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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,

  22nd January, Friday, 2010

New treatment for refractory ascites

In patients with cirrhosis, ascites is defined as refractory when it cannot be mobilized or recurs early in standard diuretic therapy.

A randomized controlled trial has shown a beneficial effect from infusion of small volume hypertonic saline plus high dose furosemide in patients with refractory ascites.

A study, published in the May 2009 edition of Aliment Pharmacol Ther, compared the safety and efficacy of intravenous high dose furosemide + hypertonic saline solutions (HSS) to repeated paracentesis in patients with cirrhosis and refractory ascites.

Eighty-four subjects (59/25 M/F) with cirrhosis, admitted for refractory ascites were randomly assigned to receive furosemide (250-1000 mg/bid IV.) plus HSS (150 ml H(2)O with NaCl 1.4-4.6% or 239-187 mEq/L) (60 patients, group A) or to repeated paracentesis and a standard diuretic schedule (24 patients, group B).During hospitalization group A patients had more diuresis (1605 ± 131 mL vs 532 ± 124 mL than group B patients; p<0.001) and a greater loss of weight at discharge (-8.8 ± 4.8 kg vs -4.5 ± 3.8 Kg, p<0.00). Control of ascites, pleural effusions and/or leg edema was deemed significantly better in Group A.

This randomized pilot study suggests that HHS plus high dose furosemide is a safe and effective alternative to repeated paracentesis when treating hospitalized patients with cirrhosis and refractory ascites.

Dr KK Aggarwal
Chief Editor

1. Statins improve cardiovascular survival in both nondiabetic and diabetic patients, but diabetic patients benefit more, in both primary and secondary prevention. Statins seem to have multiple effects beyond cholesterol lowering, i.e., pleiotropic effects that may include changes in renal function. Acute treatment with atorvastatin reduces renal fractional sodium excretion in patients with type 2 diabetes. No changes are measured in glomerular filtration rate, albumin/creatinine ratio, vasoactive hormones, and blood pressure. (Journal of Clinical Pharmacology, Jan 7, 2010)

2. Antiplatelets (APs) may increase the risk of symptomatic intracerebral hemorrhage (ICH) following intravenous thrombolysis after ischemic stroke. The absolute excess of SICH of 1.4% (2.1%) in the pooled AP group is small compared with the benefit of thrombolysis seen in randomized trials. Although caution is warranted in patients receiving the combination of ASA and clopidogrel, AP treatment should not be considered a contraindication to thrombolysis. (Stroke, Jan 7, 2010)

3. Metformin reduces insulin-dose requirement in type 1 diabetes but it is unclear whether this is sustained beyond one year and whether there are benefits for cardiovascular and other key clinical outcomes. (Diabetologia, Jan 8, 2010)

4. Dexamethasone at a dose of 8 mg given intravenously 2 h before induction, delays patient request for analgesia and reduces total fentanyl consumption and PONV in patients undergoing total laparoscopic hysterectomy. (Journal of Anesthesia, Jan 5, 2010)

5. Despite statistical significant differences, from a clinical point of view oral gabapentin  600 mg was as effective as low-dose transdermal estradiol in controlling moderate to severe hot flushes in post-menopausal women, and should be recommended as an alternative option in those with contraindications to estrogen therapy. More research is warranted in this regard. (Gynecological Endocrinology, Jan 5, 2010)

News and views
(Dr G M Singh)
1. Harlow and colleagues noted in the January 2007 issue of the Archives of General Psychiatry that postpartum psychotic or bipolar episodes occurred in 14% of women with previous psychiatric hospitalizations vs 0.05% of women without previous psychiatric hospitalizations. The role of maternal and obstetric factors is not clear.

2. Women with increased breast density on mammography results have a higher risk for breast cancer, and a previous study suggests that breast symptoms in women during menopause may predict the degree of breast density. In another study by Crandall and colleagues, which was published in the August 14-28 issue of the Archives of Internal Medicine, middle-aged and older women with new-onset breast discomfort had a significant 3.9% increase in total breast density vs women who did not have discomfort. Although participants in this research were enrolled in a trial of postmenopausal hormone therapy, the positive relationship between breast density and breast discomfort was present whether they were receiving active treatment or placebo.

3. Celecoxib and other coxibs may interfere with the antiplatelet activity of low-dose aspirin, according to a study published online Dec. 16 in the Proceedings of the National Academy of Sciences. 4. Many patients with peptic ulcer bleeding die of non-bleeding-related causes: According to a study in the American Journal of Gastroenterology, nearly 80 percent of patients with peptic ulcer bleeding die of non-bleeding-related causes, with multi-organ failure, cardiopulmonary conditions, and terminal malignancy being the most common causes for death.

5. Statins may help treat sickle cell disease: Statins hold promise as a treatment for sickle cell disease, a common genetic disorder. The study, found that among mice with a type of sickle cell disease, those that were treated with statins lived much longer after being infected with pneumococcal bacteria than those who did not get the treatment.

6. High levels of omega-3 fatty acids may be linked to lower rate of biological aging: A study in the Journal of the American Medical Association has shown that people with heart disease who had high levels of omega-3 fatty acids in their blood had a lower rate of shortening of telomere length, a marker for aging, compared with similar heart patients who had the lowest levels of omega-3 fatty acids. The study of 608 heart patients targeted marine omega-3, which is found in fish, rather than omega-3 fatty acids typically in certain vegetable sources. However, the researchers remained uncertain over whether the effect of omega-3 fatty acids on telomere length is present in those without coronary heart disease, suggesting that telomere shortening may occur in everyone.

Punjab & Sind Bank
Our HIP's

 Question Of the day
What are the indications for colectomy in ulcerative colitis?
Patients with toxic megacolon (i.e. those with colonic dilation of 6 cm or greater who appear toxic) who do not respond to therapy within 72 hours should be considered candidates for colectomy. Surgical consultation should be obtained early on in such patients. Less severely ill patients usually respond to parenteral corticosteroids within 7-10 days. Despite advances in therapy, rates of colectomy for severe ulcerative colitis have not changed substantially in more than 30 years. (Source: Clin Gastroenterol Hepatol 2007;5:103-10.)

Dr Good Dr Bad
Situation: A patient came with finger pointing chest pain.
Dr Bad: It is a cardiac pain
Dr Good: Its non cardiac pain
Lesson: Cardiac chest pain is often diffuse and never pin pointed

Make Sure
Situation: A patient after GA developed sudden high grade fever 40ºC, muscle rigidity and metabolic acidosis and died.
Reaction: Oh my God, why was he not treated with dantrolene.
Make sure that malignant hyperthermia is suspected in such cases. The condition is inherited as an autosomal dominant trait in 50 percent of cases and thought to be present in 1 in 15,000 to 1 in 40,000 of the general population. Fifty percent of clinical cases occur in children. Most are triggered by succinylcholine, and halothane. Early intervention and treatment with dantrolene may be life saving. (Anaesthesia 1993;48:892.)

Formulae in Imaging
On decubitus radiographs, pleural fluid less than 10 mL, and possibly as little as 2 mL, can be identified.

Mistakes in Clinical Practice
Adverse drug events are a particular problem for nursing home residents; atypical antipsychotic medications and warfarin are the most common drugs involved in ADEs in this population.

ENT Facts
Common bacteria causing AOM in both children and adults are Streptococcus pneumoniae and Haemophilus influenzae.

Emedinews Try this It Works
Green cannula
Whenever you want to give fast IV. fluids remember G: G for 'GREEN' and G for 'GO'. Green cannula is a high bore cannula and provides avenue for fast fluid drip.

Milestones in Neurology
Joseph Jules François Félix Babinski was a French neurologist. He is best known for his 1896 description of the Babinski sign, a pathological plantar reflex indicative of corticospinal tract damage.

Laughter the Best Medicine
Psychologist - a man who watches everybody else when a pretty girl enters the room.

The Lord's Prayer may be committed to memory quickly, but it is slowly learnt by heart. (Frederick Denison Maurice)

SMS Anemia
Microcytic anemias are associated with an MCV below 80 fL.

If payment of expenditure is made to related person, which is unreasonable as per the view of assessing officer, then will it be allowed as deduction?
If payment of expenditure has been made to related person and assessing officer is of the opinion that such expenditure is unreasonable as compared to fair market value, then the expenditure considered unreasonable may be disallowed.

What is the role of Consent in protection in the Court?
In most of the cases filed against the doctor, it is alleged that consent was not obtained. Obtaining consent will thus be a cornerstone of protection against litigation.

DocConnect Milestones
DocConnect: Patients can request for appointment via doctors’ webpage.

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
Acetoacetic acid                    mg/dL                        0.098                              mmol/L

Presswatch (Dr Vivek Chhabra)
Daily Mail: Could this drug end the misery of tinnitus?  A drug pump which is implanted in the ear is the latest approach for tackling tinnitus. It works by releasing a powerful new medicine that calms the overactive nerves thought to cause the condition. The new therapy, developed by US-based company NeuroSystec, uses a drug known as NST-001. This is thought to block the production of excessive glutamate, in turn reducing this rogue nerve firing. Researchers claim it may even result in the elimination of tinnitus. It is estimated that about 15 million people in the UK experience tinnitus at some time. For 10 to 15 per cent of sufferers, the condition is so loud and debilitating it affects sleeping and concentration.

Letter to the editor
Sir, pitavastatin, by brand name of PITASTAT remained on Indian chemists' shelves for quite some time a few years ago. Neither medical professionals nor the pharmaceutical industry took this molecule seriously. I have tried it on a number of my patients with good results.
Dr. A.P. Bhatia (9811636096, Consultant Physician, East Delhi)

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