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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 …

20th January, 2011, Thursday                                eMedinewS Presents Audio News of the Day

View Photos and Videos of 2nd eMedinewS – Revisiting 2010

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

Crimean–Congo hemorrhagic fever (CCHF)

The Pune–based National Institute of Virology (NIV) has confirmed India’s first cases of the deadly Crimean Congo Haemorrhagic Fever (CCHF) from Sanand, near Ahmedabad. The virus has so far killed three people, including a woman who first picked it up, and the doctor and a nurse who treated her at a private hospital in Ahmedabad. As of Tuesday evening, two more patients had been hospitalised. The NIV is testing some 50 samples from the area, and the Gujarat government, warned of a possible outbreak, has begun a screening exercise in the area, covering about 16,000 villagers.

The NIV was able to isolate the CCHF virus within 15 hours of getting the samples from Sanand. “We have alerted the Gujarat authorities that the virus is highly infectious and immediate precautions need to be taken," Dr A C Mishra, Director, NIV, said. (Indian express)

  • Crimean–Congo hemorrhagic fever is a severe, potentially fatal disease in humans caused by CCHF virus.
  • The disease has been documented in parts of Africa, Asia, eastern Europe, and the Middle East.
  • Transmission to humans occurs through tick bites, contact with a patient with CCHF during the acute stage of infection, or contact with blood or tissue from infected livestock.
  • The typical course of CCHF has four distinct phases: incubation, prehemorrhagic, hemorrhagic, and convalescence
  • The incubation period that follows a tick bite is usually short (3 to 7 days).
  • The prehemorrhagic period is characterized by the sudden onset of fever, headache, myalgia, and dizziness.
  • Additional symptoms of diarrhea, nausea, vomiting are also seen in some cases. After approximately three days, hemorrhagic manifestations, from petechiae, large hematomas, and frank bleeding (vaginal, gastrointestinal, nose, urinary and respiratory tracts) usually follow.
  • The convalescence period begins in survivors about 10 to 20 days after onset of illness.
  • Viral isolation needs to be conducted in biosafety level four laboratories.
  • IgM and IgG antibodies are detectable by ELISA and immunofluorescence assays from about seven days after the onset of disease.
  • Specific IgM antibodies decline to undetectable levels approximately four months after presentation.
  • Treatment is mainly supportive.
  • Ribavirin has been demonstrated to be effective in observational clinical studies.
  • Patients should be treated for 10 days (30 mg/kg as an initial loading dose, then 15 mg/kg every six hours for four days, and then 7.5 mg/kg every 8 hours for six days).
  • Case fatality rates range from 3–30%; disseminated intravascular coagulation and vascular dysregulation is commonly seen in severe cases.
  • Higher serum levels of proinflammatory cytokines IL–6 and tumor necrosis factor (TNF) were demonstrated in patients with fatal infection than in those who survived
  • In the setting of suspected or proven CCHF infection, careful adherence to contact and droplet precautions and safe burial practices are critical.
  • Environmental surfaces should be cleansed via chlorination with household bleach (2-5 % hypochlorite).
  • Post exposure prophylaxis with oral ribavirin should be considered for high risk contacts of CCHF patients
  • In addition, personal tick preventive measures should be implemented.
  • Slaughter of animals that may have acquired infection should be avoided given the possibility of asymptomatic viremia.

Case definition

Suspected Case: Patient with sudden onset of illness with high–grade fever over 38.5°C for more than 72 hrs and less than 10 days, especially in CCHF endemic area and among those in contact with sheep or other livestock (shepherds, butchers, and animal handlers). Note that fever is usually associated with headache and muscle pains and does not respond to antibiotic or anti-malarial treatment.

Probable case: Suspected case with acute history of febrile illness 10 days or less, AND Thrombocytopenia less than 50,000/mm3 AND any two of the following: Petechial or purpuric rash, Epistaxis, Haematemesis, Haemoptysis, Blood in stools, Ecchymosis, Gum bleeding, Other haemorrhagic symptom AND No known predisposing host factors for haemorrhagic manifestations.

Confirmed case: Probable case with positive diagnosis of CCHF in blood sample, performed in specially equipped high bio–safety level laboratories, i.e. Confirmation of presence of IgG or IgM antibodies in serum by ELISA, Detection of viral nucleic acid in specimen by PCR, isolation of virus.

Treatment Protocol for CCHF disease
High-dose oral Ribavirin therapy constitutes the following: 2 gm loading dose, 4 gm/day in 4 divided doses (6 hourly) for 4 days and then 2 gm/day in 4 divided doses for 6 days

Dr KK Aggarwal
Editor in Chief
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  eMedinewS Audio PostCard

  MEDICON 2010

Dr BB Rewari speaks on ‘What’s New in HIV/AIDS Management’

Audio PostCard
  SMS of the Day

(By Dr Prabha Sanghi)

"Confidence is that feeling by which the mind embarks in great and honorable courses with a sure hope and trust in itself."

Marcus Tullius Cicero

    Photo Feature (from the HCFI Photo Gallery)

2nd eMedinewS Revisiting 2010

Doctors braved the chilly morning to register for the Conference.

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

Forensic fraternity tears apart MCI’s Vision–2015

Terming the Medical Council of India’s ‘Vision–2015’ for undergraduate courses in medicine as "myopic and tunneled", the forensic fraternity from across the country has trashed the proposal claiming it would be detrimental to the growth of the discipline and adversely impact probes in medico–legal cases. Leading the opposition, Indian Academy of Forensic Medicine (IAFM), which has around 4,000 members countrywide, said that at a time when the discipline should have been strengthened with adequate teaching staff and infrastructure – given that shoddy forensic probes have led to closure of cases or poor prosecution – the council’s move raises a question mark on its motive.

A large number of doctors have also registered their opposition to the ‘Vision–2015’ at the blog forensicmedicine123.blogspot started by the IAFM. The eight–member Undergraduate Education Working Group 2010, which is part of the Vision Document 2015, notes that the forensic course need not be a separate subject but can be taught "effectively" with other subjects…during Gynaecology and Obstetrics (rape, assault), surgery (injuries), pharmacology (toxicology)."

It also says, "Forensic medicine skills can be acquired during internship such as documentation of medico–legal cases of alcoholism, suicide/homicide, rape, assault and injury cases." However, Dr Adarash Kumar, IAFM general secretary, argued, "Nothing can be considered as equivalent to a teaching by a subject specialist." "This transpires that a Gynae or a Surgery teacher may not be able to pick up the nuances of a rape case or an injury case in comparison to a doctor trained in MD Forensic Medicine. Similarly, toxicology can not be taught by a pharmacologist who is well versed with medicines but not drugs and poisons."

VV Pillay, chief of Poison Control Centre Head, Department of Analytical Toxicology and Forensic Biotechnology, Amrita Institute of Medical Sciences & Research, Kerala called the move "retrogressive" with regard to toxicology and "may undermine all the efforts that we have been making in ameliorating the dismal scenario of poisoning in the country." He pointed out that it would further dilute the importance of this speciality among students and faculty of medicine leading to even more neglect of it. (Source: The Pioneer, January 19, 2011)

    International News

Working out for as little as 15 minutes three days a week reduces the risk of dementia and Alzheimer’s by 40%

This long–term study (more than six years) determined that men and women aged 65 and older dramatically lessened their chances of developing the heart -breaking conditions of dementia and Alzheimer's by regularly exercising.

Increasing step counts linked to improved insulin sensitivity

A study reported in the British Medical Journal that middle–aged Australian men and women (mean age 50 years) who increased their daily step count over 5 years’ follow–up showed significant improvements in insulin sensitivity and adiposity. The daily step count decreased during follow–up in almost two thirds of study subjects. Individuals whose step count increased between the two evaluations had a much lower BMI: mean change 0.08 per 1000 steps. An increase in step count was also associated with a lower waist–to–hip ratio, 0.15 per 1000 steps; and greater insulin sensitivity, 1.38 HOMA units.

Genetic loci are linked to coronary artery disease and myocardial infarction

New research finds that certain genetic loci are associated with the risk of angiographic coronary artery disease (CAD) and, among those who already have it, with the risk of myocardial infarction. The results of the study are published online in The Lancet.

Combination therapy superior to monotherapy for initial treatment of hypertension

Findings of ACCELERATE (Aliskiren and the calcium channel blocker amlodipine as an initial treatment strategy for hypertension control), a randomised, parallelgroup trial show that initial treatment of hypertension with a combination therapy (renin inhibitor + calcium channel blocker) is more effective in lowering the raised BP than monotherapy with either drug alone. Patients who received combination therapy in the study reported significantly greater reduction in mean systolic blood pressure between weeks 8 and 24.

Osteoporosis screening guidelines updated

The U.S. Preventive Services Task Force updated its 2002 recommendations on osteoporosis screening to call for routine screening in all women aged 65 years or older and in any younger women whose fracture risk is equal to or greater than that of a 65yearold white woman who has no additional risk factors (equivalent to a 9.3% or greater risk of fracture within 10 years). Previously, women younger than 65 years would be screened if they were at least 60 years old with risk factors for fracture. The new recommendations were posted on the USPSTF Web site and published online by the Annals of Internal Medicine on Jan. 18.

    Infertility Update

Dr. Kaberi Banerjee, Director Precious Baby Foundation

Can sperms be taken out from the testes?

When there are no sperm in the ejaculate but there are germ cells in the testes, ICSI can be performed with spermatozoa isolated from testicular biopsies or fine needle aspirates. Successful pregnancy has been reported even with injection of fresh or cryopreserved immature sperm cells, such as elongated and round spermatids, but not with spermatocytes.

For queries contact: banerjee.kaberi@gmail.com

    Pediatric Update

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

What is the risk of transmission of the infection with hepatitis B from the carriers?

HBsAg–positive women who are pregnant should be counseled to inform their doctors so that hepatitis B immunoglobulin (HBIG) and hepatitis B vaccine can be administered to their newborn immediately after delivery. HBIG and concurrent hepatitis B vaccine have been shown to be 95% efficacious in the prevention of perinatal transmission of HBV. Transmission of HBV from infected health care workers to patients has also been shown to occur in rare instances.The risk of infection after blood transfusion and transplantation of nonhepatic solid organs (kidneys, lungs, heart) from persons with isolated anti–HBc is low i.e. 0% to 13%. The risk of infection after transplantation of liver from HBsAg –negative, anti–HBc positive donors has been reported to be as high as 75% and is related to the HBV immune status of the recipients.

    Medicolegal Update

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

What is the Pre–Natal Diagnostic Techniques (PNDT) Act 1994

Determination of fetus sex is prohibited in India

The Pre–Natal Diagnostic Techniques Act 1994 provide for the regulation of the use of pre–natal diagnostic techniques for the purpose of detecting genetic or metabolic disorders or chromosomal abnormalities or certain congenital malformations or sex-linked disorders and for the prevention of the misuse of such technique for the purpose of per–natal sex determination leading to female feticide.

  • No person referred to in Clause (2) of Section 3 shall conduct the pre–natal diagnostic procedures unless:
    • He has explained all known side and after effects of such procedures to the pregnant woman concerned;
    • He has obtained in the prescribed form her written consent to undergo such procedures in the language which she understands;
    • A copy of her written consent obtained under Clause (b) is given to the pregnant woman.
  • No person conducting pre–natal diagnostic procedures shall communicate to the pregnant woman concerned or her relatives the sex of the fetus by words, signs or in any other manner.
  • No genetic counseling center or genetic laboratory or genetic clinic shall conduct or cause to be conducted in its centre, lab or clinic, pre–natal diagnostic techniques including ultrasonography for the purpose of determining the sex of a fetus;
  • No person shall conduct or cause to be conducted any pre–natal diagnostic techniques including ultra sonography, for the purpose of determining the sex of a fetus.
    Legal Question of the Day

(Contributed by Dr MC Gupta, Advocate)

Q. My hospital sometimes advertises in the newspapers inviting philanthropists to help poor patients who do not have money to pay for costly surgery etc. When the donors, including MLAs, come to the hospital for the charity, they bring with them local press and media people for publicity. This sometimes affects the normal functioning of the hospital. Are any hospital ethics being violated? What are your comments?

A. My comments are as follows:

  • Your hospital is doing a good service. No hospital ethics are being violated.
  • The media and press coverage might cause some disturbance in the hospital but that is for a good cause. Moreover, the hospital gets free publicity. This may be good for the hospital.
    Lab Update

(Dr Arpan Gandhi and Dr Navin Dang)

Assessment of atherosclerosis risk: Triglycerides, Cholesterol, HDL–Cholesterol, LDL–Cholesterol, Chol/HDL ratio

All of these studies find greatest utility in assessing the risk of atherosclerosis in the patient. Increased risks based on lipid studies are independent of other risk factors, such as cigarette smoking.

    Medi Finance Update

(Contributed by Dr GM Singh)

What is Automatic Investment Plan?

Under this plan, the investor mandates the mutual fund to allot fresh units at specified intervals (monthly, quarterly, etc.) against which the investor provides post–dated cheques. On the specified dates, the cheques are realized by the mutual fund and on realization; additional units are allotted to the investor at the prevailing NAV.

    Drug Update

LIST OF APPROVED DRUG FROM 01.01.2010 TO 31.8.2010

Drug Name
DCI Approval Date
Sarpogrelate hydrochloride film coated Tablets 100mg
For the improvement of ischemic symptoms including ulcer, associated with chronic arterial occlusion.
    IMSA Update

International Medical Science Academy (IMSA) Update

Bone mineral density and metabolic syndrome

In a cross–sectional study of 2,265 women, In the premenopausal group, women with MS had a lower BMD at the lumbar spine, but not at the femoral neck. In stepwise linear regression analysis, predictive variables for BMD of the lumbar spine were systolic blood pressure in the premenopausal group and HDL–cholesterol and diastolic blood pressure (DBP) in the postmenopausal group.

(Ref: Jeon YK, et al. Association between bone mineral density and metabolic syndrome in pre- and postmenopausal women. Endocr J. 2011 Jan 13. Epub ahead of print)

Our Contributors
  Docconnect Dr Veena Aggarwal
  Docconnect Dr Arpan Gandhi
  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
    IJCP Special

Dr Good Dr Bad

Situation: A patient with Mediclaim of Rs. 2 lakhs has used a cumulative bonus of Rs. 40000 after 8 years. How much can he claim in the next year.
Dr. Bad: Same as 2.4 lakhs.
Dr. Good: It will be 10% less.
Lesson: Incase of claim under the policy in respect of insured person who has earned the cumulative bonus, the increased percentage will be reduced by 10% of claim of sum insured on the next renewal. However, basic sum insured will be maintained and will not be reduced.

Make Sure

Situation: A 14 year–old girl suffering from dysmenorrhea wanted an analgesic for her pain.
Reaction: Oh My God! Why was aspirin given!
Lesson: Make sure to remember that aspirin is contraindicatd in children.

    Lighter Side of Reading

An Inspirational Story
(Contributed by Dr Prachi Garg)

What is confidence and dedication? One incidence is quoted.

India vs Australia [2004] match... Brad Hogg took Sachin's wicket. At the end of the match Hogg gave that Ball to Sachin for his autograph. Sachin put his sign with one beautiful sentence, "It will never happen again."

Till today Hogg could not take his wicket for the second time.

That's Confidence & Cedication..! Hats off to our little master Sachin.

After this incident Brad Hogg and Sachin Tendulkar came face to face 21 times...but he could never get the Master Blaster out. Howzaaat!


Mind Teaser

Read this…………………


Yesterday’s Mind Teaser: c o n

Answer for Yesterday’s Mind Teaser: condescending

Correct answers received from: Dr. Rajiv Dhir, Dr Muthumperumal Thirumalpillai, Dr. T. Samraj

Answer for 18th January Mind Teaser: Sailing over the seven seas
Correct answers received from: Dr Rajendra Kumar, Dr.Mamta sharma, Dr Vijay Kansal, Dr Hena Vasdeva, Dr H P Moglani, Dr Jainendra Upadhyay

Send your answer to ijcp12@gmail.com


Laugh a While
(Contributed by Dr. G.M.Singh)

A blond gets pulled over for speeding by a blond cop. The blond cop comes up to the window and says: "Show me your license". The blond driver says: "It's on the back of the car."

The blond cop says: "No, the one with your picture on it." So the blond driver looks through her purse and finds a mirror and says: "Oh, here it is" and hands it to the cop.

The blond cop looks at the mirror and says: "Well, if I had known you were a cop I wouldn't have pulled you over."

    Readers Responses
  1. Dear Sir, many thanks for ANCIPS-2011 Publication. I was able to go through the 17th Jan issue. It was very accurate reporting of the lectures given by delegates and it was very informative and useful for quick reminder of the lectures. I appreciate your good effort. But I could not get 18th& 19th Jan, 2011 issues. I will be very thankful to you if you could send me the above issues. Please also give me website of eMedinewS. Thanking you! Dr. RS Lamba.
    Public Forum

(Press Release for use by the newspapers)

Doctors should report errors

It is compulsory in the West to report errors related to medical practice or treatment. Unfortunately, there is no such policy in our country. The Ministry of Health should come out with a policy where doctors can directly feed medical errors on the website. It does not involve disclosure of the name of the doctor or of the patient. This was stated by Padma Shri & Dr. B.C. Roy National Awardee, Dr. KK Aggarwal, President, Heart Care Foundation of India.

Reporting errors helps in better treatment in future and in identifying potential side effects of various treatments. A drug approved in US or tried in US patients may not have the same effects when given to Indian patients.

Medical errors do not mean medical negligence. Medical accidents and medical adverse events are part and parcel of medical treatment all over the world.

Dr. Aggarwal said that 80% of medical errors are related to medical prescriptions. One should avoid giving prescriptions on phone. Every time a patient comes to a doctor the doctor must match the drugs given by the doctor and drugs taken by the patients.

One should never write .3 mg but write 0.3 mg as 3 mg can be mistaken as 3 mg. similarly, one should never write 3.0 mg as it can be mistaken as 30 mg.

Dr. Aggarwal said instead of writing 'u' write 'units' as 'u' can be mistaken as '0'. For e.g. 4U of insulin may be misread as 40 insulin.

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