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  From the Desk of Editor–in–Chief
Dr KK Aggarwal

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; Chairman Ethical Committee 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

 

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  Editorial …

26th July 2011, Tuesday

Evaluation of cognitive impairment and dementia

Suresh Kalmadi is suffering from dementia. This has given us an opportunity to revise the subject of dementia.

What is dementia?

Dementia is a disorder characterized by impairment of memory and at least one other cognitive domain (aphasia, apraxia, agnosia, executive function). These must represent a decline from previous level of function and be severe enough to interfere with daily function and independence.

What are cognitive functions?

The cognitive functions are: Memory, reasoning, language, calculations and spatial orientation.

How common is dementia?

About 5% of individuals over age 65 years and 35–50% of persons over age 85 years have dementia; the pretest probability of dementia in an older person with reported memory loss is estimated to be at least 60%.

What are dementia syndromes?

The major dementia syndromes include

  • Alzheimer’s disease
  • Dementia with Lewy bodies
  • Frontotemporal dementia
  • Vascular (multi–infarct) dementia
  • Parkinson’s disease with dementia

What is Alzheimer’s disease?

Alzheimer’s disease is the most common form of dementia in the elderly, accounting for 60–80% of cases.

What is DSM–IV definition of dementia?

Evidence from the history and mental status examination that indicates major impairment in learning and memory as well as at least one of the following:

  • Impairment in handling complex tasks (e.g., balancing a checkbook)
  • Impairment in reasoning ability (e.g., unable to cope with unexpected events)
  • Impaired spatial ability and orientation (getting lost in familiar places)
  • Impaired language (word finding)

The cognitive symptoms must significantly interfere with the individual’s work performance, usual social activities, or relationships with other people. There must be a significant decline from a previous level of functioning. The disturbances are of insidious onset and are progressive. The disturbances are not due to delirium (a major psychiatric diagnosis), systemic disease or another brain disease.

Patients with dementia may also have difficulty with

  • Learning and retaining new information (e.g., trouble remembering events)
  • Behavior

Who reports dementia in a patient?

Most patients with dementia do not present with a complaint of memory loss; it is often a spouse or other informant who brings the problem to the physician’s attention.

What is age–related cognitive decline?

The normal cognitive decline associated with aging consists primarily of mild changes in memory and the rate of information processing, which is not progressive and does not affect daily function. Learning or acquisition performance decline uniformly with age. Delayed recall or forgetting remains relatively stable. Aging is associated with a decline in the acquisition and early retrieval of new information but not in memory retention.

What is mild cognitive impairment?

Mild cognitive impairment is the presence of memory difficulty and objective memory impairment but preserved ability to function in daily life. These patients appear to be at increased risk of dementia.

Should these patient be screened for B12 levels?

The American Academy of Neurology recommends screening for B12 deficiency and hypothyroidism in patients with dementia.

Should MRI be done in all cases?

Neuroimaging rules out patients who might have reversible causes of dementia that can be diagnosed with imaging studies (subdural hematoma, normal pressure hydrocephalus, treatable cancer). Structural neuroimaging with either a non–contrast head CT or MRI should be considered in the initial evaluation of all patients with dementia.

Is there a role of biopsy?

Brain biopsy has a very limited role in the diagnosis of dementia.

What is the association with depression?

Screening for depression in patients with dementia is recommended because depression is a common treatable co–morbidity that may also masquerade as dementia.

What is Mini–Mental State Examination?

Mini–Mental State Examination (MMSE) is the most widely used cognitive test for dementia. The examination takes approximately 7 minutes to complete. It tests a broad range of cognitive functions including orientation, recall, attention, calculation, language manipulation, and constructional praxis.

The MMSE includes the following tasks:

  • What is the date: (year)(season)(date)(day)(month) – 5 points
  • Where are we: (state)(county)(town)(hospital)(floor) – 5 points
  • Name three objects: Ask the patient all three after you have said them. Give one point for each correct answer. Then repeat them until he/she learns all three. Count trials and record. The first repetition determines the score, but if the patient cannot learn the words after six trials then recall cannot be meaningfully tested. Maximum score – 3 points.
  • Serial 7s, beginning with 100 and counting backward: one point for each correct; stop after five answers. Alternatively, spell WORLD backwards: one point for each letter in correct order. Maximum score – 5 points.
  • Ask for the three objects repeated above: one point for each correct answer. Maximum score – 3 points.
  • Show and ask patient to name a pencil and wrist watch – 2 points.
  • Repeat the following, "No ifs, ands, or buts." Allow only one trial – 1 point.
  • Follow a three stage command, "Take a paper in your right hand, fold it in half, and put it on the floor." Score one point for each task executed. Maximum score – 3 points.
  • On a blank piece of paper write "close your eyes;" ask the patient to read and do what it says – 1 point.
  • Give the patient a blank piece of paper and ask him/her to write a sentence. The sentence must contain a noun and verb and be sensible – 1 point.
  • Ask the patient to copy a design (e.g., intersecting pentagons). All 10 angles must be present and two must intersect – 1 point.

A total maximal score on the MMSE is 30 points.

A score of less than 24 points is suggestive of dementia or delirium.

Using a cutoff of 24 points, the MMSE had a sensitivity of 87% and a specificity of 82%.

The test is not sensitive for mild dementia, and scores may be influenced by age and education, as well as language, motor, and visual impairments.

For research purposes, some investigators use a cutoff score of 26 or 27 in symptomatic populations in order to not miss few true cases.

For More editorials...

Dr KK Aggarwal
Group Editor in Chief

 
  eMedinewS Audio PostCard

Stay Tuned with Padma Shri and Dr BC Roy National Awardee Dr KK Aggarwal on

Evaluation of cognitive impairment and dementia

Audio PostCard
 
    Photo Feature (from the HCFI Photo Gallery)

National Conference on Insight on
Medico Legal Issues

Dr Sudhir Gupta delivering a lecture in the recently concluded National Conference on Insight on Medico legal issues

 
Dr K K Aggarwal
 
    National News

National Conference on Insight on Medico Legal Issues – For the First time any conference was posted live on Facebook & Twitter

http://blogs.kkaggarwal.com/?p=1134
http://twitter.com/#!/search/medicolegal
https://www.facebook.com/pages/Insight–on–Medicolegal–Issues/247091668637671

Many districts reeling under Japanese encephalitis

JORHAT: It’s a season of double blow for the people of Sivasagar, Jorhat, Lakhimpur, Sonitpur and Golaghat districts in Assam are already reeling under Japanese encephalitis (JE) has taken a serious turn in the state as death toll climbed 56 till Friday. The disease has reached an epidemic form in Sivasagar, Jorhat, Lakhimpur, Sonitpur and Golaghat district. Sibsagar district joint director of health Sadhana Dutta said, "Forty–six persons have died so far in the district, 14 of Japanese Encephalitis (JE) and 32 in Acute Japanese Encephalitis Syndrome (AES). These cases have been reported from the block level public health centres like Dimow, Geleki, Gaurisagar, Kalugaon, Khelua, Morabazzar, Patsaku, and Sapekheti. "She added, "So far we received reports of 152 more cases of both JE and AES from several block PHCs of the district and 55 of them have found JE positive so far." (Source: TOI, Jul 23, 2011)

For comments and archives

Blood donation camp collects a record 7,001 bags

PUNE: The massive blood donation camp held at the Sambhaji Park on Thursday collected 7,001 bags; each containing 350 ml. Considering the city’s daily requirement of 350 blood bags, the collected blood can fulfill the city’s transfusion needs for 20 days at a stretch. (Source: TOI, Jul 21, 2011)

For comments and archives

Certificate courses in 2D and 3D Echocardiography/Fellowship Diploma in non invasive cardiology Contact Dr KK Aggarwal, Moolchand Medcity, email: emedinews@gmail.com

 
    International News

(Dr Monica and Brahm Vasudev)

iPad to impart greater accuracy to diagnosis

SYDNEY: A new iPad application will help doctors in delivering the appropriate treatment at the right place and time. Known as Diagnostic Imaging Pathways (DIP), the tool has been developed by the Centre for Software Practice (CSP) with the Royal Perth Hospital, under Professor Richard Mendelson from the University of Western Australia. "Thirty percent of imaging requests are incorrect or inappropriate – the iPad application DiPHD will help make sure that patients have the best chance of getting the most accurate diagnosis," Mendelson said, according to a CSP statement. Having the pathways available on a platform like the iPad ensures that doctors will be able to access vital information, literally at their fingertips, said CSP director associate professor David Glance. "Imaging is the first step in future pathways that will also involve pathology and clinical referral guidelines," Glance said.
(Source: http://expressbuzz.com/tech/ipad7nd to–impart–greater–accuracy–to–diagnosis/297144.html, 23 Jul 2011)

For comments and archives

ADHD kids unlikely to follow crosswalk rules

Although children with attention–deficit/hyperactivity disorder, combined type (ADHD–C) behave largely the same as other children when crossing the street, they chose to cross in riskier situations, researchers found. The findings suggest that executive dysfunction might at least partly explain why kids with ADHD–C have a higher pedestrian injury risk than those with typical development, and those with other developmental disabilities, according to Despina Stavrinos, PhD, of the University of Alabama at Birmingham, and colleagues. (Source: Medpage Today)

For comments and archives

U.S. Chicken pox deaths almost eradicated

The varicella vaccination program has all but wiped out deaths due to the infection in children and younger adults since it started in 1995, CDC researchers found. Annual mortality from chicken pox fell 96% in those under age 50 and 88% overall in the decade after vaccination programs started, Mona Marin, MD, of the Centers for Disease Control in Atlanta, and colleagues reported in the August issue of Pediatrics. (Source: Medpage Today)

For comments and archives

New information added to Chantix label

The FDA has updated the label for varenicline (Chantix) to include additional information about the safety and efficacy of the smoking cessation drug in patients with cardiovascular disease or chronic obstructive pulmonary disease (COPD). The label update follows an FDA statement last month noting that it was reviewing reports that use of the drug was associated with an increase of recurrent myocardial infarction or new onset peripheral arterial disease. (Source: Medpage Today)

For comments and archives

 
    Fitness Update

(Contributed by Rajat Bhatnagar, International Sports & Fitness Distribution, LLC, http://www.isfdistribution.com)

Parents are the key to preventing childhood obesity: Study

A recent study conducted at Maastricht University in the Netherlands reported some new and interesting findings about childhood obesity. Their study, published in the International Journal of Obesity, found that treating parents of obese and overweight children was effective in helping kids to lose weight. The study did not treat kids – only parents – and the intervention was still effective. The study enrolled the parents of 98 overweight or obese children (aged from seven to 13) in training sessions aimed at helping their children lose weight. Parents were randomly assigned to either a treatment group or a waiting list (the control group). Training sessions occurred over the span of ten weeks. The study found that children’s weight decreased significantly in the treatment group. However, there was no change in weight in the waiting–list control group. Researchers followed up three months after the study and found that there was no weight gain or relapse in the children whose parents attended the treatment group.

These novel study results show more evidence reinforcing the long standing idea that parents should be accountable for children’s weight. Now, researchers plan to replicate the study with a larger group, and these methods should be considered when planning treatment approaches for childhood obesity.

For comments and archives

 
    Twitter of the Day

@DrKKAggarwal: Watch Padma Shri Awardee Dr KK Aggarwal on High fat diet cancer prone in Hindi http://t.co/WpY3kBc via @youtube

@DeepakChopra: #CosmicConsciousness Does mathematical truth reside in consciousness or universe Is it the same thing as universe resides in consciousness?

 
    Dr KK Answers

(Dr KK Aggarwal, Group Editor in Chief, IJCP Group of Publications and eMedinews)

Dr KK Answers: Why should one treat high blood pressure? Antihypertensive therapy is associated with reductions in incidence of paralysis averaging 35–40%, heart attack (20–25%) and heart failure (> 50%).

For comments and archives

 
    Spiritual Update

The Power of Prayer

We read about people praying for rain, drought or other natural calamities in Vedic literature. It is usual for people to pray in hospitals for the sick. People also pray regularly for the departed souls. When Amitabh Bachchan was injured during the shooting of the film C

For comments and archives

 
    An Inspirational Story

(Dr Prachi)

Lesson in Leadership

Excerpt from: "You Can’t Send a Duck to Eagle School" – by Mac Anderson

In 1982, Jan Carlson had just been named the CEO of Scandinavian Airlines. His company was in trouble. They had just been ranked by a consumer poll as the worst airline in the world. Last in service, last in dependability, and last in profits as a percentage of sales. Yet one year later, in the same poll, they were ranked number one in all three categories. What happened?

Carlson had decided to focus on what he thought was the most critical issue…serving the customer. He wanted to keep it simple: Identify every contact between the customer and the employee, and treat that contact as…"a moment of truth." He set out to let his people know the importance of that moment…the captain, the ticket agent, the baggage handler, the flight attendant. "Every moment, every contact," he said, "must be as pleasant, and as memorable as possible."

He figured that he had approximately 10 million customers each year, and on average each customer made contact with five of his people for approximately 15 seconds apiece. Therefore, in his mind, these 50 million contacts, 15 seconds at a time, would determine the fate of his company.

He set out to share his vision with his twenty thousand employees. He knew the key was to empower the front line. Let them make the decision and take action, because they were Scandinavian Airlines during those fifteen seconds. He now had twenty thousand people who were energized and ready to go because they were focused on one very important thing…making every moment count.

"A leader’s job is to look into the future and see the organization, not as it is, but as it should be." Jack Welch

For comments and archives

 
  Idioms

(By Ritu Sinha)

A Toss–Up: A result that is still unclear and can go either way.

 
    Pediatric Update

(Dr. Neelam Mohan, Director Pediatric Gastroenterology, Hepatology and Liver Transplantation, Medanta – The Medicity)

What is Wilson’s disease and its clinical manifestations?

Wilson disease (WD), also known as hepatolenticular degeneration is a familial, lethal neurological disease accompanied by chronic liver disease leading to cirrhosis. The pattern of inheritance is autosomal recessive. It occurs worldwide with an average prevalence of 30 affected individuals per million population. Absent or reduced function of ATP7B protein leads to decreased hepatocellular excretion of copper into bile which results in copper accumulation and injury of liver and failure to incorporate copper into ceruloplasmin. Over a period of time, copper is released into the bloodstream and deposited in other organs, like brain, kidneys, and cornea. It can present clinically as liver disease (more often in children and younger adult patients than in older adults), as a progressive neurological disorder, or as psychiatric illness. Symptoms at any age are frequently nonspecific.

For comments and archives

 
    Lab Update

(Dr Arpan Gandhi and Dr Navin Dang)

Platelet aggregation

Platelets aggregate quickly enough to prevent important lack of blood and also to prevent exogenous agents to enter the blood stream.

Platelet aggregation test evaluates the ability of platelets to clump together in blood i.e. how well they function. The blood sample is drawn from the vein in the arm. Possible reasons why this test may be done:

  • Hereditary platelet function disorder
  • Platelet dysfunction due to drugs

Patients with history of thrombosis or similar problems of clots in the blood need medication to keep this parameter within a narrow band, and also monitors platelet aggregation levels frequently.

  • If the level of platelet aggregation in blood is low, this increases risk of hemorrhage and edema.
  • If level is too high, this increases risk of heart attack, thrombosis or emboli.

Platelet aggregation can be increased by:

  • Hemolysis
  • Lipemia
  • Nicotine

For comments and archives

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    IJCP Special

Dr Good Dr Bad

Situation: A 63–year–old male with pneumonia was admitted with blood urea of 44 mg/dL.
Dr Bad: You need ICU admission.
Dr Good: You need OPD treatment.
Lesson: Patients with a CURB–65 score of 0 to 1 could probably be treated as outpatients, those with a score of 2 should be admitted to the hospital, and those with a score of 3 or more should be assessed for ICU care, particularly if the score was 4 or 5 (Thorax 2003;58:377–82). For comments and archives

Make Sure

Situation: A patient of stroke with fever worsened.
Reaction: Oh my God!! Why was normothermia not maintained!
Lesson: Make sure that normothermia is maintained for at least first several days after acute stroke. Fever may occur in patients with acute stroke and can worsen brain ischemia.

For comments and archives

 
  Quote of the Day

(Dr GM Singh)

To acquire knowledge, one must study; but to acquire wisdom, one must observe. Marilyn vos Savant

 
    Medicolegal Update

(Dr Sudhir Gupta, Additional Prof, Forensic Medicine & Toxicology, AIIMS)

What is a Medical negligence Arbitration Agreement?

In addition to expert testimony, include medical textbooks and other published medical data. The admissibility of such evidence as proof of the standard of care varies among jurisdictions. Medical texts or treatises may be effectively used to cross–examine the adverse medical expert

  • A physician or an institution may privately, or pursuant to legislation enter into an agreement with a patient to arbitrate a medical malpractice claim. The purpose of the agreement is to avoid litigation, and not to avoid liability.
  • Arbitration is merely an alternative to a full–blown litigation. An agreement to arbitrate a medical malpractice claim, particularly one that follows statutory procedure, is generally enforceable because it does not violate due process and is constitutional.
  • If an agreement to arbitrate is accepted by the parties, basic requirements of due process must be met, and there must be a fair composition of the tribunal or arbiters.

(Ref: American College Of Legal Medicine, The Medical Malpractice Survival Handbook)

For comments and archives

 
    Mind Teaser

Read this…………………

Enlarged corneal nerves may be seen in all of the following except:

1. Keratoconus
2. Herpes simplex keratitis
3. Leprosy
4. Neurofibromatosis

Yesterday’s Mind Teaser: The mother of a one and a half year old child gives history of a white reflex from one eye for the past one month. On computed tomography scan of the orbit there is calcification seen within the globe. The most likely diagnosis is:

1. Congenital cataract
2. Retinoblastoma
3. Endophthalmitis
4. Coats of disease

Answer for Yesterday’s Mind Teaser: 2. Retinoblastoma

Correct answers received from: Dr Surendra Bahadur Mathur, Dr yJ Vasavada, Dr K Raju, Dr Neelam Nath, Dr SK Bansal, Dr Anil Bairaria, Dr Priyanka Sharma, Dr Nikunj Garia, Dr Anil Bairaria, Dr Jainendra Upadhyay.

Answer for 24th July Mind Teaser: made in Japan
Correct answers received from: Dr Prabha Sanghi, Dr Priyanka Sharma, Dr Sumit Mehndiratta, Dr.K.Raju, Dr (LtCol) Gopal Agarwal, Dr SK Bansal.

Send your answer to ijcp12@gmail.com

 
    Medi Finance Update

(Dr GM Singh)

Who is required to deduct tax at source while making payments of the nature referred to in above?

In case of Companies and Partnership Firms, tax is required to be deducted at source on every payments on which TDS is applicable. Individuals carrying out any business or profession are required to deduct at source on every payments on which TDS is applicable only when during previous financial year they were supposed to get their accounts audited under Income Tax law.

 
    Laugh a While

(Mr Sudesh Kumar)

It is said that when a woman closes her eyes, she sees the person she loves the most; and when a man does that… the slide show begins.

 
    Drug Update

List of Approved Drug From 01–01–2011 to 30–06–2011

Drug Name
Indication
DCI Approval Date
Combikit of tablet & sachet Each bowel preparatory kit contains: One enteric coated tablet Biscodyl IP 5mg & One sachet of powder for reconstitution contains: Polyethylene glycol 3350NF: 210gm + Sodium Bicarbonate IP 2.86gm + Sodium Chloride IP 5.6gm + Potassium Chloride IP 0.74gm
For bowel cleansing prior to colonoscopy in adult patients only
11.02.11
 
    Public Forum

(Press Release for use by the newspapers)

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Vegetarian diet reduces BP

Ingestion of a vegetarian diet may reduce systolic blood pressure by 5 mmHg and a 5 mm reduction in blood pressure reduces the risk of heart disease by 21%, said Padmashri and Dr B C Roy National Awardee Dr K K Aggarwal, President Heart Care Foundation of India and MTNL Perfect Health Mela.

Also the high fiber content of the vegetarian diet may add to the BP lowering effects.

A typical vegetarian’s diet contains more potassium, complex carbohydrates, polyunsaturated fat, fiber, calcium, magnesium, vitamin C and vitamin A, all of which may have a favorable influence on blood pressure.

Soy is another vegetarian item good for the heart. It is naturally high in potassium and low in sodium.

Soy should be taken as an alternative protein source to unhealthy meats. Soy–based meat is higher in fiber and lower in sodium. However soy does not contain the long–chain omega–3 fatty acids that are found in fatty fish and shellfish.

Soya is also good for the thyroid and post menopausal heart symptoms. For comments and archives

 
    Readers Responses
  1. Just like 24 Gurus for Dattatreya, eMedinews is the 25th Guru for medical fraternity. With my profound regards: Gayatri.
 
    Forthcoming Events

September 30th to October 2nd, 2011, Worldcon 2011 – XVI World Congress of Cardiology, Echocardiography & Allied Imaging Techniques at The Leela Kempinski, Gurgaon (Delhi NCR), INDIA

from Sept 29, 2011: A unique & highly educative Pre–Conference CME, International & National Icons in the field of Cardiology & Echocardiography will form the teaching faculty.

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