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  Address:  39 Daryacha, Hauz Khas Villege, New Delhi, India. e-Mail: drkk@ijcp.com , Website: http://www.ijcpgroup.com 

Dr K K Aggarwal

Dr KK Aggarwal
Dr BC Roy Awardee
Sr Physician and Cardiologist,
Moolchand Medcity
President, Heart Care
Foundation of India
Gp Editor-in-Chief,
IJCP Group
Delhi Medical Council
Director, IMA AKN Sinha Institute (08-09)


Dear Colleague,                                                                                   23rd October

Is tempering of record punishable?

A warning has been issued in this regard vide order number DMC/DC/F.14/Comp.347/2008/ dated 5th August, 2008. In this case DMC examined a complaint of Shri Raj Kumar Jain, alleging medical negligence and professional misconduct on the part of Respondents 1 to 4, in the treatment administered to complainant?s father late O.P. Jain at Sunderlal Jain Charitable Hospital; resulting in his death on 14.4.2006.  Even though the records added may not alter the treatment process, it will be taken as temperament once the records have been submitted to the relations. Never add or delete any thing in medical records once they have been given to the relations.
Late Shri O.P. Jain (patient) was admitted in Sunderlal Jain Hospital (Hospital) with recurrent giddiness associated with numbness in left hand and tingling.  The ECG was suggestive of flutter fibrillation with varying blocks.  He was diagnosed as Acute CAD with unstable Angina.  The patient was planned for coronary Angiography for 12.4.2006 but the same was deferred to 14.4.2006 as the patient became febrile.  The patient was taken up for Angiography under informed consent on 14.4.2006.  In angio a large thrombus was seen in left main Artery distally obstructing the origin of LAD and OX (distal LMCA) and patient started having severe symptoms, henceforth, taken up for Rescue PTCA.  After Intra coronary (I/C) STK and I/C integrellin failed and as patient crashed on table, rescue PTCA and rescue stenting with all  resuscitative measures including ventilation and TPI was attempted.  In spite of all these the patient could not be revived and was declared dead at 2.45 pm on 14.4.2006.
The following issues were taken up for consideration :-
1) Was there any medical negligence in the treatment administered: On perusal of medical records of the said Hospital, it is observed that the clinical condition of the patient warranted undertaking of CAG to conclusively diagnose the condition of the patient hence, the patient under the facts and circumstances was rightly taken up for CAG procedure under  an  informed  consent  dated  11.4.2006  which comprehensively detailed all the risks associated with the procedure and also authorized the doctors to perform such additional surgical, or other procedure as may deem necessary or desirable in their best judgement.  Hence, the allegation of the complainant that he had instructed the said Hospital that he did not wish to undergo any surgery in the said Hospital is untenable.  It is further observed that the clinical picture of the patient as reported in the coronary Angiography report dated 14.4.2006 as mentioned hereinabove i.e. of ?large thrombus in left Main Artery distally obstructing in the origin of LAD and LCX?, is an uncommon but a documented condition which has an extremely high mortality rate.  The necessary measures were undertaken to deal with above condition.

2) Was there tampering of medical records? : It is alleged by the complainant that on 14.4.2006 at his request a copy of medical records of the patient were made available to him.  However, since he was not satisfied with the cause of death of the patient as detailed in the death certificate, he demanded an attested copy of the complete medical records, which were supplied to him on 16.6.2006.  It is alleged by the complainant that the medical records given to him on 14.4.2006 and the attested medical records given on 16.6.2006 were completely different from each other and various additions, alterations, manipulations were made in the case history, treatment chart, declaration of death, time of death, cause of death, as well as in the death certificate itself.

The attending doctors whilst refuting the allegation of complainant stated that the relatives of complainant forcibly took away the medical paper on 14.4.2006 and the same were returned after a gap of two days with  the  help of  police intervention.  The medical documents  which  were  returned  were  not complete and certain papers including death certificate was missing.  Thereafter Shri S.K. Jain brother of the complainant on 20.5.2006 visited Sunderlal Jain Hospital along with one of his friend who was stated to be a doctor and they requested to peruse the medical case sheet of late O.P. Jain.  While the medical case sheet was being shown to Shri S.K. Jain and his doctor friend they sought certain clarifications in the medical case sheet and requested the Respondents to clarify it.  Accordingly the respondents answered their queries and penned down the explanation which is now being alleged as manipulation on the part of the Respondents.  The alleged manipulation are nothing but explanation to make things and opinions more clear and does not changed the original notes.  It is submitted that nothing has been deleted from the record which in itself is evident from the medical records placed on record by the complainant.  No tampering has been done by the Respondents and no false documents have been created.  Thereafter a complete set of medical case sheet history of lat O. P. Jain was handed over to Shri S.K. Jain the brother of the complainant.

DMC in its order gave a verdict that the action of doctors of making additions in the medical record, albeit as explanatories, was highly unprofessional of them.  The sanctity of medical records under all circumstances has to be preserved.

However the council said that the additions made to various notes in the medical records do not alter the nature of the notes recorded therein and are explanatory as claimed by the respondents. 

In light of the observations made hereinabove, it is the decision of the Delhi Medical Council that no medical negligence can be attributed on the part of doctors.  However, a warning is issued to Dr. Bharat Kumar Aggarwal (DMC Registration No. 2948), Dr. N.C. Krishnamani (DMC Regn No. 10172) and Sunderlal Jain Hospital for making / permitting additions to be made in the medical records.  

Dr KK Aggarwal

Heavy drinking shrinks brain

Following years of chronic alcohol misuse, alcoholics suffer from alcohol-related dementia due to severe brain damage. Evaluation of postmortem effects of alcohol on the brain has shown atrophy of the brain leading to a classical ?pickled walnut? effect as evident on MRI.

Choose a healthy neighborhood

According to a new study published in October 12 issue of JAMA, people who live in healthy neighborhoods may have a lower risk of developing type 2 diabetes. A team examined 2285 adults aged 45 to 84 years from three neighborhoods. Blood glucose levels were obtained from study participants at baseline and three follow-up examinations. Measures for neighborhood were rated by the suitability of the environment for physical activity i.e. if it was pleasant to walk in their neighborhood including access to healthy foods in the form of large, high-quality fruits, vegetables and other low-fat foods. Scores were calculated on scales of one to five, with five representing the healthiest areas. Better neighborhood resources were associated with a 38% lower incidence of type 2 diabetes.

The diabetes epidemic: India maintains lead

In its annual report, the 20th annual World Diabetes Congress of the International Diabetic Federation (IDF) has warned the diabetic epidemic in India is in the danger of becoming uncontrollable. India has the highest number of diabetic population in the world, 50.8 million followed by China with 43.2 million and USA with 26.8 million. In India, this number is expected to increase to 58.7 million by the year 2010, about 7 % of its adult population. Due to the increasing life expectancy and urbanization, more than 8.4 % of the Indian adult population will suffer from by 2030. Sounding a note of caution to the authorities, the report said that the rural prevalence is higher than in less affluent rural areas in more affluent parts of the country, indicating that increasing economic growth will raise diabetes prevalence in India even more than these possibly conservative estimates have indicated. This not only means squandering away billions in lost productivity but that India would also be spending $2.8 billion every year on diabetes control measures by 2010. The estimated global healthcare expenditures to treat and prevent diabetes and its complications are expected to total at least $376 billion in 2010. The incoming president of IDA, Jean-Claude Mbanya said that the epidemic was getting out of control and if the trend continues unchecked, there will be 435 million people with diabetes worldwide by 2030.

Connection between blood counts and human disease

Genetic variations that are crucial to formation of blood cells have now been discovered, a development that may significantly affect common diseases. Researchers from UK carried out routine blood tests viz. hemoglobin, red and white cell count and platelet counts. They found 22 regions of the human genome implicated in the development of these blood cells, of which 15 were earlier unidentified. The team also said that one of the genetic variants associated with platelet counts increases risk of heart disease. This new variant was in a region of the genome that has been recognized to impact risk of type 1diabetes, high blood pressure and celiac disease. The researchers are hopeful that this characterization of the regions has the potential to improve the understanding of formation of blood cells and how blood cell development is linked with human diseases, including blood cell cancers.

FDA Approves Asacol HD for Moderately Active Ulcerative Colitis

Asacol HD, mesalamine delayed-release tablets from Procter & Gamble Pharmaceuticals, indicated for the treatment of moderately active ulcerative colitis (UC), has been approved by the FDA. The approval was based on evaluations from the ASCEND (Assessing the Safety and Clinical Efficacy of a New Dose of 5-ASA [4.8 g/d, 800 mg tablet]) studies. In six-week clinical studies of patients with moderately active UC flares, Asacol HD at 4.8 g per day helped many patients reduce their UC symptoms, including number of bowel movements and rectal bleeding, for some as early as three weeks. Asacol HD decreased the number of trips to the bathroom (i.e., number of bowel movements) in approximately three out of four of patients by six weeks and decreased rectal bleeding for approximately 80% of patients by six weeks. The recommended dose of Asacol HD for adults is two 800-mg tablets, three times per day, with or without food, for a total daily dose of 4.8 g. Asacol HD is the newest addition to Procter & Gamble?s gastrointestinal product line, which also includes Asacol 400 mg delayed-release tablets, the number one most-prescribed oral 5-ASA therapy, according to information derived from IMS National Prescription Data. If for any reason a patient is dissatisfied with the first course of therapy, Procter & Gamble will refund the receipted cost of the original prescription. Receipted cost includes only the amount actually paid by the patient. Procter & Gamble will not refund costs covered by third-party payers, including Medicaid.
Source: Gastroenterology and Endoscopic News October 2009

FRAX®, a new online tool in osteoporosis management

World Osteoporosis Day was observed on October 20, 2009. To mark the event, the International Osteoporosis Foundation (IOF) issued a new 16-page report on FRAX®. FRAX® or ?WHO Fracture Risk Assessment Tool?, is a free online tool developed by the WHO available at http://www.shef.ac.uk/FRAX/. The FRAX® tool uses many several known clinical risk factors to calculate 10-year fracture probability and helps identification of high-risk individuals who require interventions. It is especially useful in areas where DXA scan is not available. According to John Kanis, President IOF, with this new easy-to-read report, the IOF hopes to bring understanding of FRAX® to a broad audience of health professionals so that it is possible to identify and treat more people at risk of debilitating fractures before these fractures occur. Dr. Eugene McCloskey of the University of Sheffield and author of the IOF report said that clinicians should feel encouraged to make FRAX® a part of their clinical assessment of patients.

Managing Sleep Problems Can Decrease Cancer Pain

Sleep disruptions, depressed mood and pain contribute to fatigue in patients with cancer, according to a new study in the Journal of Clinical Sleep Medicine. Data also suggest that resolving sleep problems should improve pain management in this group. ?It is very common for cancer patients to experience the symptom cluster of depression, pain, insomnia and fatigue, yet it is not well understood how all of these factors interact,? said lead author Edward Stepanski. Responses by 11,445 patients to the Patient Care Monitor, a validated software package for assessing oncology-related symptoms, were analyzed using structural equation modeling techniques. Data were split into two groups, with one set used to develop the model and the other to cross-validate the information. Moderate to strong associations were seen between trouble sleeping and physical pain as well as physical pain and fatigue. Although the relationship between pain and sleep was thought to be reciprocal, a model of reciprocal causation could not be fit to the data. Fatigue ratings increased as trouble sleeping, depressed mood and pain worsened. Although depression acted directly to increase fatigue, there was an indirect impact by worsening pain and trouble sleeping. According to Dr. Stepanski, the study results suggest that if a cancer patient has an abrupt change in pain control, one of the first things to be asked is, ?How are you sleeping? If that has worsened, one must keep in mind that the pain has gotten worse because of the insomnia and not just assume the pain is causing the sleep disturbances. That is important clinically because managing sleep can also help manage the pain.
Source: Clinical Oncology News 2009

H1N1 flu: Initial chest x-rays may be deceptive

A retrospective study has noted that though chest x-rays are quite often normal in patients with H1N1 flu, but it can quickly evolve into extensive, bilateral air-space disease in severely ill patients. The study is published in the Oct. 15 online issue of the American Journal of Roentgenology. The records of 222 patients hospitalized with confirmed H1N1 flu were examined; 66 of whom underwent chest x-ray. Taken as a whole, the initial chest x-rays were normal in 58% of the group. But major differences were noted when the patients were grouped on the basis of severity. These initial images were abnormal in 100% of those who went on to develop severe disease. According to the researchers, in view of the imminent flu season, it is important to know the radiologic features of H1N1, as well as the virus?s likely complications. CT scans were more valuable in identifying those patients at risk of developing more serious complications as a possible result of the H1N1 virus

FDA gives its nod to Berinert to treat acute hereditary angioedema

The US FDA has approved Berinert for the treatment of acute abdominal or facial manifestations of hereditary angioedema in adults and adolescents. Berinert is a plasma-derived concentrate of C1 esterase inhibitor (human). Hereditary angioedema is a genetic disorder due to a deficiency of the C1 inhibitor (C1-INH). Symptoms include episodes of edema (swelling) in the face and the abdomen. Patients who develop intestinal wall swelling may have severe pain, diarrhea, nausea, and vomiting. Hereditary angioedema involving the face can cause painful distortions and swelling. Berinert, a plasma-derived intravenous therapy, is used to treat the primary cause of the disease by providing the human protein to patients who lack C1-INH in their systems. The drug is contraindicated in individuals who have a history of an anaphylactic reaction to C1-INH preparations. Patients should be monitored for early signs of allergic or hypersensitivity reactions. The safety and efficacy of Berinert for prophylactic use has not been established.

This is life
A short history of medicine: Doctor, I have an earache.

2000 B.C. - Here, eat this root.
1000 B.C. - That root is heathen, say this prayer.
1850 A.D. - That prayer is superstition, drink this potion.
1940 A.D. - That potion is snake oil, swallow this pill.
1985 A.D. - That pill is ineffective, take this antibiotic.
2000 A.D. - That antibiotic is artificial. Here, eat this root!

Thought of the Day

You can never cross the ocean unless you have the courage to lose sight of the shore?.  Christopher Columbus

Conference Calender

DFSICON 2009,   8TH Annual National Conference of Diabetic Foot Society of India, November 27-29th, Hotel Lalit New Delhi (www.dfsicondelhi2009.com

Medinews Doctor of the Year Award

IJCP group will starting 10th Jan 2010 this year will award 20 Medinews  Doctor of the Year Award to eminent doctors who have done outstanding work in the year 2009. The award will be distributed during a day long CME: MEDINEWS 2009- Revisiting 2009. This will be a yearly event.  The award will carry a citation, shawl, coconut kalash, scenery and a memento.



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