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Dr KK Aggarwal

From the Desk of Editor in Chief
Dr B C Roy National Awardee,

Dr KK Aggarwal
President, Heart Care Foundation of India; Sr Consultant and Dean Medical Education, Moolchand Medcity; Member, Delhi Medical Council; Past President, Delhi Medical Association; Past President, IMA New Delhi Branch; Past Hony Director. IMA AKN Sinha Institute, Chairman IMA Academy of Medical Specialities & Hony Finance Secretary National IMA; Editor in Chief IJCP Group of Publications & Hony Visiting Professor (Clinical Research) DIPSAR

Dear Colleague,

21st January, Thursday, 2010

Common mistakes in ICU: not taking enough blood cultures

One blood culture is rarely, advisable or sufficient. A positive result on a single culture may be uninterpretable unless an unequivocal pathogen is isolated.

Two blood cultures should be drawn when bacteremia due to a pathogen not likely to be a contaminant is anticipated (as in intra-abdominal sepsis or pneumonia) and when the pretest probability of bacteremia is low to moderate.

Three blood cultures should be drawn when a continuous bacteremia is suspected and the pretest probability of bacteremia is high (as in patients with suspected infective endocarditis who have not received prior antimicrobial therapy).

Four blood cultures should be taken when the pretest probability of bacteremia is high and the anticipated pathogen is likely to be a common contaminant such as coagulase-negative staphylococci. Clinical examples include prosthetic valve endocarditis or endovascular infections due to infected devices, such as pacemakers or grafts. Four blood culture sets may also be necessary to diagnose endocarditis in patients who have received antimicrobial therapy in the preceding two weeks. Prior antibiotic therapy, however, more often delays rather than ablates positive blood cultures.

Additional blood cultures are rarely taken but may be taken in patients where a new focus of infection is suspected.

Dr KK Aggarwal
Chief Editor

Hypertension update
1. Cardiovascular disease continues to be the number 1 cause of preventable death in the industrialized world.

2. A UK study in middle-aged men that began in 1967 has shown that the presence of three cardiovascular risk factors viz. high blood pressure, high cholesterol, and smoking, is associated with an almost 10-year shorter life expectancy compared with men with none of these risk factors. The men also had a 3-fold higher rate of vascular mortality and a 2-fold higher rate of nonvascular mortality. These calculations were based on long-term follow-up data from the Whitehall study, which first examined 19,019 men aged 40-69 years between 1967 and 1970. At entry, 42% of the men were current smokers, 39% had high blood pressure, and 51% had high cholesterol. The study was funded by the British Heart Foundation and the UK Medical Research Council. (Robert Clarke, Jonathan Emberson, University of Oxford)

3. A study, from China, published in the lancet found that an extraordinary percentage of Chinese deaths can ultimately be traced to hypertension. Using data from a large prospective cohort study done in a nationally representative sample of Chinese adults, US and Chinese researchers calculated that in 2005, more than 1 million premature cardiovascular deaths were attributable to hypertension or prehypertension. (Dr Jiang He, Tulane University, New Orleans)

4. US National Guidelines recommend a diuretic as a first-line choice for antihypertensive therapy, but what happens when the diuretic is added later? A new review from the Cochrane Collaboration has concluded that diuretics, especially thiazides, are as effective in lowering blood pressure when added as a second agent as they are when given as first-line treatment. The review also showed that addition of a diuretic effectively lowers blood pressure further, regardless of the class of antihypertensive agent the patient is already taking. (Dr Chen et al. University of British Columbia, Vancouver, and the Canadian Institutes of Health Research)

5. Further analysis of the Anglo Scandinavian Cardiac Outcomes Trial (ASCOT) data investigated whether a second effect of beta blockade, retardation of heart rate, might be beneficial in hypertensive patients compared with the effects of amlodipine. Increased resting heart rate is associated with higher cardiovascular risk, and reducing heart rate with beta-blockers has been shown to have a beneficial effect on cardiovascular mortality and morbidity in patients post MI and in patients with heart failure. It has been unknown whether this benefit extends to patients with hypertension. Now a new analysis of data from the Blood Pressure Lowering Arm of the Anglo-Scandinavian Cardiac Outcomes Trial (ASCOT-BPLA) has shown that in patients with hypertension uncomplicated by heart disease, a greater reduction in cardiovascular events seen with therapy based on a calcium channel blocker amlodipine compared with beta-blocker (atenolol)- based therapy occurred despite a greater reduction in heart rate with atenolol. There was no tendency toward a reduction in the advantage of amlodipine over atenolol based therapy in patients with higher baseline heart rates, even in the highest categories of heart rate.

6. A single pill to lower blood pressure by double blockade of the renin angiotensin system (RAS) with the ARB valsartan and the direct renin inhibitor aliskiren was approved for the treatment of hypertension in the United States on September 16, 2009.

7. A catheter-based renal denervation procedure may offer an alternative for treating resistant hypertension.

8. The Physicians Health Study of US male physicians, endorses the benefits of moderate alcohol consumption. In this report, alcohol lowered not just the risk for myocardial infarction, but also the risk for all coronary heart disease, including angina pectoris, coronary bypass surgery and percutaneous coronary intervention.

Caffeine may help reduce hepatic fibrosis in patients with chronic liver disease
Those who consumed more than 308 mg of caffeine a day, equal to about 2.25 cups of coffee, were 75% less likely to have advanced fibrosis than those who consumed less (p=0.006), according to Jay Hoofnagle and colleagues, the National Institutes of Diabetes and Digestive and Kidney Diseases in Bethesda. The two-cups-plus appeared to be a threshold, the researchers reported in the January issue of Hepatology.

Antidepressants use limited to patients with severe illness
The effectiveness of antidepressant drugs in clinical trials may be limited to patients with severe illness, researchers conducting a meta-analysis said. For patients with Hamilton depression scores of less than 23 participating in six placebo-controlled trials, the treatment effect was considered small. (Jay C. Fournier and colleagues, University of Pennsylvania, Jan. 6 JAMA)

COX-2 advantage
In a phase II trial, the drug slowed the increase in basal cell carcinoma burden by an absolute 11% to 30% in patients with Gorlin syndrome, also known as basal cell nevus syndrome (Dr Ervin H. Epstein, Children's Hospital, Oakland Research Institute) The COX-2 inhibitor appeared significantly effective only in patients with less severe disease. (January issue of Cancer Prevention Research)

Punjab & Sind Bank
Our HIP's

 Question of the Day
Is colonoscopy indicated in all individuals above the age of 50 years to rule out bowel cancer?
This is a controversial and a much debated issue with present practice recommending annual stool testing for occult blood (three samples with dietary restriction of meat, etc.). Colonoscopy, barium enema or sigmoidoscopy, should be limited to patients with positive occult blood results. Colonoscopy is obviously indicated for screening of high-risk patients, such as those with prior polyps or cancer, ulcerative colitis or familial polyposis.

Dr Good Dr Bad
Situation: A patient came with suspected acute heart failure.
Dr Bad: Get X ray chest done.
Dr Good: Get BNP test done.
Lesson: A number of conditions can elevate BNP (B-type natriuretic peptide) but levels above 100 pg/mL have 90 percent sensitivity for acute heart failure and levels below 50 pg/mL have a 96 percent negative predictive value for heart failure. (N Engl J Med 2002;347:161-7.)

Make Sure
Situation: A patient on penicillin developed a relapse of fever while still on the antibiotic.
Reaction: Oh my God! Why was the antibiotic continued for so long?
Make sure that drug fever is always excluded in such situations. Antibiotics are the most common cause of drug fever, accounting for approximately one-third of episodes. This especially applies to beta-lactams, sulfonamides and nitrofurantoin. (Am J Med Sci 1987;294:275-86.)

Formulae in Imaging
If pleural effusion reaches the level of the fourth anterior rib, this indicates that close to 1000 mL of fluid is present.

Mistakes in Clinical Practice
Adverse drug events (ADEs) result in four times as many hospitalizations in older compared with younger adults.

ENT Facts
Eustachian tube dysfunction, commonly related to seasonal allergic rhinitis or upper respiratory tract infection, is the most important factor in the pathogenesis of middle ear infections.

Emedinews Try this It Works
The Rockwell approach
If an obviously anxious child comes into the office clutching a doll or stuffed animal, examine the toy first. Tell the child what you are doing, listen to the toy's heart and lungs, touch the tummy, feel the glands, check the eyes, ears, and so on. The child often relaxes and allows a similar examination on himself or herself.

Milestones in Neurology

Jules Cotard was a French neurologist who is best known for first describing the Cotard delusion, the delusional belief that you are dead, do not exist or do not have bodily organs.

Laughter the Best Medicine
Mistress - something between a mister and a mattress.

Grow flowers of gratitude in the soil of prayer. (Verbena Woods)

SMS Anemia
Anemia is first classified via the mean corpuscular volume (MCV).

To what extent can payment be made by cheque, cash, etc.?
As per section 40 A (3), in case of payment made in excess of Rs. 20,000 other than by crossed cheque or bank draft (cross), then 20% of such expense shall be disallowed.

What is Article 20 (3)?
Article 20 (3) provides protection that every individual has the right to do what he likes with his body, in order to protect and preserve his health and personal privacy. Any examination or treatment done to a patient, which involves any interference with the physical integrity of the patient is unlawful unless done with the consent of the patient.

Emedinews Calculator
To convert from a conventional unit to a SI Unit, multiply by the conversion factor listed.  To convert from SI Units to conventional units, divide by the listed conversion factor.
Agent                         Conventional Unit              Conversion Factor         SI Unit
Acetaminophen                  µg/mL                               6.62                      µmol/L

Presswatch (Dr Vivek Chhabra)
The Independent: TV addicts risk heart disease, study finds: People who spend more than four hours a day watching television are 80 per cent more likely to die from heart disease than those watching for less than two hours. Researchers in Australia monitored 8,800 adults for six years to see what impact watching TV had on their long-term health. They found that each hour spent per day in front of the television increased the risk of death from all causes by 11 per cent... It also raised the risk of dying from cancer by 9 per cent and the risk of heart disease-related death by 18 per cent.

DocConnect Milestones (www.docconnect.com)

DocConnect Finder:  Patients can search for doctors based on specialization and geography.

Letter to the editor

Dear Dr K K Aggarwal Sahib:  It is heartening to know and read the good work u are doing and your writeups are not only informative but educative and empower the legalities of the profession. Congratulations for the recent Honours and awards conferred on u which u very richly deserve. I always read ur mails and benefit with them. Regards. Dr. M. Wali MD FACC  (USA): Physician to the former President and the former Prime Minister of India)

(Advertorial section)


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