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FIRST NATIONAL DAILY eMEDICAL NEWSPAPER OF INDIA
emedinews is now available online on www.emedinews.in or www.emedinews.org
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


YOU CAN DOWNLOAD EMEDINEWS AT www.emedinews.in

Dear Colleague

22nd April, 2010 Thursday

What are the effects of smoking in the heart?

  1. Smoking is associated with high bad LDL cholesterol, high triglycerides and low good HDL cholesterol levels.1

  2. It can cause insulin resistance.2, 3

  3. Free radicals in cigarette smoke damage lipids, resulting in the formation of proatherogenic (clot promoting) oxidized LDL cholesterol.4–5

  4. A similar effect is seen with acute secondhand smoke exposure.7

  5. Smoking activates the sympathetic nervous system, producing an increase in heart rate and blood pressure, and cutaneous and coronary vasoconstriction. 8–10

  6. Smoking enhances the prothrombotic (clot promoting) state via inhibition of tissue plasminogen activator release from the endothelium 11, elevation in the blood fibrinogen concentration 12, increased platelet activity (enhanced sympathetic activity)13, increased expression of tissue factor 14 and in patients with advanced lung disease, elevated blood viscosity due to secondary polycythemia (high red cells count).

  7. Smoking can damage the vessel wall leading to impaired prostacyclin (artery dilator) production and enhanced platelet–vessel wall interactions.15  The end result is reduvtion in the elastic properties of the aorta, resulting in stiffening of and trauma to the wall.16

  8. Smoking (including passive), impairs endothelium–dependent vasodilatation of normal coronary arteries and reduces coronary (heart artery) flow reserve.17

  9. Smoking can also potentiate the endothelial dysfunction induced by high cholesterol.18

  10. This endothelial dysfunction results from oxidative stress with enhanced oxidation of LDL (bad cholestaerol)and from reduced generation of nitric oxide.19

  11. Concentrations of soluble adhesion molecules are higher in smokers than nonsmokers.19

  12. Smokers have elevated levels of C–reactive protein and fibrinogen.20

  13. Smoking contributes to the inflammatory response, a factor in the pathogenesis of atherosclerosis.

  14. Smokers have high serum homocysteine levels, which induce vascular injury.20

References
  1. Craig WY, Palomaki, GE Haddow, JE. Cigarette smoking and serum lipid and lipoprotein concentrations: an analysis of published data. BMJ 1989; 298:784.

  2. Facchini FS, Hollenbeck CB, Jeppesen, J, et al. Insulin resistance and cigarette smoking. Lancet 1992;339:1128.

  3. Reaven G, Tsao PS. Insulin resistance and compensatory hyperinsulinemia: the key player between cigarette smoking and cardiovascular disease?. J Am Coll Cardiol 2003;41:1044.

  4. Miller ER, Appel LJ, Jiang L, et al. Association between cigarette smoking and lipid peroxidation in a controlled feeding study. Circulation 1997; 96:1097.

  5. Heitzer T, Yla–Herttuala S, Luoma, J, et al. Cigarette smoking potentiates endothelial dysfunction of forearm resistance vessels in patients with hypercholesterolemia. Role of oxidized LDL. Circulation 1996;93:1346.

  6. Pech–Amsellem MA, Myara I, Storogenko, M, et al. Enhanced modifications of low–density lipoproteins (LDL) by endothelial cells from smokers: a possible mechanism of smoking–related atherosclerosis. Cardiovasc Res 1996; 31:975.

  7. Valkonen M, Kuusi, T. Passive smoking induces atherogenic changes in low–density lipoprotein. Circulation 1998;97:2012.

  8. Cryer PE, Haymond MW, Santiago, JV, Shah, SD. Norepinephrine and epinephrine release and adrenergic mediation of smoking–associated hemodynamic and metabolic events. N Engl J Med 1976;295:573.

  9. Winniford MD, Wheelan KR, Kremers MS, et al. Smoking induced coronary vasoconstriction in patients with atherosclerotic coronary artery disease. Evidence for adrenergically mediated alterations in coronary artery tone. Circulation 1986;73:662.

  10. Narkiewicz K, van de Borne PHJ, Hausberg, M, et al. Cigarette smoking increases sympathetic outflow in humans. Circulation 1998;98:528.

  11. Newby DE, Wright RA, Labinjoh C, et al. Endothelial dysfunction, impaired endogenous fibrinolysis, and cigarette smoking. A mechanism for arterial thrombosis and myocardial infarction. Circulation 1999;99:1411.

  12. Kannel WB, D’Agostino RB, Belanger, AJ. Fibrinogen, cigarette smoking, and risk of cardiovascular disease: insights from the Framingham Study. Am Heart J 1987;113:1006.

  13. Fusegawa Y, Goto S, Handa S, et al. Platelet spontaneous aggregation in platelet–rich plasma is increased in habitual smokers. Thromb Res 1999; 93:271.

  14. Matetzky S, Tani S, Kangavari, S, et al. Smoking increases tissue factor expression in atherosclerotic plaques: implications for plaque thrombogenicity. Circulation 2000;102:602.

  15. Nowak J, Murray JJ, Oates, JA, et al. Biochemical evidence of a chronic abnormality in platelet and vascular function in healthy individuals who smoke cigarettes. Circulation 1987;76:6.

  16. Stefanadis C, Tsiamis E, Vlachopoulos, C, et al. Unfavorable effect of smoking on the elastic properties of the human aorta. Circulation 1997; 95:31.

  17. Celermajer DS, Sorensen KE, Georgakopoulos, D, et al. Cigarette smoking is associated with dose–related and potentially reversible impairment of endothelium–dependent dilation in healthy young adults. Circulation 1993; 88:2149.

  18. Sumida H, Watanabe H, Kugiyama, K, et al. Does passive smoking impair endothelium-dependent coronary artery dilation in women? J Am Coll Cardiol 1998;31:811.

  19. Kaufmann PA, Gnecchi–Ruscone T, di Terlizzi, M, et al. Coronary heart disease in smokers: vitamin C restores coronary microcirculatory function. Circulation 2000;102:1233.

  20. Mazzone A, Cusa C, Mazzucchelli, I, et al. Cigarette smoking and hypertension influence nitric oxide release and plasma levels of adhesion molecules. Clin Chem Lab Med 2001;39:822.

  21. Bazzano LA, He J Muntner, P, et al. Relationship between cigarette smoking and novel risk factors for cardiovascular disease in the United States. Ann Intern Med 2003;138:891.

     

Dr KK Aggarwal
Padma Shri Awardee and Chief Editor


News and Views (Dr Monica and Dr Brahm Vasusdeva)

BNP–guided therapy helps heart failure outcomes

Therapy guided by B–type natriuretic peptide (BNP) reduces all–cause mortality in patients with chronic heart failure compared with usual clinical care, especially in patients younger than 75 years, even if it does not reduce hospitalizations or increase hospital–free survival.

Researchers did a meta–analysis of eight prospective randomized, controlled trials of 1,726 outpatients with a history of heart failure. Results were reported in the March 22 Archives of Internal Medicine. There was a significantly lower risk of all–cause mortality {relative risk (RR), 0.76P=0.003} in the BNP–guided therapy group compared with the control group. Patients younger than 75 years in the BNP–guided group had significantly lower all–cause mortality (RR, 0.52; 95% CI, 0.33 to 0.82;). However, patients 75 years or older had no reduction in mortality with BNP–guided therapy (RR, 0.94;95% CI, 0.71 to 1.25;).

More patients in the BNP groups had their doses of angiotensin–converting enzyme inhibitors (ACEI) and β–blockers titrated up to reach target levels (21% and 22% in the BNP group vs. 11.7% and 12.5% in the control group, respectively).

High dose of simvastatin poses muscle injury risk

Patients taking high doses of simvastatin face an increased risk of myopathy, according to a new FDA warning. The warning highlights the greater risk of rhabdomyolysis, for patients who take the 80–mg dose of this drug. Rhabdomyolysis is the most serious form of myopathy and can lead to severe kidney damage, kidney failure, and sometimes death.

Don’t use Rotarix vaccine, FDA warns

FDA warning: Doctors should temporarily suspend the use of Rotarix, one of the vaccines used to prevent rotavirus disease. The suspension is being taken as a precaution after DNA from porcine circovirus type 1 (PCV1) was found in Rotarix. PCV1 is not known to cause disease in humans and the FDA reports no evidence of a safety risk. No medical follow–up is recommended for patients who have been vaccinated with Rotarix, according to the FDA safety alert. However, use of the other licensed rotavirus vaccine, RotaTeq, is currently advised. In children who have received one dose of Rotarix, clinicians can complete the series with RotaTeq for the next two doses, according to the CDC.

Bupropion combined with weight–focused counseling helps women quit

Women who are worried about gaining weight if they quit smoking may benefit from a combination of cognitive behavioral therapy (CBT) and treatment with bupropion, according to a new study appeared in the March 22 Archives of Internal Medicine.

IMSA Update:  This daily column from IMSA will update the members about its activities and also about the latest in medicine.   

Become a member of IMSA

The objectives of IMSA are as under:

  1. To bring together national and international medical scientists, medical educationists, medical and health workers and research workers in medical and health sciences on a worldwide basis for the development of medical and health sciences for the advancement of the health of all people of the world.

  2. To undertake, organize and facilitate research, study courses, conferences, lectures and research in matters relating to different health sciences and health care systems of the world.

  3. To undertake, facilitate and provide expertise for the publication of newsletters, research papers, books and a journal for the exposition of developments in the field of medicine and health in different parts of the world.

  4. To establish and maintain effective collaboration with all similar organizations, both governmental and non governmental in the world

  5. To facilitate exchange of workers between different countries and provide cooperation and international understanding between workers in different countries of the world.

  6. To develop, establish and prescribe international standards with respect to medical education, medical and health care medical research and to establish an International Institute of Medical Education.

  7. To constitute or cause to be constituted Regional Chapters at convenient places in India and elsewhere in the world to promote the objectives of the society.

  8. To establish, maintain and cooperate with libraries and information services to facilitate the study of world medicine and health and spread information in regard thereto.

  9. To cooperate with approved institutions and interested bodies for the purposes of helping the cause, understanding amongst medical educationists, scientists specialists and administrators of different countries.

  10. To invite as and when feasible, leaders of the profession, scientists and scholars who may or may not be Fellows of the society to utilize the facilities of the society.

  11. To establish a trust for the management and administration of all the properties, monies, assets and activities of the society.

  12. To issue appeals and applications for finances/funds for the furtherance of the said objectives and to accept gifts, donations and subscriptions of cash and securities and of any property either movable or immovable in India or any part of the word.

  13. To invest and deal with funds and money of the society and to vary, or to transfer such investments from time to time, in India or outside India. 

  14. To purchase or otherwise acquire to lease to exchange and otherwise transfer or deal or hire in Delhi or outside, temporarily or permanently, any movable or immovable property necessary or convenient for the furtherance of the objectives of the society.

  15. To sell, mortgage, lease, exchange and otherwise transfer or dispose of, or deal with all or any property, movable or immovable anywhere of the society for the furtherance of the objectives of the society.

  16. To construct, maintain, alter, improve or develop any buildings or works necessary or convenient for the purposes of the society.

  17. To undertake the management of any endowment or trust fund or donation with objectives similar to those of the society.

  18. To establish or provide fund for the benefit of the employees of the society.

  19. To establish or help to establish colleges in various disciplines of medicine for continuing education.

  20. To offer prizes and to grant scholarships and stipends to medical scientists in furtherance of the objectives of the society.

  21. To do, get done, all such other lawful things as are conducive or incidental to the attainment of the above objectives.

     
  22. All income of society shall be utilized towards the promotion of aims and objectives of the society.


  23. The Academy shall have the power to enlarge, alter, extend or abridge any of the objectives or purposes specified hereinabove.
Dr KK Aggarwal ( Chairmanship IMSA, Delhi State Chapter) drkk@ijcp.com

Mnemonic of the Day (Dr Prachi Garg)

Past–pointing

Intention tremor

Nystagmus

Ataxia

Rebound

Dysdiad

Slurred Speech

What’s New

Increased risk of lymphoma and other cancers associated with use of tumor necrosis factor (TNF) inhibitors

A safety review indicates an increased risk of lymphoma and other cancers associated with use of tumor necrosis factor (TNF) inhibitors in children and adolescents, and the US Food and Drug Administration (FDA) has required that this information be included in a boxed warning for TNF inhibitors. Food and Drug Administration MedWatch. (Available at: www.fda.gov/ Safety/ MedWatch/ SafetyInformation/ Safety Alertsfor Human Medical Products/ ucm175843.htm. (Accessed September 29,2009)).

Quote of the day

"Finish each day and be done with it. You have done what you could. Some blunders and absurdities no doubt crept in; forget them as soon as you can. Tomorrow is a new day; begin it well and serenely and with too high a spirit to be encumbered with your old nonsense" (Ralph Waldo Emerson)
 

Diabetes Fact

Painful neuropathy; treat with gabapentin, tagretol, phenytoin.

Public Forum (Press Release for use by the newspapers)

School Children Celebrate World Earth Day

On the occasion of World Earth Day, A Walk and competitions were organized by Heart Care Foundation of India in association with Ministry of Environment & Forests, Govt. of India and Delhi Public School, Mathura Road.

Earth Day is celebrated every year to inspire awareness about earth’s environment. The theme this year is "The Green Generation".

Over 500 school children participated in the ‘Environmental–friendly Walk’ and the ‘Slogan cum Poster’ making competitions. Fifteen Eco Club Schools were present at the occasion.

Padma Shri and Dr B C Roy Awardee Dr KK Aggarwal, President Heart Care Foundation of India, said that everyone should participate in taking care of their environment. Children should plant herb gardens in their balcony.

Dr Aggarwal showed concern that in past few years, Delhi is experiencing noticeable shift in climate like winters are becoming short with each passing year and temperatures staying over 45 degrees C for most part of the summer. Scientists worldover are attributing this climate change to increase in global temperatures. Unless the general public is sensitized and convinced to take measures and adopt environment friendly actions at their work places, in their homes, this trend of global warming cannot be arrested.

Environment education among school children is an important step towards making a sustainable and safer future. It was emphasized that each school child should plant a tree to help in reducing the problem of Global Warming in the country.

It was also urged that the schools should participate actively in conducting such awareness programs as part of their curriculum.

Speaking on the occasion, Sh. R Mehta, Advisor, Ministry of Environment & Forests, Govt. of India, said the Ministry would be willing to support all such environment–oriented educational programs aimed at educating the general public, and especially the children. He suggested that children could take pride by planting something on their own.

Sh. Pramod Grover, Vice-Chairman, DPS Society and Sh. M I Hussain, Principal Delhi Public School, urged children from other schools who had come to participate, to help their parents in the Green Campaign. Children should learn to make use of waste material like milk cartons can be made into bird houses, glass jars into vases and frames, egg cartons into jewelry boxes etc.

Pamphlets carrying Dos and Dont’s messages for the general public to adopt were distributed free to the public.

Senior officers from Ministry of Environment & Forests, Govt. of India, members of Delhi Medical Association and eminent persons from the locality joined this campaign with full zeal and vigor. Winners of the competitions were felicitated with prizes and certificates by the officials present.

Question of the day

What would you say to patients who insist their sore throat only ever gets better once they have started antibiotics? (Dr.GM Singh)

It is more likely to be down to the placebo effect than the antibacterial action of the antibiotic. For some patients, a clear explanation of the likely viral cause of the sore throat and the expected eight–day duration of symptoms may be enough to reassure them. If you need to reinforce the message, explain that antibiotics are statistically only likely to reduce the duration of symptoms by eight hours, but that taking these drugs is not without risk, including development of resistance, disturbance of gut flora causing diarrhea, risk of allergy developing and candida infections.

Some people may still not feel satisfied without a prescription. One option is writing a delayed prescription.

The exceptions to this advice are patients who meet at least three of the following Centor criteria for a streptococcal throat infection:

  • Fever

     
  • Purulent tonsillar exudates 

  • Tender anterior cervical lymph nodes 

  • Absence of cough

They are more likely to have a group A streptococcus – with a positive predictive value of 40–60% – and therefore benefit from antibiotics.

eMedinewS Try this it Works

Stained contact lenses

When rifampin is being used in combination therapy for group A streptococcal tonsillopharyngeal infections, patients should be advised that the drug produces orange discoloration of urine and tears. It may cause permanent staining of contact lenses.

Dr Good Dr Bad

Situation: A diabetic came with urinary tract infection (UTI).

Dr Bad: Get routine culture done.

Dr Good: Get routine and fungal culture done.

Lesson: It is important to search routinely for yeast in the urine of patients with type 2 diabetes to detect candidiasis, and to perform antifungal susceptibility tests to Candida isolates in order to establish antifungal therapy for these patients. (Rev Med Inst Mex Seguro Soc 2008;46(6):603–10).

Make Sure

Situation: A patient on contact lens with keratitis developed severe infection

Reaction: Oh my God! Why was he not treated intensively?

Make sure that all patients with suspected bacterial keratitis who use contact lens are promptly and empirically treated with a fourth–generation fluoroquinolone (gatifloxacin or moxifloxacin) with a combination fortified aminoglycoside/fortified cephalosporin eye drops instilled hourly.

IJCP
 
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Docconnect

Laughter the best medicine

After nearly forty years in practice as Gynecologist,
John decided he had enough money to retire and take up
his real love, auto mechanics. He left his practice,
enrolled in an auto mechanics school, and studied hard.
The day of the final exam came and John worried if he
would be able to complete the test with the same
proficiency as his younger classmates. Most of the
students completed their exam in two hours. John, on
the other hand, took the entire four hours allotted.
John tossed and turned in bed that night, dreading the
next morning when the exam scores would be returned.

The following day, John was delighted and surprised to
see a score of 150% for his exam.

John spoke to his professor after class. "I never
dreamed I could do this well on the exam. But tell me,
how did I earn a score of 150%?"

The professor replied, "I gave you 50% for perfectly
disassembling the car engine. I awarded another 50% for
perfectly reassembling the engine. I gave you an
additional 50% for having done all of it through the
muffler."

Formulae in Critical Care

ESR in men

Formula: ESR = Age in years/2

Milestones in Medicine

Wilhelm Roentgen the won first Nobel Prize for Physics in 1901 for discovering that the passage of electricity though rarefied gases produced x–rays

Lab Test (Dr Arpan Gandhi and Dr Navin Dang)

17–Hydroxyprogesterone: To screen for, detect, and monitor treatment for congenital adrenal hyperplasia (CAH); sometimes to help rule out other conditions.

List of Approved drug from 1.01.2009 to 31.10.2009

Drug Name

Indication

Approval Date

Nevirapine tablet 50 mg for oral suspension mg

For the treatment of HIV infection in combination with other anti retroviral agents

18.7.2009


(Advertorial section)

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Advertising in eMedinewS

eMedinewS is the first daily emedical newspaper of the country. One can advertise with a single insertion or 30 insertions in a month.

Contact: drkk@ijcp.com or emedinews@gmail.com

eMedinewS–PadmaCon 2010 

Will be organized at Maulana Azad Medical College, New Delhi on July 4, 2010, Sunday to commemorate Doctors’ Day. The speakers, chairpersons and panelists will be doctors from NCR, who have been past and present Padma awardees.

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.

IMANDB Annual Day Meet : Scientific feast, in association with Board of Medical Education Moolchand Medcity, emedinews and IMSA (Delhi) ; No fee SMS 9811090206 for registration

Date: Sunday April 25, 2010,

Venue: Moolchand Medcity Auditorium, New Delhi

Scientific Program: 4–7 PM

4.00 PM–5.00 PM: Fatty Liver, Workshop for GPs: Padma Shri and Dr B C Roy Awardee Dr KK Aggarwal

5.00 PM–6.00 PM:

Cardiac Update (Max Hospital)

a. Dr JJ Sood Oration: Cardiac Interventions: Dr Mohan Bhargava

b. Dr K L Chopra Oration: Endovascular Approach to Aortic Aneurysm: Dr Kumud Mohan Rai, (Max Hospital)

6.00 PM – 6.30 PM

Dr Sheila Mehra Oration: Management of osteoporosis: Dr Ramneek Mahajan

7.00 PM –7.30 PM

Medical Ethics: A panel discussion: Dr Ashok Seth, Dr Sudesh Ratan, Dr Rajiv Khosla, Dr KK Aggarwal, Dr Girish Tyagi, Dr Sanjiv Malik, Dr H K Chopra, Dr Madhu Handa, Dr Kumud Mohan Rai, Dr Archna Virmani

Annual Day Function: 7–8 PM

Eminent Guests: Padma Shri and Dr B C Roy Awardee Dr KK Aggarwal, Dr Narender Saini (President DMA), Dr Vinod Khetrapal (President-elect DMA), Dr Girish Tyagi (Registrar DMC), Dr Ashwini Dalmiya (Secretary DMA), Dr Naresh Chawla (Immediate Past President DMA)

Dinner: 8.00 PM onwards...

Also, if you like emedinews you can FORWARD it to your colleagues and friends. Please send us a copy of your forwards

Readers Responses

  1. Dear Editor, edited by an optometrist for informational needs of eye care professionals from across the country, Optometry Today, a quarterly journal is in publication since 1970 and is the official organ of the charitable trust, Eye Care India: Dr. Narendra Kumar.

  2. Dr Manoj Aron: Sir, I want your advice regarding treatment of Dyslipidemia in following situations:

    a. Recently detected HT in 43-year-old male with H/O alcohol intake 3–4 times/wk––2–3 pegs/sitting; Investigations: SGPT & SGOT– Twice the normal value; TC – 250;TG – 180; HDL – 43; LDL – 180; S. Creatinine – 0.9. All these reports are after lifestyle changes recommended for 3 months.Will you start statins?

    eMedinewS Responds: Yes, 10 mg atorvastatin and follow up SGPT.

    b. Hypertensive patient well-controlled; dislipidemia + (TC – 250; LDL – 180) Rise in CPK more than twice the normal limits with the use of Statin/EZ/Fibrates used alone. What to do?

    eMedinewS Responds: Give statin on alternate days, or reduce dose or add Co Q 10.