Benign prostatic hyperplasia
  • Tumours and/or cancer in the urinary system
  • Urinary Schistosomiasis
  • Prostate infection or inflammation (prostatitis)
  • Arteriovenous malformation of the kidney
  • Nephritic syndrome
  • Allergy may rarely cause episodic gross hematuria in children
    Medicolegal Update

Dr Sudhir Gupta, Associate Professor, Forensic Medicine & Toxicology, AIIMS

What is Somatic Death?

For many years it was accepted that death occurred if respiration and circulation ceased for more than 10 minutes. Now it is possible for methods such as cooling the whole body to 15°C or 59°F or less to stop the heart and respiration for an hour or longer and restart them again at will. During this period, ECG and EEG show no electrical activity and body looks like a corpse. This leads to the view that it is not the cessation of the respiration or circulation but it is their failure to return that indicates death. Thus we are driven from a positive to negative approach. Therefore, the doctor while taking decision must satisfy himself that not only respiration and circulation has stopped, but their failure has persisted to such a period that under no circumstances it is possible for the person to come to life again.

  • Death is said to have occurred when a final expiration is followed by continuous immobility of the chest, loss of pulse and alteration of the features. These changes indicate that respiration and circulation have been stopped and the brain will stop functioning if it has not been so.
  • Residual heart movement is not of practical importance as they are insufficient to maintain the circulation.
  • Somatic death can be detected by ECG that will stop within minutes.

(Ref: Dr. PC Dikshit Head (MAMC) MD LLB, Textbook of Forensic Medicine, Peepee Publishers)

    Legal Question of the Day

(Contributed by Dr MC Gupta, Advocate)

Q: What course should be adopted when admission may be helpful or advisable (say, for observation) but not necessary or mandatory and the patient may not be willing for admission? Should admission be advised and refusal obtained?

A: A physician should err on the side of caution to save the patient (and himself). If admission may be helpful or advisable, it should be advised, recording the reason for the advice, and, if refused, the refusal should be recorded under the patient’s signature. Not doing so may impose a risk of negligence on the part of the physician.

    Medilaw – Medicolegal Judgement

(Dr KK Aggarwal)

Is consent in Gynecology any different?

‘Gynaecology’ (second edition) edited by Robert W. Shah, describes ‘real consent’ with reference to Gynaecologists (page 867 et seq) as follows: No–one may lay hands on another against their will without running the risk of criminal prosecution for assault and, if injury results, a civil action for damages for trespass or negligence. In the case of a doctor, consent to any physical interference will readily be implied; a woman must be assumed to consent to a normal physical examination if she consults a gynaecologist, in the absence of clear evidence of her refusal or restriction of such examination. The problems arise when the gynaecologist’s intervention results in unfortunate side effects or permanent interference with a function, whether or not any part of the body is removed. For example, if the gynaecologist agrees with the patient to perform a hysterectomy and removes the ovaries without her specific consent, that will be a trespass and an act of negligence. The only available defence will be that it was necessary for the life of the patient to proceed at once to remove the ovaries because of some perceived pathology in them.

The term ‘informed consent’ is often used, but there is no such concept in English law. The consent must be real: that is to say, the patient must have been given sufficient information for her to understand the nature of the operation, its likely effects, and any complications which may arise and which the surgeon in the exercise of his duty to the patient considers she should be made aware of; only then can she reach a proper decision.

But the surgeon need not warn the patient of remote risks, any more than an anaesthetist need warn the patient that a certain small number of those anaesthetized will suffer cardiac arrest or never recover consciousness. Only where there is a recognized risk, rather than a rare complication, is the surgeon under an obligation to warn the patient of that risk.

He is not under a duty to warn the patient of the possible results of hypothetical negligent surgery. In advising an operation, therefore, the doctor must do so in the way in which a competent gynaecologist exercising reasonable skill and care in similar circumstances would have done. In doing this he will take into account the personality of the patient and the importance of the operation to her future well being. It may be good practice not to warn a very nervous patient of any possible complications if she requires immediate surgery for, say, a malignant condition.

The doctor must decide how much to say to her taking into account his assessment of her personality, the questions she asks and his view of how much she understands. If the patient asks a direct question, she must be given a truthful answer.

To take the example of hysterectomy: although the surgeon will tell the patient that it is proposed to remove her uterus and perhaps her ovaries, and describe what that will mean for her future well being (sterility, premature menopause), she will not be warned of the possibility of damage to the ureter, vesicovaginal fistula, fatal haemorrhage or anaesthetic death.


"e–patient" … The Impatient Patient

Dr. Parveen Bhatia: MS, FRCS (Eng.), FICS, FIAGES (Hon.), FMAS, FIMSA, Chairman, Institute of Minimal Access, Metabolic & Bariatric Surgery, Sir Ganga Ram Hospital, Consultant Laparoscopic & Bariatric Surgeon & Medical Director, Global Hospital & Endosurgery Institute, New Delhi

Dr. Pulkit Nandwani: MD, DMAS (WALS), DMAS (CICE, France), Associate Consultant Gynaecologist and Laparoscopic surgeon, Bhatia Global Hospital & Endosurgery Institute, New Delhi

The Over Informed Patient

A well educated young lady belonging to a higher income group, well armed with knowledge of her medical problem, latest available management options, who actively participates in her treatment can be classically categorized as an "e–patient". Such patients have been brought up in the information age and make optimum use of it. They desire service at the speed of thought. They use cellulars, ATM, broadband access, net banking, travel, and bookings. They are used to convenient, personalized services provided by other sectors like travel finance etc. and want similar approach to their medical problem also.

    Ethical earning

What is reimbursable to a doctor?

Cardiac pulmonary resuscitation charges can be billed.

    Lab Update

(Dr Arpan Gandhi and Dr Navin Dang)

Lab Tests for Infertility in men

  • Semen analysis
  • Free and total testosterone
  • Luteinizing hormone (LH)
  • Follicle–stimulating hormone (FSH)
  • Prolactin (PRL)
  • Testicular biopsy: In some cases, a biopsy of testicular tissue can identify the problem, for example, sperm production, abnormal growths, tumors, or incomplete growth or maturation of reproductive organs.
Our Contributors
  Docconnect Dr Veena Aggarwal
  Docconnect Dr Aru Handa
  Docconnect Dr Ashish Verma
  Docconnect Dr A K Gupta
  Docconnect Dr Brahm Vasudev
  Docconnect Dr GM Singh
  Docconnect Dr Jitendra Ingole
  Docconnect Dr. Kaberi Banerjee
  Docconnect Dr Monica Vasudev
  Docconnect Dr MC Gupta
  Docconnect Dr. Neelam Mohan
  Docconnect Dr. Naveen Dang
  Docconnect Dr Prabha Sanghi
  Docconnect Dr Prachi Garg
  Docconnect Rajat Bhatnagar
  Docconnect Dr Sudhir Gupta
    Medi Finance Update

Q. What is the minimum amount on which a doctor is not assessable?

Ans. As an individual Rs. 1,60,000/–

    Drug Update

List of Approved drugs from 01.01.2010 TO 30.4.2010

Drug Name


DCI Approval Date

Olopatadine Hcl Nasal Spray 0.6% w/w (Additional Indication)

For the relief of the symptoms of seasonal allergic rhinitis in patients 6 years of age and older.


    IMSA Update

International Medical Science Academy (IMSA) Update

Parapneumonic effusion and empyema

The incidence of parapneumonic effusions in children is increasing despite reductions in pneumococcal pneumonia achieved by use of the pneumococcal conjugate vaccine. This may reflect a rising incidence of complicated pneumonias caused by invasive pneumococcal serotypes that are not included in the 7–valent vaccine.

    IJCP Special

Dr Good Dr Bad

Situation: A patient came with an EGFR of 15.
Dr. Bad: Go for immediate dialysis.
Dr. Good: Hold till proper investigations are done.
Lesson: A study published in December 2010 in the Canada Medical Association Journal shows that starting dialysis too soon may increase the risk of death.

Make Sure

Situation: A patient with rheumatoid arthritis was not responding!
Reaction: Oh my God! Why was smoking not stopped?
Lesson: Make sure that all patients of RA stop smoking. It is a major preventable factor contributing to the development of antibody–positive rheumatoid arthritis in genetically susceptible individuals.

    Lighter Side of Reading

An Inspirational Story
(Contributed by Dr Prachi Garg)

The Patriot and the Hooligan Chief

There was a great patriot who conquered everyone’s heart in India, especially the Bengalis. He was known as the leader of great leaders. When he was in college he was a brilliant student. He had always had a fondness for spiritual people. He helped the poor, the sick and the needy whenever he could. Once when he was a young man, cholera broke out in Calcutta and the rich people left the city. When the epidemic broke out, there was no medical treatment for the poor, so he went to the poorest section of town and treated the sick.

There were many hooligans in that part of town. They threatened him and said, "Don’t come here and bother us. We don’t want you. You’re well educated and come from a rich family, while we are poor and ignorant. Leave us alone." Bravely, he replied, "Do whatever you want. If you want to kill me, kill me. I’ve come into the world to help the poor and sick. I’ll continue to bring money and food and try to help as much as I can." One day the only son of the hooligan leader was stricken with cholera. So the young man went to his house and cared for the son, feeding him and giving him medical treatment. The hooligan leader was deeply moved. "I threatened you and warned you not to come here, and still you come to help my own son. You're a brave man."

The young man said, "It’s not a matter of bravery; it’s a matter of necessity. I see God in everyone. When I see someone suffering, I feel it is my duty to help. One must help one’s brother when he is in need." The hooligan chief bowed down to the young man and said, "You’re not human. You are divine."

This matchless leader and patriot was none other than Netaji Subhas Chandra Bose.

— — — — — — — — — —

Mind Teaser

Read this…………………

1 knows  

Yesterday’s eQuiz: Which of the following is NOT an effective strategy for primary prevention of stroke?

  • Dosing with vitamin K antagonists on the basis of pharmacogenetics
  • An angiotensin–converting enzyme inhibitor or an angiotensin II receptor blocker for diabetics with hypertension.
  • Physical activity (150 minutes of moderate exercise per week)
  • Treat blood pressure to below 130/80 mm of Hg
  • Aspirin for primary stroke prevention
Answer for yesterday’s eQuiz: "The correct answers are 1, 4 & 5."

According to the 2010 guidelines from the American Heart Association and the American Stroke Association there is no established role for dosing of Vitamin K antagonists on the basis of pharmacogenetics or for universal aspirin use in primary prevention of stroke. The goal blood pressure is less than 140/90 mm Hg. Only for those with diabetes or chronic kidney disease is the goal blood pressure less than 130/80 mm Hg. They also recommend dietary modifications such as the DASH diet. Regular physical exercise for 150 minutes per week is in the recommendations too. Statins are useful in select population. Aspirin is useful for primary prevention of stroke in persons whose risk is sufficiently high for the benefits to outweigh the risks associated with treatment (a 10–year risk of cardiovascular events of 6% to 10%). The full recommendations can be found online at the following website:


Correct answers received from: Dr Prachi, Dr Anupam 

Answer for 17th December Mind Teaser: "Paradise"
Correct answers received from: Dr Anurag Jain

Send your answer to ijcp12@gmail.com

— — — — — — — — — —

Laugh a While
(Contributed by Dr G M Singh)

A man is lounging in his favorite chair, drinking a beer, while his wife is cutting the lawn. A lady walking by sees this and yells at the man: "You should be hung!" The man takes a drink of his beer, and says to the lady: "I am. That’s why she’s cutting the grass."

    Readers Responses
  1. Dear Dr Aggarwal, In today’s emedinews Dr Gupta says that if patient does not agree for hospitalization – one should keep record duly signed by patients mentioning that he has been explained the risk and that he does not want to get admitted. But there are many ifs and buts – sometimes patient says that he will discuss with his relatives before getting admitted, some times he says he wants to have second opinion. Sometimes, he says that he will get himself or his ward admitted and does not reach the hospital. Is this a practical solution? I think the onus of proving negligence is on the patient and not on the doctors. The first document which the patient has to produce in the court is doctor’s prescription as a proof that he consulted the doctor on such date and time and if the doctor has written clearly on the prescription slip that the patient was advised hospitalization on such and such date and such and such time and that patient did not agree with his advise, is not this sufficient? Dr R S Bajaj
  2. I do not agree with observation that recording of the refusal to get admitted in the paper given to the patient will not help the doctor. I have drafted defense for the doctors in more than 1000 cases and have given talks in various conferences. If the patient wants to prove that he was under the treatment of a doctor he has to produce the prescription as it is easy for the doctor to show that he gives the details to all his patients who are treated as OP. Once it is produced, the recording of refusal will be present in the evidence produced by him. It is always not easy or practical to get it signed by a patient even though it is the ideal situation. But one warning – If a doctor is giving the papers to the patient he should number each page on top and write either PTO or Contd on page no. at the bottom so that if the patient suppresses any page favorable to the doctor that can be brought out. Dr George F Moolayil
    Public Forum

(Press Release for use by the newspapers)

Yoga – Not the Panacea

Padma Shri & Dr. B.C. Roy National Awardee, Dr. KK Aggarwal, President, Heart Care Foundation of India, said that yoga as a science is more preventive than curative for most disorders. Evidence–based clinical trials are available, which define that when introduction of medicines or surgical interventions becomes a must, there is no way yoga can cure a patient with congenital heart disease or with valvular involvement in rheumatic heart disease. A refractory heart failure which is irreversible on Echocardiography cannot be cured by any system of medicine.

Even Ayurveda classifies any disease as sadhya or asadhya. The tridosha asadhya pattern of a disease is considered incurable in Ayurveda. Most of the evidence based trials for reversal of heart disease have shown only 4% reduction in blockages over a year after adapting to a lifestyle which is based on a combination of yoga, diet and exercise. An emergent patient waiting for angioplasty or surgery should not and cannot take the risk for trying lifestyle yogic management alone.

A fasting blood sugar level of more than 250 and persistent blood pressure of more than 160/100 invariably will require drug treatment and it is very unlikely that yoga alone will be able to reverse the process.

Similarly, a patient with established renal failure cannot get relieved by yoga or other systems of medicine. Lifestyle management is the back bone of every treatment is not denied but it has to be done under supervision as now clear cut guidelines are available as to when lifestyle management alone will be effective. In a high blood pressure patient with no evidence of target organ damage or a high blood sugar in absence of microalbumin in the urine and/or a coronary artery disease in which a patient can walk two to three kilometer without any angina can involve a trial of lifestyle management of up to three to six months. If the same fails to provide adequate and wanted quality of life, it is mandatory, as per evidence-based medicine, to start–time tested medicines.

Advertising is banned on television for all pathies. But the continuing promotion and advertising by healers from other systems of medicine in the pretext of spiritual medicine is doing more harm than good to the people. People go to yoga camps a preconceived notion idea that an incurable disease requiring surgery will get cured by yoga. The government should interfere and ban all types of advertising by any medicine whether regular or alternative so that the right message goes to the society.

    Classifieds – Situation Vacant

Wanted a Senior Resident in Dept. of Pediatric Gastroenterology, Hepatology & Liver Transplantation at Medanta, The Medicity, Gurgaon, Delhi (NCR). Those interested please contact: Dr. Neelam Mohan (9811043475), or Secretary to Dr. Neelam Mohan – Amit (9818200582).

    Forthcoming Events

eMedinewS Events: Register at emedinews@gmail.com

eMedinewS Revisiting 2010

The 2nd eMedinewS – revisiting 2010 conference will be held at Maulana Azad Medical College, New Delhi on Sunday January 9th 2011.

The one-day conference will revisit and cover all the new advances in the year 2010. There will also be a webcast of the event. The eminent speakers will be Padma Bhushan Dr Naresh Trehan (Cardiac Surgery); Padma Shri Dr KK Aggarwal (Revisiting 2010); Dr Neelam Mohan (Liver Transplant); Dr N K Bhatia (Transfusion Medicine); Dr Ambrish Mithal (Diabetes); Dr Anoop Gupta (Male Infertility); Dr Kaberi Banerjee (Female Infertility) and many more.

There will be no registration fee. Delegate bags, gifts, certificates, breakfast, lunch will be provided. The event will end with a live cultural evening, Doctors of the Year Award, cocktails and dinner. Kindly register at www.emedinews.in

2nd eMedinewS Doctor of the Year Award

Dear Colleague, The Second eMedinews Doctor of the Year Award function will be held on 9th January, 2010 at Maulana Azad Medical College at 4 pm. It will be a part of the entertainment programme being organized at the venue. If you have any medical doctor who you feel has made significance achievement in the year 2010, send his/her biodata: Dr. KK Aggarwal, Padma Shri & Dr. B.C. Roy National Awardee.

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