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Dr KK Aggarwal

From the Desk of Editor in Chief
Padmashri 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

Dear Colleague

23rd February 2010, Tuesday

Celebrity sickness: Daytime Sleepiness

Former Prime Minister HD Deve Gowda was often seen dozing at official functions showing the characteristic symptoms of hypersomnia i.e. daytime sleepiness. It is important that people understand what daytime sleepiness is, as it is a potentially reversible and treatable condition.

What is daytime sleepiness?

Daytime sleepiness occurs when the person has an irresistible desire to sleep while awake. This can happen due to snoring, chronic sleep deprivation or due to a disease called sleep paralysis or narcolepsy. Individuals who sleep fewer than four or more than ten hours have been reported to have increased rates of mortality.

What is the commonest cause?

The commonest cause of daytime sleepiness is obstructive sleep apnea and is associated with night time snoring. It is also potentially the most dangerous cause.
An estimated 45 percent of men and 30 percent of women older than 65 years snore. These people often snore on a regular basis and have cessation of respiration (partial or total) more than five times per hour. Snoring is also associated with high blood pressure, cardiovascular disease, heart attacks, and paralysis. Simple snorers generally do not have daytime sleepiness, but can develop excessive sleepiness, if they consume alcohol, sedatives or anti–allergic drugs.

How serious is mild sleep apnea?

Mild sleep apnea does not impair daily activity or behavior. The daytime sleepiness is usually recognized by family members. Such patients have apnea attacks during sleep of 5 and 15 events per hour. They do not suffer from high BP, right heart enlargement and lack of oxygen during sleep.

How serious is moderate sleep apnea?

These patients are usually aware of their daytime sleepiness and take steps to avoid falling asleep. They continue their daily activities, but at reduced levels. There is also a higher incidence of motor vehicle violations or accidents. Hypertension may exist, but right heart enlargement is usually absent. Such patients generally have apnea attacks during sleep between 15 and 30 events per hour.

What about severe apnea?

In these patients the daytime sleepiness is disabling and interferes with normal daily activities. There are signs of right heart failure, night time heart angina, raised hemoglobin levels as well. Such patients fall asleep during the day, in a sitting posture, and are at risk for accidental injury. These patients generally have more than 30 cessation of respiration attacks per hour of sleep including an oxygen saturation below 90 percent for more than 20 percent of the total sleep time.

What is narcolepsy?

It is the second most common cause of disabling daytime sleepiness. The disease typically begins during the teens and early twenties, but can occur as early as five years of age or even after 40 years of age. The symptoms may worsen during the first few years and then persist for life. Narcolepsy is a disorder of sleep–wake state control in which elements of sleep intrude into wakefulness, and elements of wakefulness intrude into sleep. The net effect is daytime sleepiness with varying amounts of hypnagogic hallucinations, sleep paralysis, and cataplexy. In some, the sleepiness may be so severe that they may doze off with little warning (sleep attacks).

How do we differentiate sleep apnea from narcolepsy?

In contrast to the sleepiness of sleep apnea and other disorders, the sleepiness of narcolepsy often improves temporarily after a brief nap. Patients with narcolepsy often feel rested when they awake in the morning.

What is sleep deprivation?

Sleep deprivation is another cause of daytime sleepiness. It can be partial and cumulative. For example, when a person with a usual nightly sleep quota of eight hours sleeps only seven hours, there is a 1–hour sleep deficit, which is carried over to the next day. A seven-hour sleep debt accrues after seven days of losing one hour of sleep nightly, nearly equivalent to a full night without sleep. In one study, maintaining a nightly sleep quota of six hours or less for 14 days produced cognitive performance deficits equivalent to 48 hours of total sleep deprivation. Cumulative partial sleep deprivation is, equivalent of acute total sleep deprivation, and may be much harder for the patient and clinician to recognize.

Dr KK Aggarwal
Chief Editor

News and Views

NSAIDs offer no protection against skin cancer

A review yielded inconsistent and nonsignificant associations between squamous–cell skin cancer and use of NSAIDs, aspirin, ibuprofen, and non–aspirin NSAIDs. Regular use of NSAIDs or aspirin was associated with a tendency toward a 30–40% increase in the odds ratio for skin cancer. Regular use of ibuprofen or non–aspirin NSAIDs was associated with a tendency toward about a 20% lower risk of skin cancer. None of the associations achieved statistical significance, according to an article published online in Archives of Dermatology.

Happiness linked to reduced risk of heart disease

People who are naturally happy appear to have a lower risk of developing heart disease or dying from heart attacks, according to a study published in the European Heart Journal. Investigators analyzed 10 years of data about 1,739 healthy adults who participated in the 1995 Nova Scotia Health Survey. They used a five–point scale to measure people's happiness. The investigators found that for every point on the happiness scale, people were 22 percent less likely to have a heart problem.

Lack of blue wavelength light may disrupt adolescent circadian rhythms

Riding in school buses in the early morning, sitting in poorly lighted classrooms are the main reasons students have trouble getting to sleep at night.

As per a study published in the journal Neuroendocrinology Letters, adolescents need bright lights in the morning, particularly in the blue wavelengths, to synchronize their inner, circadian rhythms with nature’s cycles of day and night. If they are deprived of blue light during the morning, they go to sleep an average of six minutes later each night, until their bodies are completely out of sync with the school day.

In the study, 11 eighth–graders donned special orange goggles that block short–wavelength ‘blue light,’ but not other wavelengths necessary for proper vision, from the time they got up until the time school ended. Blocking that light for five days upset the students’ internal body clocks –– delaying by half an hour their evening surge of a hormone called melatonin that helps induce sleep.

Conference Calendar

Community Critical Care Training Program Indian Medical Association (IMA)
Date: February 27–28, 2010
Venue: TACT Academy for Clinical Training, V Block, No 70 (Old No.89), 5th Avenue, Anna Nagar, Chennai, Tamil Nadu

Quote of the Day

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

Diabetes Fact

LADA: Late–onset autoimmune diabetes of adults: elderly, antibodies present, serum insulin low, autoimmune nature, (other autoimmune diseases may be associated like Addison’s, Thyroiditis)

Homeopathy, the allopathic way (Dr Mayur Jain)

Cytotoxic effects of ultra–diluted remedies on breast cancer cells The use of ultra–diluted natural products in the management of disease and treatment of cancer has generated a lot of interest and controversy. An in vitro study was conducted to determine if products prescribed by a clinic in India have any effect on breast cancer cell lines. Four ultra–diluted remedies (Carcinosin, Phytolacca, Conium and Thuja) were studied against two human breast adenocarcinoma cell lines (MCF–7 and MDA–MB–231) and a cell line derived from immortalized normal human mammary epithelial cells (HMLE). The remedies exerted preferential cytotoxic effects against the two breast cancer cell lines, causing cell cycle delay/arrest and apoptosis. These effects were accompanied by altered expression of the cell cycle regulatory proteins, including downregulation of phosphorylated Rb and upregulation of the CDK inhibitor p27, which were likely responsible for the cell cycle delay/arrest as well as induction of the apoptotic cascade that manifested in the activation of caspase 7 and cleavage of PARP in the treated cells. The findings demonstrate biological activity of these natural products when presented at ultra–diluted doses. Further in–depth studies with additional cell lines and animal models are warranted to explore the clinical applicability of these agents. (Source: Int J Oncol 2010;36(2):395–403)

Public Forum (Press Release)

Celebrate HOLI without BHANG

Cannabis or 'bhang' can cause psychosis, increase heart rate and BP and also harm brain of the fetus if taken during pregnancy. Celebrate Holi without bhang said Dr K K Aggarwal, President, Heart Care Foundation of India and Editor eMedinewS.

The acute side-effects caused by cannabis or 'bhang' are mainly related to psyche and cognition and to circulation. Euphoria, anxiety, changes in sensory perception, impairment of memory and psychomotor performance are common effects after a dose is taken that exceeds an individually variable threshold.

Cannabis consumption may increase heart rate and change blood pressure, which may have serious consequences in people with heart disease. Effects of chronic use may be induction of psychosis and development of dependency to the drug.

The effects on cognitive abilities seem to be reversible after abstinence, except possibly in very heavy users.

Cannabis exposure in utero may have negative consequences on brain development of the fetus with subtle impairment of cognitive abilities in later life.

Consequences of cannabis smoking may be similar to those of tobacco smoking and should be avoided.

Cannabis use in young people has more detrimental effects than use by adults.

Some facts

1. The heavy use of cannabis is known to be associated with some adverse consequences, such as the occurrence of acute psychotic episodes and development of chronic schizophrenia in some people even after its use has been stopped.

2. Cannabis use may precipitate psychosis among vulnerable individuals, increase the risk of relapse among those who have already developed the disorder, and may be more likely to lead to dependence in persons with schizophrenia.

3. Cannabis is an independent risk factor, both for psychosis and the development of psychotic symptoms.

4. Many cases have been described, where long–term abuse of 'bhang', the mildest of cannabis preparations, has been found to be responsible for causing a schizophrenia–like psychosis. Disturbance in thinking and perception occurs in a state of clear consciousness with little disturbance in memory.

5. 'Bhang', similar to alcohol can impair driving skills.

6. Alcohol, smoking and 'bhang' are often consumed with each other.

Punjab & Sind Bank
Central Bank of India

Question of the day

What is refractory ulcerative colitis?

Regardless of the extent of colonic involvement, some patients remain symptomatic despite optimal doses of oral 5–aminosalicylic acid (5–ASA) drugs, topical therapy with either 5–ASA or steroids and systemic corticosteroids. In these patients, additional medical therapy should be considered.

eMedinewS Try this it Works

Less painful toenail excision

Before digital block with local anesthetic is performed, spray ethyl chloride over the site to be infiltrated.

Dr Good Dr Bad

A young female with tinnitus came for marriage counseling advise.
Dr Bad: It is familial.
Dr Good: It is not familial.
Leseson: Tinnitus doesn’t appear to be a highly heritable condition. (Source: Arch Otolaryngol Head Neck surg 2010;136:178–82)

Make Sure

Situation: Doctor, this patient has developed acute renal failure (ARF).
Reaction: Oh my God, I forgot that he was on frusemide. I gave him full dose of amikacin.
Make sure, before calculating the dose of aminoglycoside (amikacin) that frusemide and other loop diuretics, which enhance its nephrotoxicity are not being given.

Laughter the best medicine (Maj Dr Prachi Garg)

Gynecologist – a man who works and operates in another man’s field

Formulae in Critical Care

Systemic vascular resistance (SVR)
Formula: SVR = (MAP – Mean CVP/CO) × 80

MAP – Mean arterial pressure; CVP – Central venous presssure; CO – Cardiac output

Milestones in Neurology

Otto Ludwig Binswanger (1852–1929) was a Swiss psychiatrist and neurologist who came from a famous family of physicians.; Binswanger wrote over 100 publications, most notably on epilepsy and hysteria. With neurologist Ernst Siemerling (1857–1931) he co–authored an influential textbook on psychiatry titled Lehrbuch der Psychiatrie (1904). His name is attached to the eponymous Binswanger disease, which is subcortical dementia characterized by loss of memory and intellectual faculties. One of his more famous patients was German philosopher Friedrich Nietzsche, others were the writers (later on) Hans Fallada and Johannes R. Becher.

Mistakes in Clinical Practice

"q.d" – The "q.d." means every day, and "q.o.d.", means every other day. "q.d." can be mistaken as "q.i.d.", if the period after the "q" or the tail of the "q" is misunderstood as an "i". And "q.o.d." can be mistaken for "q.d." or "q.i.d." if the "o" is poorly written. Instead, write as "daily" or "every other day".

1-7 April Prostate Disease Awareness week: Prostate SMS of the Day (Dr Anil Goyal)

Prostate measures 3 cm in length, 4 cm in width, 2 cm in depth and is traversed by the prostatic urethra.

11th March World Kidney Day (Dr N P Singh)

Reducing risks of developing kidney diseases

Monitor blood pressure: Although many people may be aware that high blood pressure can lead to a stroke or heart attack, few know that it is also the most common cause of kidney damage. The normal blood pressure level is 120/80. Between this level and 129/89, one is considered prehypertensive and should adopt lifestyle and dietary changes. At 140/90 and above, one should discuss the risks with the doctor and montior blood pressure level regularly. High blood pressure is especially likely to cause kidney damage when associated with other factors like diabetes, high cholesterol and cardiovascular diseases.

Kidney terms (Dr G M Singh)

Acute pyelonephritis - Acute bacterial infection of kidney, characterized by chills and often high fever, flank pain as well as tenderness.

Lab test (Dr Navin Dang)

Maximum errors in lab medicine occur due to wrong labelling, error in collection and delay in transportation of samples.

List of Approved drug from 1.01.2009 to 31.10.2009

Drug Name Indication Approval Date
Dexmedetomidine (as HCl) 100mcg/ml Injection
For sedation of initially and mechanically ventilated patients during treatment in an intensive care setting.

(Advertorial section)

Silicic Acid and Herbs: A New Approach

Various clinical studies have proved that silicic acid as sodium metasilicate, has a synergistic effect with concomitant use of relevant herbal extracts when both are used in conjunction.

Advertising in emedinews

emedinews is the first daily emedical newspaper of the country. One can advertise with a singe insertion or 30 insertions in a month. Contact: drkk@ijcp.com. 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 hangama and live webcast. Suggestions are invited.

Stress Management Workshop

A stress management workshop with Dr KK Aggarwal and Experts from Brahma Kumaris will be organized on April 17–18, 2010.
Organizers: eMedinews, Brahma Kumaris, Heart Care Foundation of India, In association with IMA New Delhi Branch and IMA Janak Puri Branch
Venue: Om Shanti Retreat Center, National Highway 8, Bilaspur Chowk Pataudi Road, Near Manesar.
Timings: On Saturday (2pm onwards) and Sunday (7am–4pm). There will be no registration charges, limited rooms, kindly book in advance, stay and food (satvik) will be provided. For booking e-mail to emedinews@gmail.com or sms to Dr KK Aggarwal 9811090206/ BK Sapna 9811796962

Stroke Update Workshop for GPs

Indian stroke association and International Stroke Conference is organizing a Stroke Update Workshop on March 13–14, 2010 at AIIMS Auditorium. eMedinewS has tied up with the conference for free registration for first 200 GPs of NCR. Organizer: Dr Padma, Prof of Neurology, AIIMS, New Delhi SMS for free registration to 9717298178 or email to isacon2010@gmail.com

International Symposium on ‘Yogism for Healthy & Happy Living and Aging’

An International Symposium on ‘Yogism for Healthy & Happy Living and Aging’ on December 6–7, 2010. BC Harinath, Director, JBTDRC & Coordinator, BIC & Arogyadham Mahatma Gandhi Institute of Medical Sciences, Sevagram – 442102, Wardha, Maharashtra, India, E-mail: bch@jbtdrc.org, bc_harinath@yahoo.com

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Readers Responses

  1. Hello Krishan, Congratulations on your winning the Padma Shri. You were always brilliant, right from student days. I find your e – newsletter full of interesting info and read it regularly. Thank you: Dr. Nafisa J. Aptekar (nee Kapadia ), 29, Senwood Street, Brampton ON L7A 3S6, Canada, phone: 905–216–8015

  2. Respected Sir, Regards and thanks for keeping us updated. There is a printing mistake in this newsletter. The colony count for asymptomatic bacteriuria is 10 to the power 5 and not 105. Regards, Sincerely Yours: Dr.Varesh Nagrath, M.D.Gurukripa Clinic, Raghav Nagar, Deoria Sadar (eMedinewS Responds: Thanks for the correction)

  3. Respected Sir, You deserve all awards. Thanks for adding me on emedinews. I am grateful to you: Davinder Singh

  4. Heartiest congratulations. May this give you more zeal to forge ahead: Dr. Israni