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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


23rd May, 2010, Sunday

Foreign experts may testify in medical negligence case

Dear Colleague

A story published in The Telegraph on May 18, 2010 had stated that the Supreme Court has for the first time, allowed four US experts to depose before the National Consumer Disputes Redressal Commission (NCDRC) in the Anuradha Saha case of medical negligence filed by Dr Kunal Saha, against AMRI Hospital, which the commission had earlier turned down.

According to this story, the Supreme Court has directed the Commission to accept the opinion of the four experts to determine the compensation amount. The doctors accused of negligence and the hospital must also bear the costs of the deposition by these experts who could be examined and cross–examined through "video–conferencing". The four experts who may testify are: Dr John Broughton, a professor in psychology at Columbia University, Professor John Burke, a renowned economic expert from Cleveland; New York; Angela Hill, an economic expert from Ohio and Joe Griffith, a legal expert on damages allowed in medical negligence cases.

Subsequent to the publication of this story, on May 19, 2010, the hospital issued a rejoinder published in The Telegraph saying that the report was based on hearsay and not on actual facts. It states that the Supreme Court "dismissed the special leave petition as withdrawn in terms of the prayer made. The SLP having been dismissed as withdrawn a mere liberty has been reserved for Dr Kunal Saha to approach the National Consumer Disputes Redressal Commission (NCDRC) for examining foreign experts through video–conferencing."

Whether the foreign experts will depose or not yet remains uncertain. But, let's take a look at the case itself and what implications it has on us, as a medical profession.

Dr Kunal Saha, at the Children’s Hospital and Ohio State University at Columbus, Ohio, began his battle against medical negligence after his wife died in 1998 during a trip to India. He then filed negligence cases, civil and criminal, against three doctors and the AMRI hospital where she was treated before being shifted to the Breach Candy Hospital in Mumbai where she died from the Toxic Epidermal Necrolysis syndrome. Anuradha Saha was a child psychologist. He also asked for Rs 78 crores as damages at the National Consumer Disputes Redressal Commission (NDCRC) in New Delhi against the hospital.

Since then, this case has moved up from the lowest to the highest court in India. The lower court found Dr. Sukumar Mukherjee and Dr. Baidyanath Halder guilty of 'negligent and inappropriate treatment' but Dr. Abani Roychowdhury was acquitted for lack of evidence. Calcutta High Court reversed this decision in March 2004, and said that all three doctors were innocent. The NCDRC also had found no evidence of negligence by the doctors and dismissed the claim.

A civil appeal against this decision was filed in the Supreme Court, which in 2009, upheld the acquittal of three doctors from the charge of criminal negligence causing the death of Anuradha Saha, but it said that Dr Kunal Saha was entitled to seek compensation. It also awarded legal costs of Rs 5 lakh to be paid by the AMRI hospital, AMRI, and Rs 1 lakh to be paid by one of the doctors, Sukumar Mukherjee. The Apex Court had sent back the case to the NCDRC to determine the final amount of compensation. Dr Saha filed a contempt petition when the hospital refused to pay these costs even as directed by the Apex Court.

In this long journey, Dr Saha even challenged the West Bengal Govt. in the Supreme Court.

Does this case herald the way medical negligence cases are going to be decided? 
If the foreign experts do testify, this would mark a first, which may well be a precedent.

Dr KK Aggarwal
Padma Shri Awardee and Chief Editor

 

Photo Feature (From file): ealth awareness modules

School AIDS Awareness Programme

A School AIDS Awareness programme was especially planned for school children by Heart Care Foundation of India (HCFI). There were several activities and competitions in which children participated and learn many facts via simple activities and games designed by HCFI. Actor and Social Activist Nafisa Ali also participated in this programme. Also seen in the picture Dr K K Aggarwal, President HCFI.

Dr k k Aggarwal

International Medical Science Academy Update (IMSA): Practice Changing Updates

Blood pressure control in children with chronic kidney disease

Intensified blood pressure control with a targeted goal of a 24–hour mean arterial pressure (MAP) below the 50th percentile, compared with conventional blood pressure control, results in slower progression of chronic kidney disease in children.

(Wuhl E, Trivelli A, Picca S, et al. Strict blood-pressure control and progression of renal failure in children. N Engl J Med 2009;361:1639.)

 

Mnemonics of the Day (Dr Prachi Garg)

Suicide risk factors – SAD PERSON

  • Sex / Single / Sickness
  • Age 
  • Depression 
  • Previous attempt 
  • Ethanol 
  • Reality testing 
  • Social support 
  • Organized plan 
  • Note / No spouse

News and Views

CPAP reduces risk of heart disease in nonsleepy patients

A study presented at the American Thoracic Society meeting notes that patients treated with CPAP had a 17% lower incidence of cardiovascular events and new–onset hypertension during four years of follow–up. Presenting the results, Ferran Barb, MD, of Instituto Salud de Carlos III in Madrid said that hypertensive patients had a 50% reduction in cardiovascular events if they used CPAP for at least four hours each day. CPAP patients with sleep apnea that show an apnea–hypopnea index less than 20, regardless of symptoms should be treated.

Caffeine may aid shift workers

Caffeine may improve attention span of shift workers’ and decrease the risk of on–the–job errors, according to a report in the Cochrane Database of Systematic Reviews. Combined data from placebo–controlled clinical studies showed that caffeine was associated with significantly better cognitive performance, including reasoning, memory, orientation and attention, and perception.

FDA Update

Natazia (estradiol valerate and estradiol valerate/dienogest), a new birth control pill has been granted US FDA approval. Natazia is the first four–phasic oral contraceptive approved for marketing in the US. The term ‘four–phasic’ refers to the doses of progestin and estrogen varying at 4 times throughout each 28–day treatment cycle. Natazia contains estradiol valerate as the estrogen component instead of ethinyl estradiol present in the earlier available combination oral contraceptive (COCs) pills.

Diffusion–weighted MRI detects new ischemic lesions
after endovascular procedures

A study presented at the annual meeting of the American Academy of Neurology reports that more than one–third of endovascular procedures in patients with cerebrovascular disease resulted in at least one new ischemic lesion as detected by diffusion–weighted MRI. The study included patients who had undergone pre– and post–procedural diffusion–weighted MRI within 48 hours of the endovascular procedure. Diffusion–weighted MR imaging is a very sensitive modality for the detection of ischemic events.

Quote of the day (Dr Santosh Sahi)

"A great attitude is not the result of Success; Success is the result of a great attitude." Earl Nightingale

Question of the Day

What is giardiasis?

Giardiasis is an infection of the small intestine caused by the parasite, Giardia intestinalis or Giardia lamblia. It is the most common cause of parasitic GI diseases. Up to 20% of the world population is chronically infected.
It exists in two forms, an active form called a trophozoite, and an inactive form called a cyst. The active trophozoite attaches to the lining of the small intestine with a "sucker" and is responsible for causing the signs and symptoms of giardiasis. The trophozoite cannot live long outside of the body, therefore it cannot spread the infection to others.

The inactive cyst, on the other hand, can exist for prolonged periods outside the body. When it is ingested, stomach acid activates the cyst, and the cyst develops into the disease–causing trophozoite. Ingestion of only ten cysts is enough to cause infection. Cysts of Giardia are present in the feces of infected persons Trophozoites are important not only because they cause the symptoms of giardiasis, but also because they produce the cysts that exit the body in the feces and spread the infection to others. The infection is spread from person to person by contamination of food with feces, or by direct fecal–oral contamination. Cysts also survive in water, for example in fresh water lakes and streams. As a result, giardiasis is the most common cause of water–borne parasitic disease. Domestic mammals and wild mammals can become infected. Giardiasis also has occurred as outbreaks from recreational water sources such as swimming pools, water parks, and hot tubs, most likely because of an infected user rather than a source of water that was contaminated.

World No Tobacco Day, May 31, 2010

Religions and Smoking

Buddhism: The basic teaching of Buddhism is the path of freedom which cannot come if the person is addicted to smoking. Buddhism strongly feels that people are fortunate to be born in human form in order to attain a true understanding of life. Therefore, anything that harms the body and the mind must be avoided.

Evidence–Based Medicine

Effect of antibiotic prescribing in primary care on antimicrobial resistance in individual patients: systematic review and meta-analysis

Abstract

Objective: To systematically review the literature and, where appropriate, meta–analyse studies investigating subsequent antibiotic resistance in individuals prescribed antibiotics in primary care.
Design: Systematic review with meta–analysis. Data sources: Observational and experimental studies identified through Medline, Embase, and Cochrane searches.
Review methods: Electronic searches using MeSH terms and text words identified 4373 papers. Two independent reviewers assessed quality of eligible studies and extracted data. Meta–analyses were conducted for studies presenting similar outcomes.
Results: The review included 24 studies; 22 involved patients with symptomatic infection and two involved healthy volunteers; 19 were observational studies (of which two were prospective) and five were randomised trials. In five studies of urinary tract bacteria (14 348 participants), the pooled odds ratio (OR) for resistance was 2.5 (95% confidence interval 2.1 to 2.9) within 2 months of antibiotic treatment and 1.33 (1.2 to 1.5) within 12 months. In seven studies of respiratory tract bacteria (2605 participants), pooled ORs were 2.4 (1.4 to 3.9) and 2.4 (1.3 to 4.5) for the same periods, respectively. Studies reporting the quantity of antibiotic prescribed found that longer duration and multiple courses were associated with higher rates of resistance. Studies comparing the potential for different antibiotics to induce resistance showed no consistent effects. Only one prospective study reported changes in resistance over a long period; pooled ORs fell from 12.2 (6.8 to 22.1) at 1 week to 6.1 (2.8 to 13.4) at 1 month, 3.6 (2.2 to 6.0) at 2 months, and 2.2 (1.3 to 3.6) at 6 months.
Conclusions: Individuals prescribed an antibiotic in primary care for a respiratory or urinary infection develop bacterial resistance to that antibiotic. The effect is greatest in the month immediately after treatment but may persist for up to 12 months. This effect not only increases the population carriage of organisms resistant to first line antibiotics, but also creates the conditions for increased use of second line antibiotics in the community.

Comments

Primary care patients who receive an antibiotic for respiratory or urinary infections are at increased risk for developing bacterial resistance to that particular drug, according to this meta–analysis in BMJ. Researchers examined data from 24 studies investigating the association between antibiotic use in primary care and subsequent resistance in individual patients. Among the findings:

  1. Patients receiving antibiotics for urinary or respiratory tract infections had more than twice the risk for developing resistance within the first couple of months after treatment, compared with unexposed patients.

  2. Risk for resistance declined with time but was still elevated up to 1 year after treatment. Some evidence suggested that multiple courses and longer duration of treatment led to more resistance.
     
  3. These findings support current recommendations that the "fewest number of antibiotics should be prescribed for the shortest period possible."

Reference

1. Costelloe C, Metcalfe C, Lovering A, et al. Effect of antibiotic prescribing in primary care on antimicrobial resistance in individual patients: systematic review and meta–analysis. BMJ 2010;340:c2096

Pharma update

Abbott gets Piramal crown jewels for Rs 17,000 crore

US–based Abbott Laboratories is set to acquire the domestic formulations business of Piramal Healthcare Ltd for 17,000 crore in one of Corporate India’s biggest acquisition deals. Abbott will make an upfront payment of 9,900 crore to the Indian company. The rest will be paid in annual payments of $ 400 million over the next four years. The deal is expected to conclude in the second quarter of 2010. The sale, is essentially of the generics business, 350 brands and one manufacturing unit. The deal will give Abbott a 7 per cent market share in India, ahead of Cipla and Ranbaxy.

eMedinewS Try this it Works: Difficult venipuncture

When venipuncture of small veins of the extremities is difficult, apply a blood pressure cuff and manometer and then pump the pressure above diastolic but not near or over systolic levels. Because the blood escapes through the arteries but is inhibited through the veins, the latter become distended, more prominent and accessible.

Dr Good Dr Bad

Situation: A patient came with chest pain of 3 hours duration and negative trop I.
Dr Bad: You do not have cardiac disease.
Dr Good: Repeat Trop I at 12 hours.
Lesson: A single set of negative cardiac biomarkers is NOT sufficient to rule out myocardial infarction. In acute myocardial infarction, cardiac troponin I rises after approximately 6 hours, peaks at 12 hours, and remains elevated for 7 to 10 days.

Make Sure

Situation: A patient on ampicillin developed persistent diarrhea.
Reaction: Oh my God! You should have suspected Clostridium difficile–colitis
Lasson: Make sure no antibiotic is safe. All antibiotics can predispose to Clostridium difficile–colitis, and ampicillin is a commonly implicated beta–lactam. (N Engl J Med 1994;330:257)

IMANDB Joke of the Day (Dr Prachi Garg)

Punjabi is a funny language

Dil v 13
80 vi tere
Hor 10
Ki hal a 13??
Yaara–dostaan nu ainj nae 27 da
okG
ijazat 2
32 bujhao
Te 100 jao

Formulae in clinical practice

Venous Oxygen Content (CvO2)

Formula: CvO2 = {1.39 × SaO2%/100 × Hb} + (0.0031 × PvO2)

Normal value: 14.5–15.5 ml/dl.

Milestones in Gastroenterology

Samuel Fenwick 18211902: Fenwick was an English physician who discovered and described atrophy of the stomach associated with pernicious anemia. This became known as Fenwick disease. He also made pertinent observations on perforation of the appendix and abscess formation.

Lab Test (Dr Arpan Gandhi and Dr Navin Dang)

Gastrin

To detect an overproduction of gastrin, to help diagnose Zollinger–Ellison syndrome, and to monitor for recurrence of a gastrin–producing tumor (gastrinoma).

List of Approved drugs from 1.01.2009 to 31.10.2009

Drug Name

Indication

DCI Approval Date

Cefixime 200 mg + Dicloxacillin ER 500 mg Tablets

For the treatment of adult patients with Upper and Lower respiratory tract infections, skin and soft tissue infections

22.09.2009

 

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

 
 

eMedinewS–Padma Con 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 .

 

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

 

Public Forum (Press Release for use by the newspapers)

Drugs that help reduce cholesterol may also prevent nerve damage

Same drugs that help reduce cholesterol might also prevent nerve damage brought on by diabetes.

Both drugs are already highly recommended for people with type 2 diabetes to help prevent heart attacks. Now they appear to help this type of nerve damage, as per a study done by Dr. Timothy Davis, of the University of Western Australia.

In an eight–year study of statins and fibrates (atorvastatin and fenofibrate), the two classes of cholesterol medications significantly cut the risk of developing peripheral sensory diabetic neuropathy, said Padma Shri and Dr B C Roy National Awardee Dr KK Aggarwal, President Heart Care Foundation of India.

Neuropathy that affects half of all diabetics, can cause stinging or burning sensations, tingling, pain, numbness or weakness in the hands and feet and is a major cause of amputations, one in every 50 seconds.

Statins, reduce levels of LDL, or "bad" cholesterol, thus reducing the risk of heart attacks and stroke. Fibrates are drugs that have been shown to raise levels of HDL or 'good' cholesterol, and reduce triglyceride.

Statin drugs reduced the risk of developing peripheral neuropathy by 35 percent, and fibrates cut the risk by 48 percent.

MCI Update

CBI turns up the heat, reports Mint live. The investigators are examining whether any of the newely approved colleges offered monetary or other favours to Ketan Desai. CBI is probing all files related to inspections conducted over the last two years of nearly 40 medical colleges. They have seized over 170 inspections files from Desai’s office. The files belong to nearly 40 medical colleges. MCI had conducted 130 inspections in 2009 and 60 in 2010. During initial investigations, evidence indicated that Desai used his influence to grant approval to 10 colleges after accepting "hefty" favours from them including Laxmi Narayan Medical College of Chennai. The Chennai branch is to register a fresh case against Desai and the college administration.

Apart from Laxmi Narayan Medical College, some of the colleges under CBI lens are Adesh Institute of Medical Science and Research in Punjab; Vikarabad Medical College, Santhiram Medical College, and Rajiv Gandhi Institute of Medical Sciences in Andhra Pradesh; Rajendra Institute of Medical Sciences in Jharkhand; Sagar Medical College in Madhya Pradesh; Shree Balaji Medical College and Hospital, Annapoorana Medical College and Hospital, DD Medical College and Hospital, and Thiruvarur Medical College in Tamil Nadu; Baba Saheb Bhim Rao Ambedkar Medical College and Manyavar Kashi Ram Jee Allopathic Medical College in Uttar Pradesh. MCI inspectors had made negative recommendations for most of these colleges in 2009, though the applications of several were later cleared.

Good Advice

I want to be a coffee bean. Why? Read on...

A young woman went to her mother and told her about her life and how things were so hard for her. She did not know how she was going to make it and wanted to give up; she was tired of fighting and struggling. It seemed as one problem was solved, a new one arose.

Her mother took her to the kitchen. She filled three pots with water and placed each on a high fire. Soon the pots came to boil. In the first she placed carrots, in the second she placed eggs, and in the last she placed ground coffee beans. She let them sit and boil; without saying a word.

In about twenty minutes she turned off the burners. She fished the carrots out and placed them in a bowl. She pulled the eggs out and placed them in a bowl. Then she ladled the coffee out and placed it in a bowl. Turning to her daughter, she asked, ‘Tell me what you see.’ ‘Carrots, eggs, and coffee,’ she replied.

Her mother brought her closer and asked her to feel the carrots. She did and noted that they were soft. The mother then asked the daughter to take an egg and break it. After pulling off the shell, she observed the hardboiled egg.
Finally, the mother asked the daughter to sip the coffee.
The daughter smiled as she tasted its rich aroma. The daughter then asked: ‘What does it mean, mother?’

Her mother explained that each of these objects had faced the same adversity: boiling water. Each reacted differently:

  • The carrot went in strong, hard, and unrelenting. However, after being subjected to the boiling water, it softened and became weak.

  • The egg had been fragile. Its thin outer shell had protected its liquid interior, but after sitting through the boiling water, its inside became hardened.

  • The ground coffee beans were unique, however. After they were in the boiling water, they had changed the water. ‘Which are you?’ she asked her daughter. ‘When adversity knocks on your door, how do you respond? Are you a carrot, an egg or a coffee bean? Think of this: Which am I?.

  • Am I the carrot that seems strong, but with pain and adversity do I wilt and become soft and lose my strength?

  • Am I the egg that starts with a malleable heart, but changes with the heat? Did I have a fluid spirit, but after a death, a breakup, a financial hardship or some other trial, have I become hardened and stiff? Does my shell look the same, but on the inside am I bitter and tough with a stiff spirit and hardened heart?

  • Or am I like the coffee bean? The bean actually changes the hot water, the very circumstance that brings the pain. When the water gets hot, it releases the fragrance and flavour. If you are like the bean, when things are at their worst, you get better and change the situation around you. When the hour is the darkest and trials are their greatest do you elevate yourself to another level? How do you handle adversity? Are you a carrot, an egg or a coffee bean? May you have:

  • enough happiness to make you sweet,
  • enough trials to make you strong,
  • enough sorrow to keep you human, and
  • enough hope to make you happy. The happiest of people don't necessarily have the best of everything; they just make the most of everything that comes along their way. The brightest future will always be based on a forgotten past; you can't go forward in life until you let go of your past failures and heartaches.
    May we all be COFFEE!!

     

Readers Responses

  1. Dear Sir, First of all, I would like to take this opportunity to congratulate you, once again, on receiving Padma Shri. I would also like to thank you on providing me the opportunity to experience the work field with you even if it was for just for few days. I hope to have more opportunity in the coming future. It was my honor that I got the chance. Thank you Sir. Wishing you all well and best of luck. Sincerely yours: Apurva Koirala, Final Year Dow Medical College Karachi, Pakistan.

  2. If you want to avoid false negatives, or "false positives" (very early miscarriages), the best time to take a pregnancy test is after your period is late. If your cycles are irregular or you don’t chart your cycles, I wouldn’t take a test until you've past the longest menstrual cycle you usually have. For example, if your cycles range from 30 to 36 days, the best time to take a test would be day 37 or later. Also, if you've have had an hCG trigger shot like Ovidrel, then you should not take an early pregnancy test. An early test may detect the remains of the fertility medication. Dr GM Singh

  3. Dear KK, I congratulate emedinews for the detailed and nearly true account on MCI. When Dr ARN Setalvad took up appointment he was alreday chargesheeted by the Govt of Gujarat for embazzlement of public funds and High Court of Gujarat had already ordered CBI enquiry as well. He did not furnish information of his being chargesheeted while joinig MCI in Dec 2002 as Whole Time Inspector and later in June 2003 as Secretary. As per all the Govt Rules/regulations, even DOPT and UPSC and all the organisations on earth, anybody found to be having given false information for his appointmnent can be dismissed from service any time. Dr K K Arora