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Dr KK Aggarwal

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

Dr KK Aggarwal
President, Heart Care Foundation of India; Sr Consultant Physician, Cardiologist and Dean Medical Education Moolchand Medcity; Member Delhi Medical Council; Chairman (Delhi Chapter) International Medical Sciences Academy; Hony Director IMA AKN Sinha Institute (08–09); Hony Finance Secretary National IMA (07–08); Chairman IMA Academy of Medical Specialties (06–07); President Delhi Medical Association (05–06), President IMA New Delhi Branch (94–95, 02–04); Editor in Chief IJCP Group of Publications & Hony. Visiting Professor (Clinical Research) DIPSAR


20th June, 2010, Sunday

How do you know you are a parasympathetic personality? (Source Harvard Newsletter)

Dear Colleague

You are in flow if……

  1. You lose awareness of time: You aren’t watching the clock, and hours can pass like minutes. As filmmaker George Lucas puts it, talent is "a combination of something you love a great deal and something you can lose yourself in—something that you can start at 9 o’clock, look up from your work and it's 10 o'clock at night …"

  2. You aren’t thinking about yourself: You aren’t focused on your comfort, and you aren’t wondering how you look or how your actions will be perceived by others. Your awareness of yourself is only in relation to the activity itself, such as your fingers on a piano keyboard, or the way you position a knife to cut vegetables, or the balance of your body parts as you ski or surf.

  3. You aren’t interrupted by extraneous thoughts. You aren’t thinking about such mundane matters as your shopping list or what to wear tomorrow.

  4. You are active. Flow activities aren’t passive, and you have some control over what you are doing.

  5. You work effortlessly. Flow activities require effort (usually more effort than involved in typical daily experience). Although you may be working harder than usual, at flow moments everything is "clicking" and feels almost effortless.

Dr KK Aggarwal
Padma Shri Awardee and Chief Editor

 

Photo Feature (From HCFI file)

Women’s Heart Day – The "Glow Red" Campaign

Heart Care foundation of India believes that women in India have been neglecting their health to meet household and other responsibilities. Keeping this in view, HCFI initiated to celebrate 1st Sunday of September as the Women Heart Day on the theme "Glow Red". The day is dedicated to women's heart care. Celebrity women as guests and specialist doctors are invited to be the part of the efforts. The dress color code for all invited women on the day is Red signifying danger.

Dr k k Aggarwal

In the photo: Blossom kochar, Simar Duggal as special guests on the occasion of Women’s Heart Day

International Medical Science Academy Update (IMSA): New Vaccine Update

HIV vaccine

A randomized multicenter, double–blind, placebo–controlled efficacy trial was performed in Thailand among 16,000 persons at low or moderate risk of HIV infection. Four priming injections of a recombinant canarypox vector vaccine (ALVAC) plus two booster injections of a recombinant glycoprotein 120 subunit vaccine (AIDSVAX) were administered. The results of the trial suggest a modest protective effect of this vaccination strategy among persons whose main risk factor for HIV acquisition was heterosexual sex.

Reference

  1. Rerks–Ngarm S, Pitisuttithum P, Nitayaphan S, et al. Vaccination with ALVAC and AIDSVAX to Prevent HIV–1 Infection in Thailand. N Engl J Med 2009;361:2209.

Mnemonic of the Day (Dr Varesh Nagrath)

Knee jerk present but ankle jerk lost

DOCASTO

Diabetes mellitus
Old age
Cauda equina/Conus medullaris
Ataxia (Friedrich’s)
SACD (subacute combined degeneration of spinal cord)
Taboparesis(general paresis ocurring together with tabes dorsalis)
Olivopontocerebellar atrophy

The last four causes will have Plantar extensors.

News and views

Pandemic H1N1 flu similar to seasonal influenza

A prospective study from Hong Kong has found the pandemic H1N1 influenza virus to be like the seasonal influenza A viruses pertaining to viral shedding, symptoms, and household transmission. In the study, 99 index patients who tested positive in rapid diagnostic tests for influenza A virus were examined. Of these, 45 had the H1N1 pandemic virus and 54 carried the seasonal influenza A virus, H3N2, but the two strains did not differ much. The study is reported in the June 10 issue of the New England Journal of Medicine by Benjamin Cowling, PhD, of the University of Hong Kong School of Public Health, and colleagues. Secondary attack rates among household contacts were also similar for H1N1 pandemic virus and seasonal influenza A viruses; 8% vs 9%, respectively. The time between the onset of illness in the index patient and the beginning of symptoms in a household contact was 3.2 days (average) for the pandemic virus and 3.4 days (average) for seasonal influenza virus. Viral shedding stopped after 5–7 days in both and clinical symptoms generally resolved after 10 days.

2. A molecular test to detect and distinguish types of staph colonization

The first molecular test (Xpert SA Nasal Complete; Cepheid) that identifies and make a distinction between Staphylococcus aureus and methicillin–resistant S. aureus (MRSA) colonization at the same time in less than an hour has been given the go–ahead by the US FDA. A study published this year in January 7, 2010, issue of the New England Journal of Medicine reports that rapid screening and S. aureus decolonization with chlorhexidine soap and mupirocin nasal ointment reduce the risk for hospital–acquired surgical–site infections by almost 50%.

3. FDA clears new ovarian cancer Test

A chemiluminescent microparticle immunoassay (Architect human epididymis protein 4 (HE4) assay; Abbott Diagnostics) for the quantitative determination of HE4 antigen in serum samples has been given the green signal by the FDA. HE4 antigen is an ovarian cancer marker, which is used along with other clinical data to monitor recurrence or progression of epithelial ovarian cancer. Study data also suggest that HE4 is the best single marker for detecting stage 1 disease. HE4 has been reported to have the highest sensitivity and specificity of any marker, including CA125, for detecting malignancy.

4. Now a new combination pill that relieves arthritis pain and protects gut

A delayed release formulation that combines a NSAID with a proton pump inhibitor (PPI) for treatment of arthritis pain and pain associated with ankylosing spondylitis is now available. The FDA–approved combination contains a fixed–dose combination of delayed–release enteric–coated naproxen and immediate release esomeprazole and will be sold under the brand name of 'Vimovo.' It reduces the risk of NSAID–associated gastric ulcers. The FDA approval was based on data from the PN400–301 and PN400–302 studies showed significantly fewer endoscopic gastric ulcers with the combination pill than patients receiving enteric–coated naproxen. In the PN400–301 study, the incidence of gastric ulcers in patients taking Vimovo was 4.1% vs 23.1% among patients taking enteric–coated naproxen (p<0.001). In the PN400–302 study, the incidence of gastric ulcers in patients taking Vimovo was 7.1% vs 24.3% among patients taking enteric–coated naproxen (p<0.001).

Depression: Take–home points (Dr G M Singh)

  • Key pointers to distinguish depression from unhappiness include biological symptoms, a family history and global underfunctioning.

  • High–risk groups for suicide are the elderly, the widowed, the recently separated, substance abusers and those in chronic pain.

  • Exercise – three sessions of 30 to 60 minutes a week – helps all degrees of depression.

  • Antidepressants, CBT and counselling all work in different ways and shouldn’t be thought of as alternatives to each other.

  • Reserve counselling for those with a defined problem they’re having difficulty with.

  • People with depression and chronic pain may benefit from an SSRI plus a low dose of amitriptyline.

  • If a patient gets ‘stuck’ on treatment, consider poor compliance, physical illness, substance abuse and new life events.

  • ECT remains an effective treatment in certain situations.

Interesting Tips in Hepatology & Gastroenterology (

Dr Neelam Mohan, Consultant Pediatric Gastroenterologist, Hepatologist, Therapeutic Endoscopist & Liver Transplant Physician, Sir Ganga Ram Hospital, Delhi)

Yesterday, I wrote on "What test does a living related donor undergo ?" Today I shall address the following issues

Advantages & Disadvantages of Living Related Liver Transplantation over Cadaveric Transplantation

Advantages

  • Waiting time on the list is reduced

  • The waiting list morbidity and mortality of the patient is much reduced.

  • Graft quality is good.

  • Complications related to cold ischemic time (time the graft is cut off blood supply) and storage is reduced.

Disadvantages

  • Ethical issues (subjecting a living person to risk of surgery)

  • Donor morbidity (~2 – 5%)

  • Donor mortality (<0.5%)

In India, cadaveric donation is extremely poor. We all as professional doctors must work to promote cadaveric organ donation in our country.

Tomorrow I shall write on "Living related transplant surgery"

Conference Calendar

Basic Assessment and Support in Intensive Care (BASIC)
The Chinese University of Hongkong (CUHK)Accredited
Target Audience – Doctors Only
Date: June 19–20, 2010
Venue: V Block, No: 70 (Old No: 89) Fifth Avenue Anna Nagar, Chennai, Tamil Nadu.

Evidence-based Medicine (Varesh Nagrath)

Comparison of outcomes among moderate alcohol drinkers before acute myocardial infarction to effect of continued versus discontinuing alcohol intake after the infarct

Light–to–moderate alcohol consumption has been previously associated with a lower risk of acute myocardial infarction (AMI) and mortality. The association of changes in drinking behavior after an AMI with health status and long–term outcomes is unknown. Using a prospective cohort of patients with AMI evaluated with the World Health Organization’s Alcohol Use Disorders Identification Test, the present study investigated changes in drinking patterns in 325 patients who reported moderate drinking at the time of their AMI. One–year alcohol consumption, disease–specific (angina pectoris and quality of life) and general (mental and physical) health status and rehospitalization outcomes, and 3–year mortality were assessed. Seattle Angina Questionnaire Angina Frequency and Quality of Life, Short Form–12 Mental and Physical Component Summary Scales were modeled using multivariable hierarchical linear models within site. Of the initial 325 moderate drinkers at baseline, 273 (84%) remained drinking and 52 (16%) quit. In fully adjusted models, Physical Component Scale scores (beta 6.47, 95% confidence interval 3.73 to 9.21, p <0.01) were significantly higher during follow–up in those who remained drinking. Persistent moderate drinkers had a trend toward less angina (relative risk 0.65, 95% confidence interval 0.39 to 1.10, p = 0.11), fewer rehospitalizations (hazard ratio 0.79, 95% confidence interval 0.44 to 1.41, p = 0.42), lower 3–year mortality (relative risk 0.75, 95% confidence interval 0.23 to 2.51, p = 0.64), and better disease-specific quality of life (Seattle Angina Questionnaire Quality of Life, beta 3.88, 95% confidence interval –0.79 to 8.55, p = 0.10) and mental health (Mental Component Scale, beta 0.83, 95% confidence interval –1.62 to 3.27, p = 0.51) than quitters. In conclusion, these data suggest that there are no adverse effects for moderate drinkers to continue consuming alcohol and that they may have better physical functioning compared to those who quit drinking after an AMI.

Reference

Carter MD, Lee JH, Buchanan DM, et al. Comparison of outcomes among moderate alcohol drinkers before acute myocardial infarction to effect of continued versus discontinuing alcohol intake after the infarct. Am J Cardiol 2010 June 15;105(12):1651-54.

Forensic Legal Medicine (Dr Sudhir Gupta MBBS (Gold Medal), MD, DNB, MNAMS (Associate Professor Forensic Medicine & Toxicology AIIMS)

Forensic or legal medicine deals with medical aspects of crime against the human body in which alleged accused or victim or both require a medical examination; preparation of medicolegal report; detection, collection, preservation, sealing (of connected biological evidences, clothing, or any other object/weapon found during the medical examination) and a concluding opinion into the alleged case by virtue of principle and practice of medicine as corroborative medical evidence for furthering the case investigation and later on deposition before the court of law where the concerned doctor is open for scrutiny by opposite counsel and learned judge.

Question of the Day

What are the criteria for diagnosis of type 2 diabetes mellitus in young? (Dr Shaila Bhattacharyya, Bangalore)

Type 2 diabetes is diagnosed by following symptoms:

  • Polyuria

  • Polydipsia

  • Unexplained weight loss plus

  • Random glucose ≥200 mg/dl or

  • Fasting glucose ≥126 mg/dl or

  • 2 hours glucose ≥200 mg/dl (after 75 g glucose in OGTT)

No symptoms: At least two glucose tests on different days within diabetic range.

Screening (ADA criteria)

Screening is done for children with

  • Body mass index (BMI) >85%

  • Weight for height >85%

  • Weight >120% (ideal for height).

Plus

  • Family history of type 2 diabetes

  • Race/ethnic group (American–Indians, African–Americans, Hispanic–American)

  • Asians/South Pacific–Islanders

  • Signs of insulin resistance or conditions associated with insulin resistance (acanthosis nigricans, hypertension, dyslipidemia, polycystic ovarian syndrome -PCOS).

  • Age of initiation – 10 years or at the onset of puberty, if early.

  • Frequency – every 2 years.

eMedinewS try this it works

Double glove for speedier exams

Before starting pelvic and rectal exams, double–glove your right hand. After finishing the Pap smear and pelvic exam, simply discard the top glove and do subsequent digital and occult blood testing.

SMS of the day

If a person wins without any trouble, it is just a victory but if one wins with lots of troubles is history.

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eMedinewS–revisiting 2010

The second eMedinewS – revisiting 2010 conference will be held at Maulana Azad Medical College, New Delhi on January 2, 2011. The event will have a day–long CME, Doctor of the Year awards, cultural hungama and live webcast. Suggestions are invited .

 

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Dr Good Dr Bad

Situation: A diabetic patient was found to have high ESR and elevated CRP.
Dr. Bad: You are suffering from inflammatory disease.
Dr. Good: It may be a part of diabetes.
Lesson: In diabetes, both ESR and CRP can be high at the same time and this can be due to IL–6 secretion by adipose tissue.

Make Sure

Situation: A patient with uncomplicated gonorrhoea come to hospital for treatment.
Reaction: Oh my God! Why did I advise ampicillin to this patient?
Lesson: Make Sure to remember that in uncomplicated gonorrhea cure can be elicited by administering oral doxycycline to such patients.

Humor Section

IMANDB Joke of the Day

After receiving his medication from the pharmacist, the customer asks, "Are these time release pills?" The pharmacist replies, "Yes. They begin to work after your check clears."

Funny Definitions

Barium………………………… What doctors do when patients die

Formulae in Clinical Practice

Clearance of a drug from body

Formula: CL = CL renal + CL hepatic CL renal = Q × E
Q – plasma flow to kidneys in ml/min
E – extraction ratio
E = Ca – Cv
Ca – Concentration of drug in arterial plasma
Cv – Concentration of drug in venous plasma

Milestones in Neurology

Joseph Jules Fran'ois F'lix Babinski (1857 –1932) was a Polish neurologist. He is best known for his 1896 description of the Babinski sign, a pathological plantar reflex indicative of corticospinal tract damage.

 

Lab Test (Dr Arpan Gandhi and Dr Navin Dang)

Liver function tests

To screen for, detect, evaluate, and monitor for liver inflammation and damage. Periodically to evaluate liver function; whenever you are at risk for liver injury; when you have a liver disease; when you have symptoms such as jaundice.

List of Approved drugs from 1.01.2009 to 31.10.2009

Drug Name

Indication

DCI Approval Date

Sumatriptan 85 mg + Naproxen 500 mg Tablets

Additional Strength for the treatment of migraine

3.08.2009


 

Public Forum (Press Release for use by the newspapers)

Heart patients can enjoy marital life provided………?

Marietal activity in heart patients is associated with a moderate homodynamic stress and increases the risk of heart attack said Padma Shri and Dr B C Roy National Awardee Dr KK Aggarwal, President Heart Care Foundation of India. However, the absolute increase in risk is very small. In addition, risk modification can be accomplished with regular physical activity and possibly aspirin and beta blocker use.

Thus, patients with heart disease who are not deemed to be at high risk should be able to enjoy marietal life after appropriate risk stratification and optimization of therapy and can be safely treated for sexual dysfunction.

Both the Second Princeton Consensus Panel and a consensus statement from the American College of Cardiology/American Heart Association concluded that a viagra like drug is safe for men with stable coronary artery disease who are not taking nitrates.

There are no clinical differences among the Viagra–like drugs with the exception of a prolonged duration of action with tadalafil.

The Viagra–like drugs are contraindicated as co-prescription with any nitrate preparation and they should also not be taken with alpha–blocking agents.

Cardiac patients should be counseled about the interaction with nitrates, even if a Viagra – like drug is not currently prescribed.

If a man who has taken a Viagra like drug develops chest pain, nitrates should not be administered within 24 hours (or longer in patients with renal or hepatic dysfunction) of sildenafil, 24 hours of vardenafil, or up to 48 hours of tadalafil.

Viagra like drugs can be dangerous

  1. In patients with active coronary ischemia, even in those who are not taking nitrates (eg, positive exercise stress test for ischemia)

  2. Patients with heart failure and borderline low blood pressure and/or low volume status.

  3. Patients on a complicated multidrug antihypertensive drug regimen Drugs like rifampin (TB) and phenytoin (epilepsy), can be expected to reduce the effectiveness of these drugs.

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Forthcoming eMedinewS Events: Register at emedinews@gmail.com

5th September: 3 PM to 5 PM – A dialogue with His Holiness Dalai Lama at Parliament Street Annexe in association with Acharya Sushil Muni Ahimsa Peace Award Trust

12th September: BSNL Dil ka Darbar – A day–long interaction with top cardiologists of the city.
8 AM – 5 PM at MAMC Auditorium, Dilli 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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If you like eMedinewS you can FORWARD it to your colleagues and friends. Please send us a copy of your forwards.