eMedinewS1st February 2014, Saturday

Dr K K AggarwalPadma Shri and Dr B C Roy National Awardee

Dr KK Aggarwal

President, Heart Care Foundation of India; Sr Consultant Physician, Cardiologist & Dean Medical Education Moolchand Medcity; Editor in Chief IJCP Group, National Vice President Elect, Indian Medical Association; Chairman Ethical Committee Delhi Medical Council, Hony. Visiting Professor (Clinical Research) DIPSAR; Chairman (Delhi Chapter) International Medical Sciences Academy (March 10–13); 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);
For updates follow at
www.twitter.com/DrKKAggarwal
www.facebook.com/Dr KKAggarwal

Can a person appeal against the State Medical Council decision?

Yes, a person can appeal against the decision of the State Medical Council.

For example, Section 23 of Delhi Medical Council Act elaborates: 23. Appeals–

(1) Any person aggrieved by any decision of the Registrar under this Act may, within a period of one month from the date on which the decision is communicated to him, appeal to the Council which shall hear and determine the appeal in the prescribed manner. (2) Save as otherwise provided in the Medical Council of India Act, 1956 (102 of 1956) the decision of the Council under this Act shall be final.

When should one file an appeal against a State Medical Council order?

The Medical Council of India gives 60 days to file an appeal against State Medical Council (Medical Council of India Act 8.8). It is always better to file the appeal within 30 days, as the action of State Medical Council like the Delhi Medical Council is usually applicable on the 31st day of issuing of the order.

If Delhi Medical Council has taken an action for suspension of registration, simultaneously, it can be challenged in the High Court for a stay. The Medical Council of India has no provision of passing a stay order. The action of Medical Council of India should be challenged in High Court as early as possible as the Council does not give any time if it has suspended the registration of a doctor.

In Dr. Raj Bokaria Vs A. Dutta, the Medical Council of India gave a three-month suspension with immediate effect.

Reference

1. Dr. Raj Bokaria Vs A. Dutta, MCI.

Dr K K Aggarwal on Zee TV Dr K K Aggarwal on Zee TV Dr K K Aggarwal on Zee TV Dr K K Aggarwal on Zee TV Dr K K Aggarwal on Zee TV

cpr10 Mantra The CPR 10 Mantra is – "within 10 minutes of death, earlier the better; at least for the next 10 minutes, longer the better; compress the centre of the chest of the dead person continuously and effectively with a speed of 10×10 i.e. 100 per minute."

cpr 10 mantra
VIP’s on CPR 10 Mantra Video
eMedinewS
Ringtone – CPR 10 Mantra Hindi
Ringtone – CPR 10 Mantra English

Why we never eat a breakfast of onion?

sprritual blog

Anything which cannot be taken as a full meal is not good for health and either should not be taken or taken in a small amount.

For example, we never eat a breakfast of onion or garlic or radish. These are the items which either should not be taken or eaten only in small quantity only as addition to other full meal.

Onion is good for health and has anti–cholesterol properties and also blood thinning properties, yet it is consumed only in small quantity. In Vedic language, onion has both rajasik and tamasik promoting properties, which make a person more aggressive and dull.

cardiology news

Don’t let Fear Hold you Back

A man once went to a fortune teller, curious to know what she would say about his future. The fortune teller looked into her magic ball and then her facial expression said it all. The man would die, she said, involved in a bus accident. This would happen within two to three months time, but she couldn’t say exactly when. The man went home, depressed and worried telling himself how he never really believed in fortune tellers. Why should he now?

When two months passed, he had thought about what she said, day in and day out. Now he decided to lock himself in his house where he wouldn’t come close to any buses for the next month.

Another 3 weeks went by when the man came down the stairs from his bedroom to make some coffee. His little son had left his toys on the floor of which one was a little toy bus. The man stepped on the bus, after his last step down the stairs, slipped and knocked his head against the stairway railing and died instantly.

Moral of the story: "Live life on the edge, don’t lock yourself away."

News Around The Globe

6th International Conference "Recent Advances in Cardiovascular Sciences" 31st January &1st February, 2014

Dr. Ferid Murad, MD, Ph.D Nobel Laureate, George Washington University, USA

Murad studied medicine and pharmacology simultaneously at Western Reserve University, receiving both his M.D. and Ph.D. in 1965. He was an intern and resident in internal medicine at Massachusetts General Hospital until 1967, and then worked until 1970 at the National Institutes of Health’s National Heart and Lung Institute as a clinical associate and staff fellow. Then followed a series of academic, research, and administrative appointments at the University of  Virginia (1975–1981), Stanford University and Palo AltoVeterans Administration Medical Center (1981–1988), and Northwestern University and the University of Texas (starting in 1996).

Murad has also worked in the pharmaceutical industry. From 1988 to 1992 he worked for Abbott Laboratories, becoming vice president of pharmaceutical research and development, and from 1993-1995 he was full-time president and chief executive officer of Molecular Geriatrics Corporation. Murad’s work with nitric oxide began when he was in graduate school. He set out to learn how nitroglycerin, used for more than 100 years to treat angina, affected blood vessels. He found that nitroglycerin was effective because it prompted release of nitric oxide, which relaxed smooth muscle cells. Prior to this, nitric oxide was best known as an air pollutant present in automobile exhaust fumes. The gas was known to be present in bacteria, but it was not thought to be important in higher animals such as mammals.

Murad’s winning of the Nobel Prize for discovering that nitric oxide is nitroglycerin’s secret weapon against angina had an odd coincidence noted by some after the Nobel awards presentation. Alfred Nobel, the Swedish chemist who founded the famous prizes named after him, made his fortune using nitroglycer into invent dynamite. In fact, Nobel suffered from angina and his doctor once advised him to take nitroglycerin to ease his chest pain. The industrialist would not take the substance, saying that, in his case, it caused headaches.

Topic: Application of Nitric Oxide Research to Drug Development and Disease Therapy

The role of nitric oxide in cellular signaling in the past three decades has become one of the most rapidly growing areas in biology. Nitric oxide is a gas and a free radical with an unshared electron that can regulate an ever-growing list of biological processes. Nitric oxide is formed from L–arginine by a family of enzymes called nitric oxide synthases. These enzymes have a complex requirement for a number of cofactors and regulators including NADPH, tetrahydrobioterin, flavins, calmodulin and heme. The enzymes are present in most cells and tissues. In many instances, nitric oxide mediates its biological effects by activating the soluble isoform of guanylyl cyclase and increasing cyclic GMP synthesis from GTP. Cyclic GMP, in turn, can activate cyclic GMP–dependent protein kinase (PKG) and can cause smooth muscles and blood vessels to relax, decrease platelet aggregation, alter neuron function, etc. These effects can decrease blood pressure, increase blood flow to tissues, alter memory and behavior, decrease blood clotting etc. The list of effects of nitric oxide that are independent of cyclic GMP formation is also growing at a rapid rate.

For example, nitric oxide can interact with transition metals such as iron, thiol groups, other free radicals, oxygen, superoxide anion, unsaturated fatty acids, and other molecules. Some of these reactions can lead to altered protein structure function and ⁄or catalytic capacity. These effects probably regulate bacterial infections, inflammation of tissues, tumor growth, and other disorders. These diverse effects of nitric oxide that are cyclic GMP dependent or independent can alter and regulate numerous important physiological events in cell regulation and function. Nitric oxide can function as an intracellular messenger, an antacoid, a paracrine substance, a neurotransmitter, or as a hormone that can be carried to distant sites for effects.

Thus, it is a unique molecule with an array of signaling functions. However, with any messenger molecule, there can be too little or too much of the substance, resulting in pathological events. Some of the methods to regulate either nitric oxide formation metabolism, or function have been in clinical use for more than a century, as with the use of organic nitrates and nitroglycerin in angina pectoris that was initiated in the 1870s. Inhalation of low concentrations of nitric oxide can be beneficial in premature infants with pulmonary hypertension and increase survival rates. Ongoing clinical trials with nitric oxide synthase inhibitors and nitric oxide scavengers are examining the effects of these agents in septic shock, hypotension with dialysis, inflammatory disorders, cancer therapy etc. Recognition of additional molecular targets in the areas of nitric oxide and cyclic GMP research will continue to promote drug discovery and development programs in this field. Current and future research will undoubtedly expand the clinician’s therapeutic armamentarium to manage a number of important diseases by perturbing nitric oxide formation and metabolism. Such promise and expectations have obviously fueled the interests in nitric oxide research for a growing list of potential therapeutic applications. There have been and will continue to be many opportunities from nitric oxide and cyclic GMP march to develop novel and important therapeutic agents. There are presently more than 80,000 publications in the area of nitric oxide research. The lecture will discuss our discovery of the first biological effects of nitric oxide and how the field has evolved since our original reports in 1977. The possible utility of this signaling pathway to facilitate novel drug development and the creation of numerous projects in the Pharmaceutical and Biotechnology industrials will also be discussed.

USICON 2014:

Role of steroidal anti–inflammatory agent on outcome of URSL under LA for UVJ calculus: Dr. Bijit Lodh, M.Ch. Trainee, Department of Urology, RIMS, Imphal
UVJ, the narrowest part of ureter provides a gateway for stone lodgment & impaction. Inflamed and⁄or obliterated ureteric orifice is a major constraint for stone clearance at UVJ. Our study concludes that deflazacort 30 mg improves the outcome of URSL under LA. We recommend its use in patients with UVJ calculus ≥10.24mm & soft tissue prominence on NCCT KUB.

Delegate speak

Dr. Manish Patel:  The daily newspaper is an impressive add on to USICON and it should mandatory in all upcoming conference as it   gives you a backup copy of daily activity.
Dr Basavanaja K: USICON: Excellent about academics aspects; all arrangements are good ….  are excellent.
Dr. Kumar Nair: Very well-organized conference…good hospitality. There is a need to  evaluate further at end of conference.
Dr. Animesh Singh: I have learnt about new developments. New instruments and technologies are on display. The operative work shop was informative, adequate ad well-organized.
Dr. Juned Shaikh: The highlights of the conference have been recent advances in laparoscopic and robotic urological surgeries…management protocol of compliant urological cases….listing to experience urologists and their opinions.
(Prof)  R M Meyyappan: Well organized, well attended, newer information regarding technology and operative procedures
Dr Venkatesh K: Tremendous effort, timely reminders daily, good summary.
Dr. Madhumohan R Prabhu: Annual conference is for learning, updating, presenting paper/work, sharing ideas and meeting people and friends.
Dr Hanif Motiwala: I have come to see advances made and meet old colleagues.

Stoma-related complications and compliance with CISC in adolescence: Dr Aseem Shukla, USA

CIC is easier in children due to parental compliance.

Adolescence fraught with difficulties with compliance.

Prevention of stomal stenosis is a serious challenge in children due to longer life expectancies.

Must focus on education, improved care and utilization of appropriate skin flap based stomas.

The Exstrophic penis: Dr Richard Grady, USA

The untreated exstrophic penis has the problems of size (small), chordee, exposed bladder plate and urinary incontinence. Men are concerned about appearance, function and fertility. We can do something to help these patients; we cannot give them no hope. ? increase penile length by: Skin detethering with scar release, chordee repair, Kelly –Eraklis operation (radical soft tissue mobilization)

Recommendations

  • Male exstrophy patients should be offered sexual counseling advice.
  • Encourage support group participation.
  • Consider revision operations in the young adulthood.
  • Patients should be offered fertility evaluation.
  • Assisted reproductive techniques should be considered.
  • Psychological support should be offered beginning at an early age.

INTERVIEW: Dr Rajesh Taneja

What are the types of stones where holmium laser can be used?

Holmium laser can be used in all kinds of stones throughout the urinary tract

What are the advantages of using high power holmium laser in urolithiasis?

High power Holmium laser is used to rapidly pulverize hard urinary stones into dust. As a result the stones are treated in a short time. Using high frequency, the stone is converted into tiny particles, which can be flushed and need not be picked up by forceps, thus further reducing treatment time 

What is RIRS technique?

RIRS stands for Retrograde Intra Renal Surgery. Stones in kidneys are approached by passing a flexible telescope upwards, in retrograde manner, through the natural urinary passage. Having reached the stone, it is trapped in a basket and destroyed using high power Holmium laser. 

When is RIRS indicated in patients with urinary stones?

When stones are located in small pockets (calyces) of kidney, flexible ureteroscope can be negotiated under vision up to the stone, which can then be pulverized into fine dust using high power Holmium laser.

Holmium laser is the technology of the future. Do you agree & why?

Holmium laser is a versatile energy source. It can be delivered through flexible scopes thus making endourological procedures truly ‘Minimally Invasive’. Apart from rendering prostate surgery virtually bloodless, blood loss during stone surgery can be minimized using smaller scopes, thanks to possibility of miniaturization of instruments. Treatment of urethral strictures, bladder lesions and other soft tissue lesions in urinary tract can be done with minimal blood loss under clear field of vision. This reduces the inflammation and resultant cicatrization.

Dr Pinnamaneni Venkateshwara Rao Memorial Oration Dr PVLN Murthy, Hyderabad

Stricture urethra: Some are friendly, some are not!

Urethral dilatation and DVIU remain prevalent in contemporary urologic practice. There is no place for blind or forceful traumatic dilatation. An observational study in the US found that between 1992 and 2000, the overall treatments used for stricture urethra were: urethral dilatation (34–44%), visual internal urethrotomy (VIU) (51–57%) and urethroplasty (0.5–0.8%). VIU (cold knife, laser) is widely used even when the risk of recurrence is high. It is mainly used for short (<2cm) bulbar stricture.

VIU and intermittent self-dilatation (ISD) are used as an initial management. Recurrence at the end of one year 75% and with ISD once a day, the recurrence rate was 15.5% (IJU, 1997). Then comes the question of for how long should ISD be done and how frequently? It has been shown that once a week ISD was equally effective when compared to twice in a week, and once in a day SD.

The most common complications of ISD are UTIs, febrile UTIs, hematuria, false passage, epididymitis and urethral stricture. The most important prevention measures are good education of all involved ISD, good patient compliance, the use of a proper material and the application of a good catheterization technique. The use of hydrophilic catheters might be able to lower the urethral complication rate (Spinal Cord 2002 Oct;40(10):536–4).

Buccal mucosal graft (BMG) substitution urethroplasty by Asopa technique, the overall results were good (87%), with a mean follow-up period of 42 months (Eur Urol 2009 Jul;56(1):201–5).

The success rate of Asopa technique varies from 80–100%.  The dorsal onlay technique of Barbagli and the dorsal inlay technique of Asopa buccal mucosal graft urethroplasty provide similar success rates. But, the Asopa technique is easy to carry out, provides shorter operative time and less blood loss, and it is associated with fewer complications for anterior urethral stricture repair (Int J Urol 2014 Feb;21(2):185–8).

The substitution graft of choice is a full thickness buccal mucosal graft because it is easy to harvest, tough, resilient, easy to handle, and picks up blood supply very effectively. It has become the gold standard in the last decade.

Take home messages

  • VIU is a useful and commonly performed operation and can be done as a day care procedure. Self dilatation prevents recurrence.
  • BMG urethroplasty via Asopa technique is easy, simple and meatal problems are better addressed.
  • Single stage urethroplasty is feasible and successful in pan urethral strictures.
  • IOB can be recommended as preemptive analgesia to prevent long term morbidity.
  • Bioabsorbable drug eluting stents are on the horizon.

 

The neurobiological basis of transsexualism:Dr SV Kotwal, Delhi

Transsexuals have the opposite gender of their biological sex. Transsexualism is universal with many variant expressions of the opposite sex. The perception of sexual behavior has gradually changed from viewing the condition as ‘sexual deviation’ to ‘sexual aberration’ to ‘alternate sexuality’.

Transsexualism is listed as a medical condition by WHO ICD 10 (1992) and as a psychological condition by APA-DSM IV (1994).

Transsexualism is innate. Throughout history, all efforts to cure the condition either by reward, coercion, therapy or even punishment have failed. There is a high incidence of suicides amongst frustrated transsexuals. The core question is ‘Is transsexualism a mental condition or a physical one?

Neuroscientists have conducted pathbreaking research to show that the brain is dimorphic and that there are structural differences between the male, the female and the transsexual brain and that these differences take place when the baby is inside the womb. Endocrine disrupter chemicals present in our environment affect gender identity. EDCs modulate hormone receptors. Transsexualism has been correlated with DES, dilantin and barbiturate exposure  during pregnancy. Genes have been identified for predisposition to certain behaviors like depression, bipolar mania, schizophrenia and addiction but environmental exposure is essential. Genes also influence the number, volumes and distribution of ARs and ERs. The classical example is AIS which is autosomal recessive and is due to inactive ARs.
Anatomical studies have shown that certain areas of brain are dimorphic – bed nucleus stria terminalis central, interstitial nucleus anterior pituitary, amygdale and hippocampus and corpus callosum.

Difference in sexual orientation has been related to the structural brain differences: size of anterior commissure and suprachiasmatic nucleus.

Since sexual differentiation of the genitals takes place in the first two months of pregnancy and sexual differentiation of the brain starts in the second half of pregnancy, these two processes can be influenced independently, which may result in extreme cases in trans-sexuality (Endocr Dev 2010;17:22-35).

Take home messages
·  Gender identity and gender orientation originate in the brain.
· In transsexuals, the normal sex differentiation of certain hypothalamic network is altered by cerebral programming in utero before they take their first breath.

Though the last word has not been said, it is logical to deduce that transsexualism like homosexuality is determined from birth.

Real discovery is not in seeking new landscapes, but in having new eyes. Marcel Proust

Basic concepts for making successful track for PCNL: Dr SK Pal, New Delhi

The most important part of PCNL is initial puncture & making  a  track. In the US,  only 12% of urologists  make their own  tracks rest are getting  tracks made by interventional  radiologists
Steps  for  making  a  track

  1. Initial planning
  2. Ureteric  catheterization
  3. Positioning  of  the  patient
  4. Positioning of C arm
  5. RGP use of  contrast
  6. Percutaneous  renal  access  techniques
  7. Which  calyx  to  puncture
  8. Placement  of  guide  wire
  9. Track  dilatation
  10. Access to difficult  calyces

Organ donation: Har jan ko amar banana hai: Dr Rajeev Sood, Organizing Secretary

Dear Friends,
Once again it gives us immense pleasure in introducing another noble cause as a theme for this day of USICON 2014. We as a nation lag behind many other countries, even some developing nations, when it comes to donating organs post our demise. Even though the social cause served by organ donation is huge, there had been several barriers to its acceptance till recently. The Government of India has pushed forward in its favour with some important amendments in existing laws and bringing ‘Transplantation of Human Organs and Tissues Rules, 2013’. The shortfall however remains steep and it is our holy duty to promote this cause in the society. The kidney being the most common solid organ to be transplanted, the urologist community is best suited for this purpose. Continuing on from yesterday, we have chosen this theme of "Organ donation: Har jan ko amar banana hai" for today.

Let us come together on this day of 31st Jan 2014, when USICON is being held in the national capital after a gap of 31 years, to pledge all our possible 31 organs that can be transplanted after our death. Let this day be a landmark to start the spark for organ donation among general masses, by being the humble role model that we can be for them. The slogan of "Har jan ko amar banana hai" inherently carries with it the message of eternal life for all, cutting across all regional and religious barriers that we all face while trying to persuade the bereaved family of the deceased. This gift of life programme is as yet limited to very few states in southern India, esp. Tamil Nadu. Let us all use this stage of USICON to highlight this deficiency and create awareness to add to this presently meagre national pool of volunteers for organ donation. Joining us in our effort to glorify this event, there are several public figures, celebrities and important high level government officials including DGHS Dr Jagdish Prasad, Justice Anil R Dave (Supreme Court), Mr Kapil Dev, Mr Bishan Singh Bedi, Mr Praveen Kumar, Mr Ranveer Singh, Sunil Gupta (Member ASSOCHAM and Chief SARC) etc to name a few. Let us put across this message to one and all in general public and ignite this light leading to bliss of continuing to live in your recipients.

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Dr Himadri Sarkar Memorial Oration: Dr Jagdeesh N Kulkarni, Mumbai

Uro-oncology: A Journey through three decades

In his talk, Dr Kulkarni described his journey in Uro-oncology over the last 3 decades, which began in 1980 when he joined Tata Memorial Hospital. He discussed the progress of radical cystectomy and its nuances.

As an uro–oncologist most common major surgery was and is Radical cystetctomy. The incidence of various uro-oncology tumors has remained the same and bladder cancer forms the most common tumor. Prior to 1980s, we used to get patients who had open excision of tumors. It was the radiotherapy era and cystectomy was mainly a salvage procedure. There was no support system, there were no stoma clinics to educate and support the patients. The mortality and morbidity was unacceptable.

Tri facta progress 1981–1990: we addressed basic issues and standardized the technique of surgery. The three factors which improved our results were

  • Standardization of technique
  • Evolution of better ICU care and anesthesia
  • Stoma clinic and appliances

These helped the rehabilitation of the patients, the morbidity and mortality reduced and hence procedure began to be gain acceptance from patients.

The first urostomy clinic was established in 1984 at Tata Memorial Hospital.

The first urostomy clinic was established and stoma association was formed. Then we realized that it is not only the medical professional who is important. The other people too are important. This led to the concept of ‘team approach’, which included medical personnel and stoma counselor and visit from the ostomates.

So, in this decade, there was better perioperative care and there were better investigations to diagnose disease and complications at an earlier stage. But, the complication rate and morbidity was still high.

In the second decade, 1991–2000, we introspected and analyzed our data of cystectomy. But keep in mind that lot of patients had pre op radiotherapy prior to the surgery. Of course the radiation therapy was also evolving during that period. We came to realize that the two steps of radical cystetctomy are cystectomy proper and urinary diversion can independently lead to morbidity. While world was talking about continent urinary diversions (CUDs) and Neobladders (NB), hence we started the program of CUD⁄NB in second of this decade.

In next 5years, we performed 135 surgeries (almost tripling the numbers) with early experience of CUD⁄NBs in selected cases. High mortality could have been due to some factors like preoperative radiotherapy. We later analyzed the data and compared to ileal conduit and found that morbidity was still high. So we concluded that radical cystetcomy was gaining ground but there was scope of improvement. Hence in 2nd decade we decided to analyze the data and introspect and revisit the skill.

In 1993, the 4th international consensus conference on bladder talked about the neo bladders in males. But there was no discussion on female neo bladder. We also realized that continent stoma were not acceptable. In the second half of the 90s, we decided to revisit anatomical considerations and change in approach. We found that there was scope of newer technique. The urinary bladder is retroperitoneal organ. The traditional radical cystetcomy ends in loss of peritoneum and the peritoneal barrier between GI and GU tract is lost. After doing some cadaveric dissections we developed retrograde extra peritoneal technique for cystectomy based on peritoneal saving approach. WE published this as a point of technique in 1999.

The left ureter can be obstructed at two places: behind the mesentry and at the site of urteroenteric anastamosis. While in EP it is much more natural. Analysis of data showed that though it was non randomized study there were many positive findings like early return of peristalsis and reduction of ICU stay and leaks. Also, the re–exploration rate was less. Although the leak cannot be prevented in some management of leaks in EP approach is simple and non surgical. Our stand of retaining the peritoneum and reconstructing it and bringing the UD extra peritoneal was vindicated by the randomized study by Studder group in 2011. Then came the third decade, 2000–2010, which I call "the decade of Female neo bladders and standardization of complication reporting (Clavien Dindo). Our objectives were to find out which neo bladder is good and can females have neo bladder and can gyne tract be spared. We performed three types of neo bladder and reported urodynamic study and oncological outcome and found that the urologist should be familiar with more than one procedure, and customize the operation for each patient and disease. We have done gynaec tract cystetcomy and our new extra peritoneal retrograde technique sparing uterus, ovaries and gyn tract with excellent outcome. It renders good functional outcome, better sexual function and potential for fertility preservation.

From 2011–2013 can be called the era of laparascopy and Robotic surgery. We initiated the robotic surgery program in 2011 and our no. is small but indicates the reduction in surgeons’ morbidity in addition to the patients’ morbidity. At the end, I would like to pose following questions:

  • Has technology reduced the patient morbidity? Yes
  • Has it reduced morbidity of surgeons: Yes
  • Will bladder cancer prevention awareness reduce the incidence of ca bladder? Yes, but may take 3–4 decades.
  • Are more dedicated uro oncologists and institutions needed to share the burden of ca bladder in India? Yes

    Radical cystetcomy – The search for excellence continues…

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Exstrophy in the adolescent: Dr Richard Grady

The goals of management of exstrophy–epispadias: Urinary incontinence, functional genitalia, optimal renal function, satisfactory outcomes. The natural history is that it causes significant morbidity due to incontinence, chronic UTIs and bladder pain. If left untreated, it can result in incontinence, limited to no sexual function, renal failure and adenocarcinoma. The goals of reconstruction

  • Preserve kidney function
  • Provide urinary continence
  • Provide functional genitalia

Long term studies identify a subset of patients who demonstrate renal damage. As providers, we need to care about patients as they grow older. As urologists, we must worry most about kidney function. What patients care about is how they are going to function as young adults.

Women with exstrophy want to know if they can become pregnant. Pregnancy is difficult to achieve; a 30% complication rate in best series has been reported.

  • 24–66% upper tract obstruction
  • 10% complication rate during cesarean
  • Increased risk for UTI
  • Increased prolapsed

Female patients should live with the prolapse till they are done having children and then have the surgery.

Exstrophy renal recommendations

  • Renal function should be followed routinely using serial laboratory studies and imaging studies.
  • Patients are an increased risk of renal damage after surgical reconstruction.

Recommendations for female exstrophy

Female patients may require vaginal reconstruction after the initial exstrophy repair Uterine and vaginal prolapse is common. Repair should be delayed until after childbearing. Female exstrophy patients who achieve a pregnancy should be treated as a high risk pregnancy. Recommendations for male exstrophy

  • Male exstrophy patients should be offered early fertility evaluation.
  • The use of ART should be considered in these patients.
  • Psychological support to both male and female exstrophy patients should be offered.

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Dr Pramod P Reddy
Long term consequence of DSD: Delayed surgery vs early intervention

The primary human sex organ lies between the ears. Milton Diamond The most characteristic sexual differences of the human body are manifest by the external genitalia and the brain. The paradigm is changing now from doctor7–centered care to patient and family–centered care. Patients and families no longer blindly follow the recommendations from their doctor. In the information age, the patients have a right to know, ask why and have a say in matters related to their health and wellness. When caring for children with Disorders of sexual development (DSD), we need to factor in psychosocial, cultural, anatomical and physiological data into any decision making process. The developing nations differ in their attitudes towards gender of rearing in patients who present late with a DSD than those in the west.

Goals of management of DSD

Goals of holistic care for all patients with DSD conditions

  • Overall health
  • Minimized complications with normalized growth and development
  • Rewarding sexuality and fertility
  • Integration into society (local cultural and societal norms)
  • Independence and self management
  • Social continence (urinary & fecal)

Specific goals of DSD surgery

  • Normalizing the genitalia is just one aspect of care.
  • Esthetic and gender–typical appearance
  • Unobstructed urinary emptying without incontinence or infections
  • Potential for adult sexual and reproductive function appropriate with gender for rearing

Optimal timing of surgery: Should it be within the first 6–12 months of life or late after puberty? Never!!! There is very little data to guide us…we are learning as we understand how individuals are using methods

Consent: The most important person that is usually not involved in the ‘informed consent’ process is the patient himself or herself. This can cause ethical and legal problems.

The questions that maybe posed about surgery for DSD: in whom to perform surgery? The best age at which to perform surgery? Which procedure offers the best outcome?

These are the questions parents ask when child is young and the patient as adult.

Masculinizing genitoplasty: Once gender assignment has been decided upon, early intervention favored on the basis of data from hypospadias surgery outcomes. These patients may need additional interventions after puberty to address: chordee, torsion, and fistula

Feminizing genitoplasty: This is more challenging as there is very little data to fall back on. There is no consensus on timing of surgery. These patients may need additional interventions after puberty to address: clitoral tissue associated with painful erection, vaginal stenosis, cosmesis of labia and hair distribution

Early surgery: Pros

  • Easier to operate on infantile anatomy
  • Results are better
  • Stigma of living with genital ambiguity reduced
  • Aligns genital anatomy with gender of rearing

Early surgery: Cons

  • Inherent friability of infantile vaginal tissue (lack of estrogen exposure)
  • Precludes the patient from being involved in the informed consent process
  • Adult outcomes of infantile surgery
  • No data to show that early genital surgery results in successful gender outcomes.

Delayed surgery: Pros

  • Patient is actively involved in all decisions that affect them.
  • It allows for reconsideration of gender of rearing prior to genitoplasty.
  • There are fewer reported incidences of vaginal stenosis.
  • Allows for biological dilation and alteration of Mullerian tissue

Delayed surgery: Cons

  • Unwarranted social stigmatization from their peers causing poor body image, social withdrawal, psychological trauma and self inflicted injuries

    Responsibilities as a DSD surgeon
     
  • To the patient: optimize cosmesis and function, counseling and referral to appropriate experts, centers with expertise should not refuse care
  • To the parents of your patients: Address the parental guilt and anxiety – counseling
  • To yourself & your team: Multidisciplinary DSD team, detailed informed consent process; remember –always DOCUMENT

    Key points
     
  • There is a crucial need for long term longitudinal studies that rigorously compare surgical and psychosocial outcomes in order to improve our understanding of these conditions and the impact of our interventions.
  • We have to listen to our patients and their families.

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Posterior urethral valves: Dr Aseem Shukla

  • The initial therapy is inversely proportional to long term consequences. The evolution of the valve bladder is a profound event in bladder devolution. The focus on kidney distracts from the central role of bladder and pulmonary hypoppasia.
  • The long term sequelae of PUV: Voiding dysfunction, delayed acquisition of continence and end stage renal disease
  • The PUV bladder begins as small, poorly compliant bladder at birth and then progresses to very large capacity bladder with poor contractility.
  • Valve bladder syndrome
    • Polyuria from renal insufficiency
    • Poor bladder compliance
    • A bladder that fills immediately after emptying – lack of cycling
    • Bladder volume increases
    • Can affect renal graft if not treated appropriately
  • Late stage decompensation: Teenage years, increased bladder capacity, polyuria, incontinence, rising creatinine
  • PUV transplant evaluation
    • Avoid native nephrectomies
    • Assure compliant bladder
    • Ok to txp into vesicostomy
  • Challenges of transplant: A renal transplant requires a reservoir⁄bladder in which to empty. Whether a reservoir/bladder in turn is able to empty put is another question. Up to 20% of bladders are unfriendly for renal transplant. So a pediatric urologist is a critical part of the transplant team.
  • Children with urinary diversions for bladder outlet obstruction have historically been undiverted prior to renal transplant.
  • The timing and sequence of renal transplant and urinary tract reconstruction with bowel segments has been debated.
  • The addition of bowel to urinary systems in immunocompromised patients carries increased concerns.
  • A poorly compliant bladder increases the risk of graft failure after transplant (Solmon 2000) Close monitoring with urodynamics and instituting clean intermittent cath is essential.
    Summary
  • Genitourinary anomalies increase the risk for renal transplant related complications.
  • The bladder in posterior urethral valves patients requires careful considerations.
  • Pediatric transplant patients may benefit from a multidisciplinary approach.

++++++++++++++++++

Varicocele: Richard Grady

  • Varicocele maybe progressive; 75% improve (reversible). If left untreated, it is associated with a progressive decline in semen parameters. It is treatable via a minimally invasive procedure with rapid recovery.
  • Factors associated with improved outcomes following varicocele treatment for subfertility
    • Grade III varicocele
    • Lack of testicular atrophy
    • Normal FSH
    • Postivie GnRh stimulation test
    • Total motile sperm count >5x106
    • Motility> 60%
  • Semen analysis is most useful in management. But it is challenging to obtain from an adolescent male.
  • Many of these patients have asynchronous growth of testes over time.
  • Asynchronous testis growth: Varicocele recommendations
  • Adolescent males with unilateral left varicoceles often demonstrate asynchronous testicular growth that usually equalizes over time.
  • Sonographic testicular size measurement at a single point in time during adolescence is insufficient to determine the need for varicocelectomy.
  • Indications of surgical ligation
    • Significant testis volume loss (≥2 ml)
    • A >2 SD decrease of testis volume from normal controls
    • Abnormal semen analysis (WHO Criteria)
  • The right testis is not an adequate control for estimation of left testis atrophy.
  • Consideration should be given for ligation of a grade III varicocele even in the absence of measurable atrophy.
  • Surgical ligation of varicocele is indicated for protracted pain when no other etiology can be identified.
  • Generally surgery is recommended by all if left < right by more than 15–32%.

++++++++++++++++++

Dr MS Ansari, Lucknow

Primary obstructive megaureter: Observation as primary treatment

  • Most patients of Primary obstructive megaureter resolve spontaneously.
  • Meticulous follow up is required.
  • Surgery is required in selected cases.

++++++++++++++++++

Dr Mallikarjuna Reddy
Hyderabad

Primary obstructive megaureter: Surgical reimplantation

  • Only 20–25% will need surgical intervention.
  • Ureter >1cm in infants
  • Infection
  • Loss of renal function in serial imaging >5%
  • Increasing dilatation

++++++++++++++++++

Dr Dana Weiss, Philadelphia, USA

Posterior obstructive megaureter: Robotic treatment & Alternative options

Most megaureters need no intervention. The CHOP approach has been observation. With time the lumen of narrowed segment grows/UVJ develops and relative obstruction improves. Surgery only to temporize the sick child. Management goals

  • Around 20% will need surgery due to increasing dilation, loss of function, symptomatic obstruction, infection.
  • Relive obstruction
  • Minimize patient morbidity
  • Avoid second surgery (At CHOP, not concerned about secondary reflux unless the child is symptomatic – pyelonephritis)

Alternative options

  • Endoscopic: Balloon dilation with double stenting, incision in cases of ectopic urter
  • Open marsupialization of ureter to bladder
  • Robotic extravesical dismembered reimplantation

    Balloon dilation and double stenting

  • Avoids open surgery
  • Avoids devascularization of distal ureter
  • Same day surgery Balloon dilation if narrowing < 2 cm; laser incision and balloon dilation if 2–3 cm long.

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Rabies News (Dr. A K Gupta)

Is there a seasonal variation in dog bite cases?

Maximum dog bites are observed in the autumn months. It is observed that there is an increase during warm-weather months (May through August) and a corresponding decrease during colder months (November through March).

cardiology news

Heart disease starts in youth

Autopsy studies of young people who died in accidents have shown that by the late teens, the heart blockages, the kind of lesions that cause heart attacks and strokes are in the process of developing

The best opportunity to prevent heart disease is to look at children and adolescents and start the preventive process early. More than a third of children and adolescents are overweight or obese.

The first signs that men are at higher risk of heart disease than women appear during the adolescent years despite the fact that boys lose fat and gain muscle in adolescence, while girls add body fat.

Between the ages of 11 and 19, levels of triglycerides, a type of blood fat associated with cardiovascular disease, increases in the boys and drops in the girls. Levels of HDL cholesterol, the "good" kind that helps keep arteries clear, go down in boys but rise in girls.

Blood pressure increases in both, but significantly more in boys. Insulin resistance, a marker of cardiovascular risk, which is lower in boys at age 11, rises until the age of 19 years.

Any protection that the young women have for cardiovascular protection can be wiped out by obesity and hence obesity in girls at any cost should be handled on priority.

cardiology news

Total CPR since 1st November 2012 – 84500 trained

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press release

Dr KK Aggarwal receives Harpal S Buttar Oration Award from Nobel Laureate Dr Ferid Murad

Padma Shri & Dr. B C Roy National Awardee, Dr. K K Aggarwal, President Heart Care Foundation of India is awarded with Harpal S Buttar Oration Award by the 6th International conference of International Academy for Cardiovascular Sciences. The award consists of a memento and a cash prize of Rs. 10000.

The Oration was given to Dr. Aggarwal for his outstanding contribution for heart care and other achievements in cardiovascular sciences.

The Award was given by International Academy of Cardiovascular Sciences India The award was given by Nobel Laureate Dr Ferid Murad of Washington University. Others who were present were Dr Harpal S Buttar himself and Dr G N Singh Drug Controller General of India.

Prof. Buttar is an eminent professor in Canada and has made significant contributions in preventive cardiology, especially role of diet.

The Oration was chaired by Dr. Robert Roberts, President and CEO, House of Ottawa Heart Institute Canada and Dr. S C Tiwari. Dr. Aggarwal, who is also currently Senior Vice President Indian Medical Association, spoke on the concept of Savitri mantra for reviving a heart after sudden cardiac death.

Dr. Aggarwal said that consciousness does not leave the body for up to few minutes after cardiac arrest. During this period, if hands only cardiopulmonary resuscitation (CPR 10) is attempted by bystander, the person can be revived.

At Heart Care Foundation of India, Dr. Aggarwal has designed the Savitri Mantra for easy adoption of the same by the public. It is based on the traditional Indian Vedic knowledge where Savitri fought with Yamraja and saved her husband Satyavan, probably, by doing something equivalent to hands only CPR.

The Savitri Mantra is the Formula of 10 (CPR 10), which talks about the importance of the numerical number ‘10’. It says, in English "To revive a person from sudden cardiac death, within 10 minutes of death (earlier the better), at least for the next 10 minutes (longer the better), compress the centre of the chest of the dead person by 1 ½" distance continuously with a speed of 10x10 i.e. 100 per minute."

In Hindi it can be remembered as "Marne ke dus minute ke andar (jitna jaldi utna behtar), kam se kam agle dus minute tak (jitni der tak utna behtar, 10x10=100 ki gati se, apni chhati peetne ke bajaye mare hue aadmi ki chhati peeto."

In a survey conducted on 1000 school children after three months, a recall value of Hindi version of the Mantra was excellent with 90% remembering the later part of the mantra and 60% remembering the complete mantra.

About HCFI : The only National Not for profit NGO, on whose mega community health education events, Govt. of India has released two National Commemorative stamps and one cancellation stamp, and who has conducted one to one training on" Hands only CPR" of 84500 people since 1st November 2012.

The CPR 10 Mantra is – "Within 10 minutes of death, earlier the better; at least for the next 10 minutes, longer the better; compress the centre of the chest of the dead person continuously and effectively with a speed of 10×10 i.e. 100 per minute."

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Dr KK Aggarwal receives Harpal S Buttar Oration Award from Nobel Laureate Dr Ferid Murad

press release

Rhinitis medicamentosa

vedio of day

today video of the day20th MTNL Perfect Health Mela Press Conference with Marwadi Yuva Manch, Faridabad

20th MTNL Perfect Health Mela Press Conference at Marwah Studio, Noida

Cultural Evening at IMA

eMedi Quiz

Haemorrhage secondary to heparin administration can be best corrected by administration of:

1. Vitamin K.
2. Whole blood.
3. Protamine.
4. Ascorbic acid.

Yesterday’s Mind Teaser: Heat labile instruments for use in surgical procedures can be best sterilized by:

1 Absolute alcohol.
2. Ultra violet rays.
3. Cholorine releasing compounds.
4. Ethylene oxide gas

Answer for yesterday’s Mind Teaser: 4. Ethylene oxide gas.

Correct answers received from: Dr. P. C. Das, .DR.A.K.GAJJAR, Dr shashi saini, Aalia, Dr.K.Raju, Dr.(Maj. Gen.) Anil Bairaria, Dr.Bitaan Sen & Dr.Jayashree Sen, Dr Jainendra Upadhyay, Dr Pankaj Agarwal, Dr.Chandresh Jardosh, Dr Avtar Krishan, Dr Prabodh K Gupta, prajakta sambarey, Bal Kishan Agarwal, Muthumperumal Thirumalpillai,

Answer for 30th January Mind Teaser:4. Bronchogenic carcinoma.

Correct answers received from:.drjella, Tukaram Pagad, Aalia, Dr Sadai V Appan

Send your answer to ijcp12@gmail.com

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medicolegal update

Click on the image to enlarge

medical querymedical query

medicolegal update
medicolegal update

Bite my eye

A man walks into a bar has a few drinks and asks what his tab was. The bartender replies that it is twenty dollars plus tip. The guy says, "I’ll bet you my tab double or nothing that I can bite my eye."The bartender accepts the bet, and the guy pulls out his glass eye and bites it.

He has a few more drinks and asks for his bill again. The bartender reports that his bill now is thirty dollars plus tip. He bets the bartender he can bite his other eye. The bartender accepts knowing the man can’t possibly have two glass eyes.

The guy then proceeds to take out his false teeth and bite his other eye.

medicolegal update

Click on the image to enlarge

medicolegal updatemedicolegal update

medicolegal update

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

medicolegal update

Life begets life. Energy becomes energy. It is by spending oneself that one becomes rich. & Sarah Bernhardt

medicolegal update

Dr KK Aggarwal:High BP in Pregnancy Increases Risk for Future Atherosclerosis http://bit.ly/15QdVeB #Health
Dr Deepak Chopra: Why Forgiving Yourself Can Be So Hard? http://bit.ly/15QdVeB #Health

medicolegal update
  1. Dear Sir, Very Informative. Regards: Dr Karan

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