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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


24th June, Thursday, 2010

Detecting cryoglobulins, clinical bedside lab test

Precipitation of blood proteins at temperatures lower than 37°C is referred to as cryoprecipitation. Two types of cryoprecipitates are recognized. Cryoglobulin (CG) is present when proteins precipitate from an individual’s serum and plasma and cryofibrinogen refers to the precipitate from plasma only.

To detect cryoglobins (CG), 10–20 ml of blood is drawn into syringes and/or collection tubes that have been prewarmed to 37°C without anticoagulants (anticoagulants may cause false positive results by the formation of cryofibrinogen or heparin–precipitable complexes). After clotting at 37°C for one–half to one hour, the serum is separated by centrifugation at 37°C, placed in a graduated (Wintrobe) tube and refrigerated (4°C) to allow the precipitation of CG.

In type I CG, precipitates are often seen within 24 hours (sometimes in less than 90 minutes), but three to five days are usually allowed for complete precipitation, especially for the mixed CGs.

A cryocrit is then determined by measuring the packed (centrifuged) volume of the precipitate as a percentage of the original serum volume at 4°C.

One may also wash the precipitate three to six times in cold saline solution to reduce the possibility of precipitated salts or other proteins. The precipitate is then redissolved in saline at 37°C to confirm the warm solubility of the CGs.

Dr KK Aggarwal
Padma Shri Awardee and Chief Editor

 

Photo Feature (From HCFI file)

Combat with Exam Stress

Children commonly complain of exam stress and the worst part is that exam stress is a vicious cycle. The more stressed they get, the harder it is to prepare for their exams, which makes them more stressed adversely affects their health and fitness. Perceiving a need for generating awareness to tackle exam stress, Heart Care Foundation (HCFI) of India organised an exam stress awareness campaign involving celebrity model Shanaya Tuli & experts - Dr Aroona Broota, clinical psychologist and professor in the Dept. of Psychology, Delhi University and Dr Reshma Aggarwal, Consultant Psychiatrist, G B Pant Hospital.

Dr k k Aggarwal

In the photo: Model Shanaya Tuli, Dr Reshma Aggarwal, Dr Aruna Broota during a press conference in 2008 to create awareness about the exam stress. Also, in the picture: Padma Shri & Dr BC Roy Awardee Dr. K K Aggarwal, President of Heart Care Foundation of India


 

News and views

A1c may not accurately identify diabetes in elderly Asians (Dr Monica & Brahm Vasudeva)

According to research presented at the Endocrine Society’s annual meeting, HbA1c blood test may not accurately identify diabetes among elderly Asians. The American Diabetes Association has endorsed the test as an effective way to diagnose type 2 diabetes, with a cutoff reading of 6.5 % or more to indicate diabetes. But, this cut-off misses many instances of disease, and may result in under diagnosis of diabetes with increasing frequency as Asian patients get older. Compared to a standard oral glucose test that discovered 40 cases of type 2 diabetes, the A1c test was less accurate as the patients’ ages rose, only diagnosing about 55 % of cases among participants over the age of 72.

Association between reduced lung function and type 2 diabetes (Dr Varesh Nagrath)

Restrictive lung function impairment is associated with incident type 2 diabetes and fatal coronary heart disease, partially because of traditional and metabolic risk factors and inflammation, according to the results of a prospective study reported online June 2 in Diabetes Care. Accordind to Dr S. Goya Wannamethee, from University College Medical School in London, the association between impaired lung function and cardiovascular disease morbidity and mortality is well established. Reduced lung function is also one of the many clinical features associated with type 2 diabetes. Diabetes has been shown to be associated with impaired pulmonary function in a restrictive pattern and prospective studies have indicated at the association of reduced lung function and development of type 2 diabetes.

iPod users beware?

Listening to an MP3 player for even an hour can induce short–term hearing loss. Compared with controls, hearing deterioration among MP3 users was 3.97 to 4.40 times more likely when listening to pop/rock music through earbud headphones at different output levels (both P<0.001). Listening to an iPod with overtheear headphones also boosted the odds of a shortterm decline in hearing threshold by 2.18 to 3.87fold. The study was reported by Hannah Keppler, MS, of Ghent University in Ghent, Belgium, and colleagues in the June issue of Archives of Otolaryngology–Head & Neck Surgery.

Need of consultation: if the child has any of these warning signs (Dr G M Singh)

• Changes in behavior
• Constant vomiting or diarrhea
• Dry mouth
• Earache or pulling at ears
• Fever comes and goes over several days
• Highpitched crying
• Irritable
• Not hungry
• Pale
• Seizures
• Severe headache
• Skin rash
• Sore or swollen joints
• Sore throat
• Stiff neck
• Stomach pain
• Swelling of the soft spot on the head
• Unresponsive or limp
• Wheezing or problems breathing
• Whimpering

 

Legal Column

DMC Decision

Do all PNDT Act violations need to come to the DMC?

Yes. As per order DMC/DC/F.14/Comp. 548/2 dated 6th February, 2009, on the subject news item published in Dainik Jagaran dated 5.2.2009 in respect of violation of Preconception and Prenatal Diagnostic Techniques (Prohibition of Sex Selection) Act. The DMC wrote "this is in reference to a news item published in Dainik Jagaran dated 5.2.2009 wherein, it has been alleged that "Dr A" of "A Nursing Home", and "Dr P G of R Nursing Home", have been found to be indulging in activities in violation of the provisions of Pre–conception and Pre–natal Diagnostic Techniques (Prohibition of Sex Selection) Act, 1994. Your attention is also invited to the provision of section 23(2) of PNDT Act, the contents of which are reproduced hereinbelow for your reference:– "The name of the registered medical practitioner shall be reported by the Appropriate Authority to the State Medical Council concerned for taking necessary action including suspension of the registration if the charges are framed by the Court and till the case is disposed of and on conviction for removal of his name from the register of the Council for a period of five years for the first offence and permanently for the subsequent offence." You are, therefore, requested to intimate the Delhi Medical Council the outcome of any proceedings which are likely to be initiated by your office against Dr A and Dr P G, in the Court of law, so that appropriate action may be initiated by Delhi Medical Council."

MCI NEWS

Dr Desai in 14 days’ judicial custody again: gets bail, but held in DA case

A Delhi court on Tuesday granted bail to former MCI president Dr Ketan Desai but he could not be released as the CBI arrested him afresh for allegedly possessing disproportionate assets. Special Judge Rajnish Bhatnagar allowed a plea of Desai to grant him bail as the CBI has failed to file a chargesheet against him within the prescribed limit of 60 days. Within minutes of the court’s order, the CBI arrested Desai in another case registered against him for allegedly possessing disproportionate assets. The CBI had registered the DA case against Desai and his wife and mother in May for having assets worth over Rs 24 crore. The court sent Desai to 14 days’ judicial custody.

Forensic Column (Dr Sudhir Gupta, Asso. Prof, AIIMS)

Legal medicine: Doctor in witness box under oath

When a doctor is called in witness box of Court of Law, Oath has to be administered before he tenders his evidence.

A doctor as witness while administered the oath has to repeat, while standing… ‘the evidences which I shall give to the honorable court shall be the truth, the whole truth and nothing but the truth, so help me the almighty God".

If a Doctor wishes to give his evidences on solemn affirmation, he has to say that I solemnly affirm that the evidences which I shall give to the honorable court shall be the truth, the whole truth and nothing but the truth.The main objective of the oath is to find truthful statement and if any doctor/witness speaks a lie after administration of oath he is liable for punishment of perjury a criminal offence in our country as well as abroad. The Medical opinion of the doctor must be suported by reason/science and it is the reasons and not ipse dixit which is of importance in assesing the merit of the doctor’s opinion in the court of law.

 

Experts’ Views

Interesting tips in Hepatology & Gastroenterology (Dr Neelam Mohan, Consultant Pediatric, Gastroenterologist, Hepatologist, Therapeutic Endoscopist & Liver Transplant Physician Sir Ganga Ram Hospital, Delhi)

Today I shall address the following issues

Stress in Doctors (part 1)

Stress is a potential hazard of medical career. When prolonged & persistent, stress can result in what is known as ‘Burn-out’--- a state of physical, emotional and mental exhaustion caused by long term involvement in situations that are emotionally demanding. Person thus affected, will have symptoms like loss of interest in work, loss of energy, loss of optimism, feeling resentful, hostility to patients & dreading going to work. According to some estimates, the incidence of stress/burnout may be as high as 60% in G.Ps

Besides above mentioned symptoms, stress as we know, can predispose to development of diseases like hypertension, IHD, psychosomatic & mental problems like depression, anxiety and sleep–disorder.

Causes of Stress

The ones related to medical profession are:

  • Increased work load for prolonged periods.

  • Development of unexpected complication in a patient being treated

  • Not living upto the expectation of public/patient

  • Poor working conditions

  • Unfulfilled desires

  • Ego-problem (The ego strength of an average Indian is pretty fragile)

  • Declaring death & making the attendants believe that the patient is no more, perhaps is the most tricky, demanding and emotionally draining event. Most of us, I believe are poorly trained in handling such a situation There are factors, which though not related to medical profession but can’t be ignored. The one who lives in a country which has the dubious distinction of ranking very high in the list of corrupt nations, where virtue mourns & talent cries, principles are thrown to winds by those very persons who publicly pledge to uphold them and rule of law is meant for a select few, a thinking individual has reasons enough to feel stressed. Besides the stress related directly to medical profession, a lot of stress could be generated at the family level. Usually the working hours of doctors are quite prolonged resulting in less time being given to family members. Especially in lady doctors the stress factor could be very high trying to cope with profession and at the same time looking after the family needs.

to be cont tomorrow…

Question of the Day

What a pediatrician can do to prevent overweight and obesity in children? (Dr Swati Bhave & Dr Alok Gupta)

  • Encourage breast feeding in all babies.

  • Encourage healthy eating habits using the food pyramid from early infancy to adolescent age group.

  • Promote physical activity from the toddler age and inculcate importance of exercise.

  • Avoid sedentary habits. Reduce television and video time to a maximum of 2 hours per day.

  • Calculate and plot BMI once a year in all children and adolescents.

  • Start interventional measures if there is any shift in the BMI.

  • Keep a record of yearly blood pressure measurement.

  • Take a detailed history to identify at risk children (family history, birth weight, socioeconomic, environmental factors).

  • Recognize and monitor changes in obesity–associated risk factors for adult chronic disease, such as hypertension, dyslipidemia, hyperinsulinemia, impaired glucose tolerance, and symptoms of obstructive sleep apnea syndrome.

Reference

AAP Recommendations from the prevention of pediatric overweight and obesity, Pediatrics. 2003;112:424–430.

Mental exercise to prevent dementia: (Dr Anupam Sethi Malhotra)

The one sport in which neither the spectators nor the participants know the score or the leader until the contest ends: Boxing.

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Public Forum (Press Release for use by the newspapers)

Fruit juice can be harmful

To prevent diabetes, women should eat more of green leafy vegetables and whole fruits, and stay away from fruit juices said Padma Shri and Dr B C Roy National Awardee Dr KK Aggarwal, President Heart Care Foundation of India.

Eating an additional three servings of whole fruit daily, or one more serving of spinach, kale or similar leafy green vegetables was tied to a lower risk of developing diabetes over an 18year period among 71,346 women enrolled in the Nurses’ Health Study.

Dr Lydia A. Bazzano of Tulane University School of Public Health and Tropical Medicine, New Orleans analyzed data on the diets of Nurses’ Health Study participants –– 4,529 of whom developed type 2 diabetes while they were being followed. They divided women into five groups based on fruit and vegetable intake, and also grouped them on the basis of fruit juice consumption.

They found that an increase of three servings a day of whole fruit was associated with an 18 percent lower risk of type 2 diabetes, while a single additional serving of leafy green vegetables cut the risk by 9 percent. However, an additional daily serving of fruit juice increased the likelihood of developing diabetes by 18 percent.

Juice is a big sugar load and it comes in a liquid form which is absorbed rapidly. Caution should be observed in replacing some beverages with fruit juices in an effort to provide healthier options. A 100 percent fruit juice cannot be considered a serving of fruit.

 

Public Column (Readers’ column)

Recovering fom Mononucleosis (Dr G M Singh)

Once you have the virus, how you can help yourself recover:

  • Get lots of rest.

  • Drink enough fluids to ward off dehydration.

  • Soothe a sore throat with salt water gargles, throat lozenges and soothing treats, such as hard candy or a Popsicle.

  • Take acetaminophen to ease pain and bring down a fever. If your child under age 12 is ill, do NOT give him or her aspirin.
 

IJCP Special

Dr Good Dr Bad

Situation: A patient came with non-responding cough.
Dr. Bad: It may be TB.
Dr. Good: Rule out acidity.
Lesson: Chronic cough along with dysphonia/hoarseness, globus pharyngeus, mild dysphagia, chronic cough and nonproductive throat clearing are often important otoaryngologic manifestations of occult or silent GERD. (Laryngoscope 1991;101:1)

Make Sure

Situation: A-28-year old male presents with increased frequency and occasional blood in urine. Examination of urine shows sterile pyuria.
Reaction: Oh my God! Why didn’t you check for TB?
Lesson: Make Sure to rule out TB in patients with frequency, dysuria, hematuria. Sterile pyuria is the first clue to diagnosis.

Mistakes in Clinical practice

Do not write ‘QD’ (for every day): it can be mistaken for “QID” if there is period after Q.

Milestones in Diabetes

Stephen Hales (1677-1761), an English clergyman and physiologist was the first to determine arterial blood pressure in 1727.

Mnemonic of the Day (Dr Varesh Nagrath)

False negative Montoux Test - CLOWN SCAM

Corticosteroids
Live Virus vaccination (measles or smallpox vaccine, can interfere with a TB skin test).
Overwhelming TB infection like Miliary Tuberculosis
Wrong technique (Subcutaneous instead on intradermal).
New/Recent TB infection

Mx becomes positive 8-10 week later. If your doctor suspects that you've been tested too soon, you may need to repeat the test in a few months.

S
arcoidosis
Chemotherapy
AIDS /HIV/ Lymphoma
Measles/Mumps

eMedinewS try this it works

Colic from overfeeding

Babies are often overfed. Thinking that the baby is crying because of hunger, a parent typically offers more milk. The baby also swallows air while crying, making the discomfort even worse. Think of overfeeding and air swallowing when a baby cries after feeding, spits up repeatedly, or gains weight rapidly. The first step is to cut down on the feed.

 

International Medical Science Academy Update:

An International Expert Committee issued a consensus report in June, 2009, recommending that a A1C level =6.5 percent be used to diagnose diabetes (International Expert Committee report on the role of the A1C assay in the diagnosis of diabetes. Diabetes Care 2009; 32:1327), and the American Diabetes Association affirmed this decision (Diagnosis and classification of diabetes mellitus. Diabetes Care 2010; 33 Suppl 1:S62).

Drug Update

List of Approved drugs from 1.01.2009 to 31.10.2009

Drug Name

Indication

DCI Approval Date

Zolmitriptan...5.0% w/v Benzalkonium Chloride NF ... 0.01% w/v Nasal spray

For the acute treatment of migraine with or without aura in adults.

29.05.09

Medifinance

Personal Accident Individual Insurance

Built-in Features
• Repatriation of remains.
• Medical expenses.
• Education grant (if family option is chosen).

Lab Medicine

Lab Test (Dr Arpan Gandhi and Dr Navin Dang)

Multiple myeloma (MM)

MM may first be detected during routine wellness testing, showing up as an abnormal total protein level, an elevated calcium level, a low white or red blood cell count, and/or moderate to large amounts of protein in the urine.

Tests used as a follow-up to abnormal routine tests and to help diagnose the disease may include one or more of the following: Protein and Immunofixation Electrophoresis. These tests are used to diagnose and monitor multiple myeloma.

Bence Jones protein (free light chains) can be detected in the urine of some patients with multiple myeloma. The sample tested is usually a 24-hour urine because the total amount of Bence Jones protein in 24 hours is related to the amount of tumor that is present. Either the kappa or lambda light chains (but not both in the same patient) may be measured to help diagnose multiple myeloma and monitor the effectiveness of treatment.

Other tests like Serum free light chains (FLC), Quantitative Immunoglobulins. The multiple myeloma protein will be an IgG, IgA or, rarely, an IgD or IgE immunoglobulin.

 

Humor Section

IMANDB Joke of the Day: Lawyers vs charted accountants

7 Lawyers and 7 Charted Accountants are traveling from PUNE to Mumbai.

So both groups gather at Pune Station. Both groups are desperately trying to prove their superiority.

Scene 1 (Pune-Mumbai)

7 Lawyers take only 1 Ticket and 7 Charted Accountants buy all 7 tickets. Charted Accountants are desperately waiting for TC to come........When TC arrives, all 7 Lawyers get in one toilet so when TC knocks, one hand come out with the ticket and the TC goes Away....
NOW on return Journey All of them don't get a direct Train to PUNE. So they all decide to take a Passenger till Lonavala, from there they can easily get a LOCAL to PUNE.

Scene 2 (Mumbai-Lonavala)

Charted Accountants decided, "this time we will prove that we too are equal"..... All 7 Charted Accountants take 1 Ticket Lawyers don't buy any ticket at all !!!!!..
The TC arrives......
ALL CHARTED ACCOUNTANTS IN ONE TOILET. ALL LAWYERS IN THE OPPOSITE. One Lawyer gets out and knocks the door of Charted Accountants toilet, one hand comes with the tickets, he takes the ticket and comes in Lawyer’s Eng. Bathroom...!

TC DRIVES out ALL the Charted Accountants from the toilet and they are heavily fined.

Scene 3 (Lonavala)

So now both the group are on LONAVALA station. Charted Accountants planning their move for last chance, they board the local to Pune. This time Charted Accountants decide that they will play the same (1 ticket) trick.
ALL Charted Accountants take 1 ticket…
Lawyers BUY all 7 tickets this time…
The TC arrives. All Lawyers showed their tickets ……………………

Charted Accountants are still searching for toilet in the LOCAL train……………………!!!

Conclusion: Don’t mess with Lawyers.

Funny Definitions

Catscan…………Searching for Kitty

Medical bloopers on medical charts!

Exam of genitalia reveals that he is circus sized.

 

Alloveda

SMS of the Day

Always ask God to give what you deserve and not what you desire because your desires may be few but you deserve a lot.

Quote of the day (Anupam Sethi Malhotra)

Expecting the world to treat you fairly because you are nice is like expecting the lion not to attack you because you are vegetarian.

The Ten Traits of the True Spiritual Warrior (Guy Finley) 2/7

The true spiritual warrior starts life over, over and over again.

Conference Calendar

Trauma Evaluation And Management - Advanced (TEAM – A)
Target Audience – Doctors Only –
Date: June 30, 2010
Venue: V Block, No: 70 (Old No: 89) Fifth Avenue Anna Nagar, Chennai, Tamil Nadu.

Contact Person: Mrs Lucy Nadhan, Chennai
Phone: +91–44–42026644, +91–44–42026655; Fax: 91–44–42026655

 

Readers Responses

Respected Sir, Thanks for including my query in emedinews and giving your expert comments for this case of Pulmonary Koch's. Dr Manoj Saini

 

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