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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


25th May, 2010, Tuesday

Preparing for Commonwealth Games illnesses

Dear Colleague

Over one lakh people are likely to visit during the month of October to attend and participate in Commonwealth Games.

During his visit to India during Commonwealth Games, a foreigner is likely to suffer from one of the four diseases: Acute diarrhea, acute systemic febrile illness without localizing findings, skin disorders and non–diarrheal GI disorders.

Out of 100 travelers falling sick 33% will fall sick, because of fever, 40% due to acute diarrhea and the rest due to other two illnesses.

It has been estimated that out of 100 patients presenting with acute systemic febrile illness, 32 will suffer from dengue, 13 from malaria, 3 from typhoid, 5 from viral disorders and rest 45 may have no demonstrable cause. Out of 100 people developing diarrhea, 60 would be due to E. coli bacteria.

The most commonly encountered skin diseases would be insect bites, animal bites, allergic rash or reaction.

Among 100 patients suffering from non-diarrheal GI illness, 59% will be related to worm infestation, 18% to acid peptic disease and remaining to jaundice, piles or constipation.

In today’s issue, we will talk about other diseases with special reference to Typhoid.

Salient features about Typhoid

  1. Typhoid is a severe systemic illness.

  2. It presents with SUSTAINED fever with abdominal or respiratory symptoms.

  3. Abdominal symptoms usually appear in the second week; the first week is characterized by rise in fever. Liver and spleen usually becomes palpable in third week.

  4. If not treated, 15% would die. Even with treatment, the mortality is 1.5%.

  5. Blood cultures becomes positive in 40–80% cases. Blood culture should be taken as early as possible during the illness using blood or clot or bone marrow.

  6. Low hemoglobin in a patient with fever may signify typhoid or malaria.

  7. About 86% of patients with typhoid will have high SGOT and SGPT.

  8. Patients may have features suggestive of acute hepatitis (Typhoid hepatitis). In acute viral hepatitis, jaundice appears when fever disappears. Whereas, in typhoid, jaundice and fever persist together. In typhoid, fever is often more than 40°C with high SGOT/ SGPT levels, which are usually lower than 400.

  9. Multi–drug resistance cases of typhoid are on the rise. In one study, 26% of MDR cases were resistant to five drugs.

  10. Drugs like ofloxacin should be reserved as anti–TB drugs and not used for typhoid.

  11. The drug of choice for typhoid is either one or two of the three - ciprofloxacin, ceftraxione / cefixime and/or azithromycin.
     
  12. The drugs that are highly effective, as they have good penetration inside cells, are ciprofloxacin or azithromycin.

  13. Norfloxacin is poorly absorbable and not to be used.

  14. Resistance to azithromycin is not reported so far.

  15. If the blood culture is positive and all drugs are sensitive, then ciprofloxacin should always be given.

  16. If the culture report is not available and one is not sure about drug sensitivity then azithromycin should always be used.

  17. When two drugs need to be given, one of them should be ceftriaxone / cefixime.

  18. In routine clinical practice in the private sector, it is better to use two drugs than a single anti–typhoid medicine.

  19. The regimes, therefore, are ciprofloxacin with ceftriaxone / cefixime or ceftriaxone / cefixime with azithromycin.

  20. The standard approach is that for any febrile illness one should give antibiotics minimum for three days after the fever subsides and for at least 7 days after fever subsides in cases of severe illness or resistance cases or relapse.

  21. The usual clinical practice is to give two antibiotics, one of them for 14 days and the other for 7–10 days. Azythromycin is given 1 g on Day 1 and 500 mg daily for 10 days. One can also give 1 g daily for five days.

  22. Ceftriaxone is given 2 g morning and evening or 2 g morning and 1 g evening for 14 days. On the 7th day, one may substitute it with oral cefixime 200 mg twice daily.

  23. If cefixime is the initial drug selected for treatment, it should be given in doses of 200 mg twice daily for 14 days.

  24. Ciprofloxacin should be given 750 mg twice daily for 14 days.

  25. If the regime is ciprofloxacin and cefixime, then ciprofloxacin can be given 14 days and cefixime for 10 days.

  26. If the patient is toxic or has high persistent fever, not responding to paracetamol, one may give 8–16 mg of IV dexamethasone daily for 24 to 48 hours.

  27. About 1–6% of typhoid fever cases will relapse 2-3 weeks after the fever resolves. The treatment is to give medications to which the bacteria is sensitive for a longer duration of time.

  28. Presence of the organism in stool 12 months after the illness is called chronic carrier state. The treatment of choice is ciprofloxacin 750 mg twice a day for 4 weeks.

  29. In typhoid, after sublingual nimesulide, fever may rapidly fall and even go below normal.

    (Excerpts from IMSA CME organised on Sunday at Moolchand Medcity)

Dr KK Aggarwal
Padma Shri Awardee and Chief Editor

 

Photo Feature (From file)

Educating the Society

Lack of knowledge and myths are prevalent in the society. Heart Care Foundation of India has taken several steps towards societal orientation to overcome this situation. HCFI has regularily released health information in the form of small messages to educate the society. In the photo, Film actress Ms Meghna Kothari is seen releasing a health message. Also in the picture are Dr KK Aggarwal, President HCFI.

Dr k k Aggarwal

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

Changes in UpToDate recommendations for cervical cancer screening

Chest radiography in ICU patients on mechanical ventilation It is not necessary to perform routine daily chest radiographs on mechanically ventilated ICU patients; chest x–rays in ventilated patients can reasonably be ordered on an as–needed basis. (DHHS Panel on Antiretroviral Guidelines for Adults and Adolescents. Guidelines for the use of antiretroviral agents in HIV–1 infected adults and adolescents. www.AIDSinfo nih.gov. (Accessed on December 1, 2009).

 

Mnemonics of the Day (Dr Varesh Nagrath M.D.)

Indications of Anti–hyperuricemic therapy
National Transport Research Center (NTRC)

  • Nephrolithiasis
  • Tophi
  • Recurrent Gout
  • Chronic Gout

News and Views

CRT may worsen heart failure in some (Medpage)

A study reports that cardiac resynchronization therapy (CRT) may in fact worsen heart failure in at least one in five patients, and frequent optimization of device programming does little to solve the problem. Regardless of the strategy used to set the CRT device parameters, whether it was frequent changes using the QuickOpt algorithm or empiric or one–time changes (67.52% versus 67.51%, P=0.5), heart failure clinical composite scores improved in most patients, reported William T. Abraham, MD, of Ohio State University, in Columbus, and colleagues. But 23.16% of patients in the randomized controlled FREEDOM trial saw a worsening in clinical composite score after implantation even with the frequent device optimization strategy.

FDA News (Dr Kamlesh Kanodia) : Recommendations for Rotavirus vaccines

The U.S. FDA revised its recommendations for rotavirus vaccines for the prevention of the disease in infants and has determined that clinicians and healthcare professionals can resume the use of Rotarix and continue the use of RotaTeq. This decision came after a careful evaluation of information from laboratory results from the manufacturers of the vaccine and the FDAs own laboratories, a meticulous review of the scientific literature, and input from scientific and public health experts, including members of the FDAs Vaccines and Related Biological Products Advisory Committee that convened on May 7, 2010 to discuss these vaccines. The FDA also considered the following in its decision:

  • Both vaccines have strong safety records, including clinical trials  involving tens of thousands of patients as well as clinical experience with millions of vaccine recipients.

  • The FDA has no evidence that PCV1 or PCV2 pose a safety risk in humans, and neither is known to cause infection or illness in humans.

  • The vaccine offers considerable benefits, which include prevention of death in some parts of the world and hospitalization for severe rotavirus disease in the United States. These benefits outweigh the risk, which is theoretical.

Preventing sudden cardiac death in athletes

Every year about 90 young U.S. athletes suffer sudden cardiac death (SCD). The International Olympic Committee and other organizations recommend ECG screening for athletes. Researchers explored this proposal for U.S. high school and college athletes in two studies.

  1. Researchers looked for one–time screening of student athletes for known SCD risk factors (e.g., prolonged QT interval, left ventricular hypertrophy) in a decision analysis. History and physical examination alone saved 0.56 life–years per 1000 athletes screened. Adding ECG to these saved extra 2.1 life–years per 1000 athletes screened. ECG alone was more cost–effective than history and physical examination alone.

  2. The second study involved 510 Harvard University athletes who were screened with history and physical examination, ECG, and transthoracic echocardiography (TTE), which is the gold standard. Clinicians who performed ECG and TTE were blinded to results of history and physical examination and vice versa. Of 11 TTE findings considered to be significant, 5 were identified by history and physical examination alone, and 5 were detected by ECG alone; of 3 TTE findings that resulted in restriction from sports participation, 1 was identified by history and physical examination alone, and 2 were detected by ECG alone. However, 78 athletes (15%) exhibited abnormalities on ECG that were false–positives and did not result in restriction from sports; many of these "abnormalities" (e.g., increased QRS voltage) represented physiologic remodeling.

Medilaw

Avoiding malpractice risks in the patient handoff (forwarded by Drs Monica and Brahm Vasudeva)

Handoff is the transition when patients are transferred from one doctor to another, or from an outpatient setting to a hospital or nursing home. This has been often described as "Achilles’ heel" and "time bomb". Problems with handoff communication are one of the root causes in up to 70% of adverse sentinel events compiled by the Joint Commission. The probability of something going wrong viz. needed follow–up care that slips through the cracks or critical information that is not communicated in a timely manner can have life or death impact for the patients. It is also an important reason of malpractice lawsuits against health professionals. It is the responsibility of the treating physician to ensure that the covering physician is up to the mark regarding the patients’ needs, each time he or she falls ill or is going on a vacation. Every referral to a specialist also carries similar responsibility. The Joint Commission in 2006 added a requirement that hospitals seeking accreditation standardize their approaches to handoff communication as part of its patient safety goals. Several studies have often shown all sides to fail to relay timely crucial information to colleagues. Medical schools rarely teach about what constitutes an effective handoff. A 2005 study in Academic Medicine reported that only 8% of schools talk about handoffs in a formal didactic session.

Reference

1. Mark E. Crane. Avoiding malpractice risks in the patient handoff. Medscape Business of Medicine

Quote of the day (Sent by Dr R K Tuli)

A Short Column in The New York Times…

There lies the strength of India…
I love my India
"When we were young kids growing up in America , we were told to eat our vegetables at dinner and not leave them.
Mothers said, think of the starving children in India and finish the dinner.’

And now I tell my children:
"Finish your homework. Think of the children in India Who would make you starve, if you don't."
(Thomas L Friedman)

Question of the Day

Who is at risk for giardiasis and what are its signs and symptoms?

Giardiasis is one of the causes of "travelers diarrhea". The most common manifestations of giardiasis are diarrhea and abdominal pain, particularly cramping; however, diarrhea is not invariable and occurs in 60% to 90% of patients. Other common manifestations include bloating, nausea with or without vomiting, malaise, and fatigue. Fever is unusual. The severity of the symptoms may vary greatly from mild or no symptoms to severe symptoms. Stools may be foul smelling when the Giardia interferes with the absorption of fat from the intestine (malabsorption). The illness or the malabsorption may cause loss of weight. Symptoms and signs of giardiasis do not begin for at least seven days following infection, but can occur as long as three or more weeks later. In most patients, the illness is self–limiting and lasts 2–4 weeks. In many patients who are not treated, however, infection can last for several months to years with continuing symptoms.

Evidence–Based Medicine

Long-term treatment with metformin in patients with type 2 diabetes and risk of vitamin B–12 deficiency (Dr NP Singh (Nanu), Professor of Medicine, Maulana Azad Medical College and Associated Lok Nayak Hospital)

Objectives To study the effects of metformin on the incidence of vitamin B–12 deficiency (<150 pmol /l), low concentrations of vitamin B–12 (150–220 pmol/ l), and folate and homocysteine concentrations in patients with type 2 diabetes receiving treatment with insulin.
Design Multicentre randomised placebo controlled trial.
Setting Outpatient clinics of three non–academic hospitals in the Netherlands.
Participants 390 patients with type 2 diabetes receiving treatment with insulin.
Intervention 850 mg metformin or placebo three times a day for 4.3 years.
Main outcome measures
Percentage change in vitamin B–12, folate, and homocysteine concentrations from baseline at4, 17, 30, 43, and 52 months.
Results
Compared with placebo, metformin treatment was associated with a mean decrease in vitamin B–12 concentration of –19% (95% confidence interval –24% to –14%; P<0.001) and in folate concentration of –5% (95% CI –10% to –0.4%; P=0.033), and an increase in homocysteine concentration of 5% (95% CI –1% to 11%; P=0.091). After adjustment for body mass index and smoking, no significant effect of metformin on folate concentrations was found. The absolute risk of vitamin B–12 deficiency (<150 pmol/l) at study end was 7.2 percentage points higher in the metformin group than in the placebo group (95% CI 2.3 to 12.1; P=0.004), with a number needed to harm of 13.8 per 4.3 years (95% CI 43.5 to 8.3). The absolute risk of low vitamin B–12 concentration (150–220 pmol/l) at study end was 11.2 percentage points higher in the metformin group (95% CI 4.6 to 17.9; P=0.001), with a number needed to harm of 8.9 per 4.3 years (95% CI 21.7 to 5.6). Patients with vitamin B–12 deficiency at study end had a mean homocysteine level of 23.7 µmol/l (95% CI 18.8 to 30.0 µmol/l), compared with a mean homocysteine level of 18.1 µmol/l (95% CI 16.7 to 19.6 µmol/l; P=0.003) for patients with a low vitamin B–12 concentration and 14.9 µmol/l (95% CI 14.3 to 15.5 µmol/l; P<0.001 compared with vitamin B–12 deficiency; P=0.005 compared with low vitamin B–12) for patients with a normal vitamin B–12 concentration (>220 pmol/l).
Conclusions Long term treatment with metformin increases the risk of vitamin B–12 deficiency, which results in raised homocysteine concentrations. Vitamin B–12 deficiency is preventable; therefore, our findings suggest that regular measurement of vitamin B–12 concentrations during long term metformin treatment should be strongly considered.
Comments This study adds long–term data on link between metformin and vitamin B12 deficiency. Not only do patients receiving metformin face declines in vitamin B12 levels, but these declines increase with length of treatment, according to a study in BMJ.

Nearly 400 adults taking insulin for type 2 diabetes were randomized to receive metformin (850 mg, three times daily) or placebo for roughly 4.5 years. As previously reported, metformin was associated with a significant (19%) drop in vitamin B12 concentrations and a significantly greater risk for B12 deficiency. The new finding, according to the authors, is that the effect of metformin on B12 concentrations was persistent and increased with time.
The authors, noting that metformin is believed to cause malabsorption of B12, say their results "provide a strong case for routine assessment of vitamin B–12 levels during long term treatment with metformin." An editorialist, however, points out that there's "no evidence" that patients will benefit from such monitoring.

Reference

1. de Jager J, Kooy A, Lehert P, et al. Long-term treatment with metformin in patients with type 2 diabetes and risk of vitamin B–12 deficiency: randomized, placebo controlled trial. BMJ 2010 May 20;340:c2181.

Liver Fact

An SGOT/SGPT ratio of more than 2 suggests alcoholic liver disease.

World No Tobacco Day 31st May

Hinduism: Tobacco is traditionally considered in Hindu teaching as Vyasna – a dependence unnecessary for the preservation of health.

eMedinewS Try this it Works

Stretch to quell the cramps

Over–the–counter quinine may alleviate these symptoms, but it has many side effects, including tinnitus. Leg stretching exercises before bedtime alleviate painful legs cramps as effectively or more effectively than quinine––with no untoward side effects.

Dr Good Dr Bad

Situation: A patient on repaglinide wanted to skip a meal.
Dr Good: Skip the repaglinide dose.
Dr Bad: Continue the drug.
Lesson: The recommended starting dose of repaglinide is 0.5 mg before each meal for patients who have not previously taken oral hypoglycemic drugs. The maximum dose is 4 mg before each meal; the dose should be skipped if the meal is missed. (Cochrane Database Syst Rev 2007:CD004654.)

Make Sure

Situation: A patient on contact lens with keratitis developed severe infection.
Reaction: Oh my God! Why was he not treated intensively?
Lasson: 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.

IMANDB Joke of the Day (Dr Ahmed Qureshi)

A Sardar, a German and a Pakistani got arrested consuming alcohol which is a severe offense in Saudi Arabia, so for the terrible crime they are all sentenced 20 lashes each of the whip.
As they were preparing for their punishment, the Sheik announced: "It’s my first wife’s birthday today, and she has asked me to allow each of you one wish before your whipping."
The German was first in line; he thought for a while and then said:
"Please tie a pillow to my back."
This was done, but the pillow only lasted 10 lashes & the German had to be carried away bleeding and crying with pain.
The Pakistani was next up. After watching the German in horror he said smugly: "Please fix two pillows to my back."
But even two pillows could only take 15 lashes & the Pakistani was also led away whimpering loudly. The Sardar was the last one up, but before he could say anything, the Sheikh turned to him and said: "You are from a most beautiful part of the world and your culture is one of the finest in the world. For this, you may have two wishes!"
"Thank you, your Most Royal and Merciful highness," Sardar replied.
"In recognition of your kindness, my first wish is that you give me not 20, but 100 lashes." "Not only are you an honorable, handsome and powerful man, you are also very brave." The Sheik said with an admiring look on his face.
"If 100 lashes is what you desire, then so be it." And what is your second wish?" the Sheik asked. Sardar smiled and said, "Tie the Pakistani to my back" !!!
"SINGH IS KING"

Pearls for Practice

A review suggested that newer antidepressants are relatively similar in regard to their efficacy in treating major depression, although the body of original research into this subject is limited. In the current review, sertraline is the most recommended newer antidepressant for the acute management of depression.

Formulae in clinical practice

Capillary Oxygen Content (CcapO2)

Formula: CcapO2 = (1.39 × ScapO2 × Hb) + (0.0031 × PapO2) ScapO2

percentage saturation of oxygen in capillary blood.
Comment: ScapO2 is assumed to be 1.
Normal values are 21 ml O2 per 100 ml of blood.

Milestones in Dermatology

Metastatic Melanoma

John Hunter is reported to be the first to operate on metastatic melanoma in 1787. Although not knowing precisely what it was, he described it as a "cancerous fungous excrescence". The excised tumor was preserved in the Hunterian Museum of the Royal College of Surgeons of England. It was not until 1968 that microscopic examination of the specimen revealed it to be an example of metastatic melanoma.

Lab Test (Dr Arpan Gandhi and Dr Navin Dang)

Plasma Free Metanephrine

To help diagnose or rule out a pheochromocytoma.
Related tests: Catecholamines, Plasma and Urine; Urine Metanephrines; Vanillylmandelic acid (VMA).

List of Approved drugs from 1.01.2009 to 31.10.2009

Drug Name

Indication

DCI Approval Date

Calcipotriol Gel 0.005% (additional dosage form)

For the treatment of moderate plaque psoriasis in adults

3.10.2009

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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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Public Forum (Press Release for use by the newspapers)

Thyroiditis on the Rise

Thyroiditis is on the rise in the society as more number of cases are occurring every year, said Padma Shri and Dr B C Roy National Awardee Dr KK Aggarwal, President Heart Care Foundation of India. He said that thyroidits can be autoimmune or viral in origin. Thyroiditis is the inflammation of the thyroid.

Most patients clinically present with symptoms suggestive of hyper functioning of the thyroid. But these patients should not be put on thyroid lowering drugs as the disease is self-limiting and recover within three to six months.

All patients who are clinically diagnosed as hyperfunctioning of the thyroid should undergo radioactive uptake scan to differentiate between hyper functioning of the thyroid (a condition called thyrotoxicosis) and thyroiditis.

The disease is more common in young and in women.

The patient may have enlarged thyroid gland which may be tender. Thyroid antibodies may be positive in such cases.

Many cases may have silent thyroiditis which is usually common in young women following pregnancy. Eighty percent of patients with silent thyroiditis show complete recovery and return to normal after three months. A few patients with thyroiditis may end up with hypofunctioning thyroid requiring treatment.

The symptoms of hyperfunctioning of the thyroid are weight loss, weakness, exertion, palpitation and menstrual irregularities.

MCI Update

CBI approached the high court today for the custody of Dr Desai in the new case they have file involving disproportionate assets. However the police custody was denied and the court gave permission for him to be interrogated in the jail. The matter will come again for hearing on 3rd June.

Know your new chairman of MCI Dr S.K. Sarin

Dr Shiv Kumar Sarin obtained his MBBS degree with seven gold medals (1974), his MD in General Medicine (1978) from Rajasthan University, and his DM in Gastroenterology from the AIIMS in 1981. He moved to the G.B. Pant Hospital of Delhi University in 1983, becoming the Head of Gastroenterology in 1997.

He is currently the Director Professor of Gastroenterology, at the G B Pant Hospital, affiliated to the Maulana Azad Medical College and the University of Delhi. He is also the Director of Institute of Liver and biliary sciences.
Dr Sarin is a Gastroenterologist, with special interest in Liver diseases. He has built the department of Gastroenterology along with his other colleagues at the G B Pant hospital. His main thrust has been on providing first rate clinical diagnosis and management to patients with liver diseases. He has been able to bring several innovative techniques and treatment protocols in the country and evn in the world.

In particular, he focused on the pathogenesis and management of bleeding in liver diseases due to high liver pressure and hepatitis B and C. His classification of gastric varices, 'Sarin's classification', identification of a new disease entity, 'portal biliopathy', is widely recognized. He introduced the novel concept of endoscopic variceal band ligation as the primary prophylactic treatment for variceal bleeding, - which with in 7 years of its publication in the New England Journal of Medicine has achieved a global consensus and has dramatically improved the management of liver patients. His work with hepatitis B virus-infected patients and its prevention is well cited in the country. It has helped thousands of patients and their relatives.

Dr. Sarin contributed significantly by bringing out several very special books; "Hepatitis B in India, problems and prevention", "Transfusion Associated Hepatitis" and Hepatitis B and C: carrier to cancer" and hepatitis C Virus Infection in 1996, 1998, 2001 and 2002. The book on 'Hepatitis B in India: Prevention and Management' published in 2004 is the most comprehensive treatise on the subject from India. The latest book on 'Post-graduate clinics in Hepatology' is a superb update on the subject. These comprehensive texts not only provide detailed information about the work on hepatitis from India, but have become standard reference books both in Asia and the west.

His work and concepts have been given due recognition and support at the various International forums, International Journals, International Text Books on Liver diseases (such as Leon Schiff and Zakim & Boyer), Year Book of Medicine, Medical Clinics of North America, Seminars in Liver Diseases and Clinics in Liver Diseases.

Dr. Sarin has published his results in prestigious international scientific journals, and his findings are widely quoted in text books of medicine, gastroenterology and liver diseases. He has published over 200 original articles in international journals. Due to his deep interest in basic science and research he was also appointed as Adjunct Professor in Molecular Medicine at the Special Centre for 2003.

Dr. Sarin was instrumental in getting universal hepatitis B vaccination introduced in the State of Delhi and Sikkim.

One of his biggest contributions was to create public awareness about hepatitis. He launched the 'Yellow Ribbon Campaign' by initiating 'Hepatitis Awareness Day' on December 4 in 1998. This led to a public movement and helped the cause of prevention of all hepatitis. The Govt. of Delhi, for the past 7 years, is celebrating this day and besides all hospitals, a large number of schools and colleges also observe this day. People round the country now get the message and follow him in this regard.

Dr Sarin is the recipient of several awards, the important ones being: Silver Jubilee Research Award of the Medical Council of India, 2005, Dr.Yellapragada Subba Row Memorial Award by Indian National Science Academy, 2005, Federation of Indian Chambers and Industry, R & D in Life Sciences and Biotecnology 2005, Fellowship of the Indian Academy of Sciences, 2005, Fellowship of the National Academy of Medical Sciences (India) 2005, Third World Academy of Sciences (TWAS) award in Medical Sciences, Egypt 2004, Dr. V.R. Khanolkar Oration by National Academy of Medical Sciences, 2004, 'Netaji Oration" of the Association of Physicians of India, the highest Oration Award, 2003, Nominated as a Fellow of the National Academy of Science (FNA), 2003, Gifted Teacher Award - Association of Physicians of India, 1999, Parke - Davis Oration Award Indian Society of Gastroenterology (ISG), 1999, Shanti Swaroop Bhatnagar award: highest award in Science in India:1996, Ranbaxy Research Science Award in Medical Sciences, 1994, Fogarty Fellowship of the National Institute of Health, USA,1988, Japanese Research Science Award , 1986.

Dr Sarin has also served on various national and Committees. He has been the Past President Asian Pacific Association for Study of the Liver (APASL), Past President, Indian Society of Gastroenterology (ISG), Past president , Indian Association for the Study of the Liver (INASL), Member Central Health Council of Govt. of India, Councilor, International Association for the study of the Liver.

 

Readers Responses

  1. Dear Dr K K Agarwal: I am Dr Ajay Raj Kamra, Medical Superintendent ESI Hospital Baddi Himachal Pradesh. I presently have my camp office in Delhi. I am from 1970 batch of MGIMS Sewagram. I would like to know whether a patient or his attendant can seek all the medical records including Nurses report card photocopy from any Govt or pvt Hospital in Delhi. And if so what is the procedure for seeking these records. Are there any guidelines from Delhi Medical Council for this purpose. Also if a hospital fails to give these on the request how can DMC help the attendants? Thanks: Dr Ajay Raj karma
    eMedinewS Responds: Thanks, yes the hospital is bound to give the reports within 3 days. Patients can even ask for the originals. On many occasions, the DMC has taken action against the MDs for not giving the records. Kk

  2. Dear KK I am one of the of silent admirer of ur work. u r a true genieus nd ur work in the field of medicine has helped lacks of peoples,i have been reading u r bulletion regularly and go thru all the contents, they r really good nd i take an oppertunity to suggest all medicos as well as non medicos to go thru it regularly. Thanks Dr. M.S. Bhoj. MGM Medical College, Indore, Delhi

  3. Dear Dr Agrawal: As published in Indian Pediatrics May 2010; Volume 47: Number 5, US approves a 4-Dose Schedule against rabies. The five-dose schedule for post exposure prophylaxis (PEP) against rabies is the standard practice. In view of severe shortage of human rabies vaccine in the year 2007, an ad hoc National Rabies Working Group was created in the United States (US) to reassess the need for all five doses. Advisory Committee on Immunization Practices (ACIP) Rabies Workgroup has now published updated recommendations regarding the use of a 4-dose vaccination regimen in previously unvaccinated persons for rabies PEP.

    According to these recommendations, 1 mL dose of HDCV or PCECV should be given intramuscularly on day 0, 3, 7, and 14 for rabies PEP in previously unimmunized persons. Recommendations for the use of rabies immunoglobulin (RIG) remain unchanged. For previously vaccinated persons, the two dose (day 0 and 3) schedule, and for persons with altered immunocompetence, the five-dose schedule stands unchanged. Schedule for pre-exposure prophylaxis also continues to be same (3 doses on days 0, 7, and 21 or 28).

    What was the evidence based on which they shortened the schedule? In 12 published rabies vaccination studies during 1976-2008 representing approximately 1000 human subjects, all developed rabies virus-neutralizing antibodies by fourteenth day. A series of 21 fatal human cases, in which patients received some form of PEP, indicated that 20 patients developed signs of illness, and most died before day 28 of exposure. Such cases in which widespread infection of the central nervous system occurs before the stipulated fifth dose of vaccine, the utility of last dose is anyway negligible. Data from 192 rabies cases from two centers in India demonstrated that all deaths could be attributed to failure to seek timely and appropriate PEP, and none could be attributed to a failure to receive the fifth (day 28) dose. The ACIP Rabies Working Group estimated that more than 1000 persons annually in the US receive only 3 or 4 doses of PEP, with no resulting documented cases of human rabies. (MMWR, March 19, 2010 / 59(02);1-9) Thanks and Regards: Dr K K Kanodia, 9810117882

  4. Dear Sir: While your editorial, "Foreign experts may testify in medical negligence" (May 23) has aptly provided an overview of this well-known case of "medical negligence" that I've been fighting in India seeking justice for the wrongful death of my wife, Anuradha Saha, since 1998, it contains some materials that are confusing for the readers.
    While the "criminal" case was filed against three senior Kolkata doctors (medicine specialists Dr. SM, and Dr. ARC as well as dermatologist Dr. B H ), the "civil" case was against five doctors (the three in the criminal case as well as internist Dr. B P and plastic surgeon Dr. K N) as well as the Advanced Medicare Research Institute (AMRI) in Kolkata.
    My wife eventually died at the Breach Candy Hospital on May 28, 1998 from "septicemic shock in a case of toxic epidermal necrolysis" that resulted from the use of excessive steroids including long-acting methyl-prednisolone acetate ("Depomedrol") at 80 mg twice daily (BID) dose - this is not my personal observation but it is in the final judgment delivered by the Supreme Court of India on August 7, 2009 while holding all accused doctors (except the plastic surgeon) guilty for causing untimely death of my wife.
    This Supreme Court judgment is available online at the SC website at www.supremecourtofindia.nic.in (Civil Appeal No. 1727/2007; Dr. Kunal Saha vs. Dr. Sukumar Mukherjee & Ors.) and also reported recently in (2009) 9 SCC 22.
    Ironically, members of the West Bengal Medical Council (WBMC) found absolutely nothing wrong with Anuradha's treatment. Even the "Depomedrol" at 80 mg BID appeared perfectly okay with these doctor members at the WBMC.
    As you reported, although the three primary accused doctors were not convicted for "criminal" negligence, but it would be a complete travesty to imagine that the Apex Court actually agreed with the decision of the Calcutta High Court that found absolutely no negligence by any of the accused doctors. The Supreme Court judgment has made scathing comments of the High Court judge for his obvious failure to understand the case. In fact, the Apex Court has dedicated one entire section in the final judgment (Section F, page 127) to discuss the Calcutta High Court's observations and made severe criticisms of the High Court decision. The only reason that the Apex Court has not convicted the three senior doctors for "criminal" negligence is because in the Apex's Court's opinion, Anuradha died because of "cumulative negligence" by several doctors and AMRI hospitals and under such situation, only three selected doctors could not be found guilty under IPC 304A (Indian penal code section under which a doctor may be charged for "criminal negligence").

    Your editorial may be confusing who might think that the recent directions from the Supreme Court to accept opinions from "foreign experts" are related to establish "medical negligence". Where the case stands today, the four accused doctors and AMRI hospital have already been found guilty for "medical negligence" causing my wife's death. The only issue before the National Consumers' Forum (NCDRC) is to determine the quantum of compensation that must be awared in this case. The "foreign experts" that are relevant at this stage involve economic/ legal experts from USA who would provide supportive opinions that the claim I've made for the wrongful death of my wife, a permanent resident of USA who was only 36, is absolutely justified in this unique situation. Althouogh I've claimed equivalent to almost Rs. 78 crore (plus applicable interests since 1999) for my wife's untimely demise which may appear high in the Indian context, the claim was calculated based on our permanent status in the USA, not in India. However, as I've already testified during the trial and provided sworn affidavits, the entire money from this compensation will be donated for promotion of healthcare in India and for benevolent purpose for the poor Indian children (as my wife was a child psychologist and always wanted to help the unfortunate millions of poor children in India). Thank you: Kunal Saha, MD, PhD; Columbus, Ohio, USA

  5. No Lassi, No badam Milk. Only canned Energy Drink. This trend is harmful for youth of India Please check out the following link:vinod varshney http:// www.mynews.in/ News/ Energy_Drinks_New_Health_Risk_To_Children_N57001.html

  6. Dear KK, Action against Dr Setalvad, even now will not be too late. Every Govt servant has to give correct information at the time of employment, and police verification is also carried out, but in his case all the norms were thrown to the winds. Let the new panel apply their mind in the light of Govt rules and instructions, otherwise I am sure the panel will not be able to work as it happened earlier during the time Maj Gen (Retd) SP Jhingon took over charge on the orders of High Court in 2001: Dr K K Arora

  7. Dealing with the physical addiction. Get ready for the second wave. Throw away your cigarettes and ashtrays. Stay away from situations that will tempt you. Distract yourself. Avoid rationalizations. Remind yourself why you're doing this. Accept an occasional slip. Dr GM Singh