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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


27th June, 2010, Sunday

STOP PRESS

Dear Dr. K K Aggarwal :  This is to inform you that your name has been included in the name of the Central Council of IMA as per the Court Order dt. 25/6/2010 – CS (OS) No. 1275/2010.

 

With regards, 

Dr. Dharam Prakash

Hony. Secretary General

New guideline helps determine brain death in adults

In an effort to create a uniform and accurate method for determining brain death, the American Academy of Neurology has issued an updated guideline that provides doctors with a step–by–step process for determining brain death in adults. The guideline is published in the June 8, 2010 issue of Neurology, the medical journal of the American Academy of Neurology.

The new AAN guideline is an improvement over the 1995 guideline and examines recent studies on clinical determination of brain death, said Dr Eelco Wijdicks, with the Mayo Clinic in Rochester, Minn. and Fellow of the American Academy of Neurology.

The diagnosis of brain death is made only after a comprehensive clinical evaluation and often involves more than 25 separate assessments. The new guideline includes a checklist that will help doctors with this diagnosis.

Brain death is the permanent loss of brain function and means that the person has died. The only way to keep the lifeless body working is through intensive care support. Brain death can result from severe traumatic brain injury, stroke or prolonged CPR after cardiac arrest. No further medical support is needed unless the person’s organs can be donated.

According to the guideline, there are three signs that a person’s brain has permanently stopped functioning.

  1. The person is comatose, and the cause of the coma is known.

  2. All brainstem reflexes have permanently stopped working.

  3. Breathing has permanently stopped. A ventilator, or breathing machine, must be used to keep the body functioning.

The guideline describes several complex steps that doctors must follow to diagnose brain death. It carefully reviewed that the best way is to demonstrate absence of breathing. Laboratory tests such as EEG or cerebral flow studies are not needed to come to a diagnosis. The guideline also makes clear that this complex process must be completed by a doctor with considerable skill and experience in diagnosing brain death.

Dr KK Aggarwal
Padma Shri Awardee and Chief Editor

 

Photo Feature (From HCFI file)

 

Summers call for Heat stroke prevention and care

Heart Care Foundation of India (HCFI) recommends high fluid intake and prevention from direct exposure to peak sun. HCFI has used press conferences as a medium to spread this message and involved celebrities to enhance its outreach.

Dr k k Aggarwal

In the photo: Former Wrestler and MP Dara Singh and Padma Shri & Dr BC Roy Awardee Dr KK Aggarwal, President HCFI


 

News and views

Help prevent a stress fracture (Dr GM Singh)

  • When beginning a new sport or exercise plan, increase your activity gradually and not all at once.

  • Try cross training; vary your exercise routine, rather than doing the same exercises each day.

  • Eat healthy foods, especially those rich in calcium and vitamin D.

  • Invest in good equipment, such as new running shoes with plenty of support.

  • If any swelling or pain develops, take a break and give yourself a few days of rest. See a doctor, if the pain persists.

Two experimental drugs for osteoarthritis pain no better than placebo
(Dr Monica and Brahma Vasudeva)

In a trial of more than 400 patients with osteoarthritis of knee, two experimental drugs failed as treatments for pain caused by osteoarthritis. The trial found that neither ADL5859 nor ADL5747, showed a statistically significant improvement over the placebo, or dummy pill in reducing pain.

Aspirin for primary prevention of cardiovascular events in people with diabetes: ADA /AHA/ACCF Position Statement (Dr Varesh Nagrath)

Low-dose (75–162 mg/d) aspirin use for prevention might be considered for patients with diabetes at intermediate CVD risk (younger patients with one or more risk factors, or older patients with no risk factors, or patients with 10–year CVD risk of 5–10%) until further research is available.

Smokeless tobacco damages DNA and key enzymes

Smokeless tobacco affects the normal function of a key family of enzymes found in almost every organ in the body. Its adverse effects are not just limited to the mouth. The study is published in the American Chemical Society's monthly journal Chemical Research in Toxicology. Enzymes play important roles in production of hormones, including the sex hormones estrogen and testosterone; production of cholesterol and vitamin D. They also help the body to metabolize prescription drugs and potentially toxic substances. Smokeless tobacco also damages genetic material in the lungs, liver and kidney.

 

Legal Column: DMC Decision

Can the council take up a complaint after six years?

As per an order DMC/DC/F.14/Comp.567 dated 22nd May, 2009, "the Council examined a complaint of Shri P.C. J Haryana, alleging medical negligence on the part of Dr R.P.S,  in the treatment administered to the complainant. On perusal of the complaint, the Council observes that since the cause of action in this matter arose in the year 2003 and the complaint has been made to the Council after a gap of almost six years, it does not merit consideration and stands rejected."

Forensic Column (Dr Sudhir Gupta, Associate Professor, Forensic Medicine & Toxicology, AIIMS)

Does a Doctor have a right to refuse to be a part of torture?

The WMS Declaration of Tokyo defines torture as the deliberate, systematic or wanton infliction of physical or mental suffering by one or more persons acting alone or on the orders of any authority, to force another person to yield information, to make a confession, or for any other unethical reason. The Tokyo Declaration states that doctor should never be a part of torture under any given situation. Doctors are obliged by the Hippocratic Oath, not to use their medical knowledge to harm anybody.

The management of torture victims comprises diagnosis, treatment and rehabilitation. Though, it is quite easy to diagnose a torture victim by taking a proper history, general and physical examination including investigations, but sometimes, special diagnostic tools like bone scintigraphy may be required. The principles for the treatment should be both physical and psychological.

Torture producing physical or mental injuries is a criminal offence. The treating doctor should inform the nearest police/magistrate if he suspects/found that his/her patient is a victim of torture. The doctor should prepare a MLC containing the statement of patient, a detail record of injuries, treatment provided with medical opinion.

The Supreme Court (IE, 11 Nov 1997) directed the CBI, to pay a compensation of Rs 2.1 lakhs to the wife of Gopal Behara, who died two years ago in the CBI custody. Behara was a tea stall owner in the Sukinda mines of Jaipur district in Orissa and was a key witness in a murder case. He was taken by CBI for interrogation and died in custody. The wife claimed it to be a murder by CBI officials. The Dy SP of CBI was however charged under ss 341, 343 and 306 of the IPC. The WMA Declaration of Hamburg also prohibited doctors all over the world from being a part of torture/inhuman degrading act for any reason.

 

Experts’ Views: Interesting tips in Hepatology & Gastroenterology

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

Celiac Disease

Celiac disease is very common in north Indian population. It is an autoimmune disorder of the small intestine that occurs in genetically predisposed people of all ages from middle infancy onward. It is a digestive disease that damages the small intestine and interferes with absorption of nutrients from food. People who have celiac disease cannot tolerate gliadin, a prolamin (gluten protein) found in wheat, and similar proteins found in the crops of the tribe Triticeae (which includes other cultivars such as barley and rye). Gluten is the rubbery mass left over when wheat dhough is washed to remove starch granules and other soluble constituents. Gluten is found mainly in foods but may also be found in everyday products such as medicines, vitamins, and lip balms. Coeliac disease is caused by a reaction to upon exposure to gliadin, and certain other prolamins, the enzyme tissue transglutaminase modifies the protein, and the immune system cross-reacts with the small-bowel tissue, causing an inflammatory reaction. This condition has several other names, including: cœliac disease, c(o)eliac sprue, non-tropical sprue, endemic sprue, gluten enteropathy or gluten-sensitive enteropathy, and gluten intolerance. The term coeliac derives from the Greek κοιλιακός (koiliakόs, "abdominal"), and was introduced in the 19th century in a translation of what is generally regarded as an ancient Greek description of the disease by Aretaeus of Cappadocia.

Prevalence of Celiac Disease

In USA in average healthy people an incidence of 1 in 133 is noted. In people with first-degree relatives (parent, child, sibling) who are celiac: 1 in 22. Estimated prevalence for African-, Hispanic- and Asian-Americans: 1 in 236. In the landmark prevalence study on celiac disease, investigators determined that 60% of children and 41% of adults diagnosed during the study were asymptomatic (without any symptoms). Only 35% of newly diagnosed patients had chronic diarrhea, dispelling the myth that diarrhea must be present to diagnose celiac disease. The average length of time it takes for a symptomatic person to be diagnosed with celiac disease in the US is four years; this type of delay dramatically increases an individual’s risk of developing autoimmune disorders, neurological problems, osteoporosis and even cancer. Early diagnosis of celiac disease thus is important, as it might prevent complica¬tions, and awareness is the key. There are several “at risk” groups, such as six percent of those diagnosed with Type 1 Diabetes also have celiac disease. Unexplained infertility, 6% of these women might never learn that celiac disease is the cause. In Down syndrome 12% also have celiac disease

In India most of the CD are from northern India (Punjab, Haryana, Delhi, Rajasthan, Uttar Pradesh) where wheat is the staple cereal diet. In a field study conducted among school children in Punjab, the estimated frequency of disease was 1 in 310 (0.3%). This prevalence is probably an underestimation. The siblings of CD patients have a high prevalence of CD (22%). In other studies, the prevalence of CD among the first-degree relatives has been reported to be 8%-25%.

Genetics: The main genetic factors are HLA-DQ genes, HLA-DQ2 allele is present in >90% case of celiac disease vs 30% in general population. In studies from India it has been shown HLA-DQ2 allele is present in 93-95% of cases.

Tomorrow I shall address manifestation celiac disease.

Question of the Day

How should one approach an elderly patient with isolated hypertension? (Dr M E Yeolekar, Mumbai)

Isolated systolic HT is a fairly common phenomenon in elderly patients because SBP increases continuously throughout adult life, while diastolic pressure tends to rise until the age of 50 years, then plateaus and decreases after the age of 60 years. Thus, pulse pressure widens with age. It affects around 50% of elderly patients. It is known to increase the risk of stroke by 60% and of coronary disease by around 40% in elderly patients. So timely intervention is required in such patients.

Treatment approach

If patient is asymptomatic, I normally try for lifestyle modification for at least 3 to 6 months. I give the following instructions to my patients:

  • Stop smoking, limit alcohol consumption
  • Increase physical activity in a gradual manner
  • Decrease salt intake
  • If overweight, lose weight
  • Increase intake of fruits, vegetables and low fat dairy products and
  • Limit intake of saturated and total fats.

Drug therapy

In isolated systolic HT, I prefer diuretics as firstline therapy e.g., indapamide (2.5 mg) o.d. and depending upon edematous state of patient. I prefer other diuretics e.g., chlorthiazide (12.525 mg) o.d., while patients with renal impairment or patients on concomitant NSAIDs, I prefer long acting dihydropyridines or CCBs e.g., diltiazem.

In the occasional patients with benign prostatic enlargement, I utilize alpha blockers (e.g., prazosin 1 mg at bed time) explaining risk of postural hypotension, while in those patients with CAD, I prefer βblockers (e.g., atenolol 2550 mg or bisoprolol) in few patients, I got better results with nebivolol also, but in view of risk of vascular dementia as a longterm issue, ACE inhibitors or ARBs should be preferred in elderly patients.
Apart from ramipril and losartan, I have obtained excellent results with telmisartan too.

In a nutshell, I find it is important to identify whether patient is suffering from isolated systolic HT alone or with concomitant CAD or metabolic disease (diabetes, hyperlipdemia) with whatever degree of renal impairment. In general, antihypertensive drugs are well-tolerated in elderly as well as in young patients, However, polydrug use is an issue in older patients and may be responsible for poor compliance, so rationalized prescription, combination drugs wherever required and most importantly, oncedaily formulations are need of the hour in patients with isolated systolic HT.

Evidence-Based Medicine

Dr NP Singh (Nanu), Professor of Medicine, Maulana Azad Medical College and Associated Lok Nayak Hospital

Steroid dosage and route in patients admitted for COPD

Oral lowdose steroid use was associated with less treatment failure than was highdose parenteral use. Patients admitted for chronic obstructive pulmonary disease (COPD) usually receive systemic steroids, which have been associated with better outcomes in several prior randomized trials, but the best dose is still in question. Several major clinical practice guidelines recommend lowdose oral steroids.

In a retrospective cohort study, based on data from 414 U.S. hospitals, Massachusetts investigators compared outcomes in nearly 80,000 patients admitted for COPD to nonintensive care unit settings. About 74,000 received parenteral steroids (equivalent to a median dose of 600 mg of prednisone total for the first 2 days), and the rest received oral prednisone (median, 60 mg for the first 2 days). Treatment failure defined as need for mechanical ventilation after the first 2 days, death, or readmission for COPD within 30 days occurred in 11% of all patients.

In analysts adjusted for about 50 clinical and demographic variables, as well as propensity scores, treatment failure was 16% lower in patients who received oral lowdose steroids than in those who received parenteral steroids; length of stay and cost were about 10% lower in the low-dose group.

Comment: Although this study was retrospective, its sophisticated analysis convinced editorialists that the results should influence clinical practice and that a randomized controlled trial would be prohibitive in size and cost and is unnecessary. A worrisome secondary finding is that the vast majority of COPD patients received high–dose parenteral steroids, despite the contrary recommendations of major national and international guidelines – including those of the Global Initiative for Chronic Obstructive Lung Disease (GOLD).

Thomas L. Schwenk, MD [Journal Watch General Medicine June 24, 2010]

Mental exercise to prevent dementia: Dr Anupam Sethi Malhotra

The fruit with its seeds on the outside: Strawberry.

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Public Forum (Press Release for use by the newspapers)

Active lifestyle can prevent cancer

Physically active people are less likely than sedentary types to develop cancer, said Padma Shri and Dr B C Roy National Awardee Dr KK Aggarwal, President Heart Care Foundation of India.

As per a research led by the Japanese Health ministry and published in the American Journal of Epidemiology, men in the most active group of people surveyed had 13 percent less risk of developing cancer compared with the least active group, and women in the most active group had a 16 percent lower risk than their sedentary counterparts.

Around 80,000 men and women between the ages 45 to 74 living in nine Japanese prefectures were included in the survey. The surveyed population was divided into four groups according to their ratio of individual working metabolic rate, or MET (metabolic equivalent), which was determined by the amount of time respondents spent sitting, walking, standing, sleeping and exercising.

The trend was most noticeable among Japanese women, who were less likely to develop cancer if they were engaging in regular exercise and led an active lifestyle.

 

IJCP Special

Dr Good Dr Bad

Situation: A diabetic was found to have low HDL cholesterol.
Dr Bad: Do not worry your LDL is normal.
Dr Good: You are at high risk.
Lesson: Low levels of high-density lipoprotein cholesterol represent a major cardiovascular risk factor, with a stronger relationship to coronary heart disease than that seen with elevated levels of lowdensity lipoprotein cholesterol. Risk is amplified in such patients due to the common coexistence of other risk factors, including excess adiposity, metabolic syndrome, type 2 diabetes mellitus, hypertriglyceridemia, and the atherogenic dyslipidemia characterized by small dense LDLC. HDLC has important antiatherogenic effects, including reverse cholesterol transport, inhibition of LDLC oxidation, and antiplatelet and antiinflammatory actions. (Rev Cardiovasc Med 2008;9(4):23958)

Make Sure

Situation: A 4yearold girl with rickets is unresponsive to high doses of vitamin D.
Reaction: Oh my God! Why didn’t you advise alfacalcidol?
Lesson: Make sure to advise alfacalcidol in patients unresponsive to calcium/vitamin D therapy. Alfacalcidol, in numerous studies, has been found to be effective in refractory cases of rickets.

Mistakes in Clinical practice

Do not write ‘U’: it can be mistaken as sub lingual "SL".

Milestones in Gastroenterology

17851850: William Prout, a British Chemist and Physiologist, identified hydrochloric acid in stomach secretions aor gastric juice. He presented a paper to the Royal Society of London, entitled ‘Nature of Acid and Saline Matters usually existing in the Stomachs of Animals’, in which he quantified the concentration of free and total hydrochloric acid, including chlorides in gastric secretion.

Mnemonic of the Day (Dr Maj Prachi Garg)

Management of Renal failure (acute): Remember your vowels .... AEIOU

Anemia/ Acidosis
Electrolyte and fluids
Infections
Other measures (eg nutrition, nausea, vomiting
Uremia

 

International Medical Science Academy Update (IMSA)

Management of primary sclerosing cholangitis
The 2010 guidelines issued by the American Association for the Study of Liver Diseases (AASLD) strongly recommend against use of ursodeoxycholic acid in patients with primary sclerosing cholangitis. (Chapman, R, Fevery, J, Kalloo, A, et al. Diagnosis and management of primary sclerosing cholangitis. Hepatology 2010; 51:660).

Drug Update

List of Approved drugs from 1.01.2009 to 31.10.2009

Drug Name

Indication

DCI Approval Date

Tranexamic Acid Tab SR 750mg

For the treatment of menorrhagia

20.02.09

Medifinance

Personal Accident Individual

For children the maximum cover shall be limited to death and permanent disablement (total and partial) i.e. upto Table B benefits only.

Lab Medicine

Lab Test (Dr Arpan Gandhi and Dr Navin Dang)

Tests for deep and systemic fungal infections
With lung and systemic fungal infections, the symptoms are frequently nonspecific and may be confused with those due to other microorganisms or to another disease process. Laboratory testing is primarily used to diagnose these serious fungal infections, to identify the microorganism responsible, and to determine its likely susceptibility to specific antimicrobial agents. Sometimes testing is also performed to detect and identify bacteria that may be causing a concurrent infection. The sample collected depends upon the suspected location(s) of the infection.

It may include one or more of the following: the collection of blood, sputum, urine, cerebrospinal fluid (CSF), and/or the collection of a tissue biopsy. Testing may include Microscopic examination of the sample using techniques such as KOH prep and calcofluor white stain may be used to quickly determine whether or not the infection is due to a fungus. Fungal culture: This is the primary test used to diagnose a fungal infection. Many fungi are slowgrowing and may require up to several weeks for recovery and identification. Susceptibility testing: A followup test to the fungal culture that is sometimes ordered to help guide treatment. Antigen and Antibody testing: Available for a variety of different fungi but only for deep or systemic infections. May be performed on blood or other body fluids, such as CSF.

 

Humor Section

IMANDB Joke of the Day

A pretty young lady named Nancy just broke off her engagement to a young doctor.

Do you mean to tell me, exclaimed her friend, that he actually asked you to return all the presents?

Nancy: Not only that, but he also sent me a bill for house calls.

Funny Definitions

Colic…………………A sheep dog

Medical bloopers on medical charts!

Rectal exam revealed a normal size thyroid. (Long fingers?)

 

SMS of the Day (Dr Maj Praci Garg)

I decided to send you the most loveliest, cutest and sweetest gift of the world but the postman shouted at me saying come out of the postbox.

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

The true spiritual warrior makes it her aim to never burden another human being with what is her own pain.

 

Readers Responses

  1. Dr Sudhir Gupta’s comment that "law emerges from the society by the process of experience" is really a well deserved inference culled from experience. It leads me to think if the law really can always preserve good conduct in the society. Yes, self–observance of law definitely. This self–observance of law should become a national culture. If this happens then India certainly can be a greater country. I mention all this in the context of recent incident of removal of Dr KKA’s name from the list of IMA Central Council Members. Of course, by seeking the help of law he could bring his name back in the list, but the incident roars volumes about the degeneration in the society. If this happens in doctors’ community, who can then blame any pettiest politician of the country? Vinod Varshney

  2. Dearest Brother Dr KK: TU JAHAN JAHAN CHALEGA TERA SAYA (Dr. Bhatia) SAATH HOGA…… we are all there with you…EVEN LORD KRISHNA FACED INDIGNITIONS AT THE HANDS OF CRITICS…SO YOU AS OUR KRISHNA LEAD THE BATTLE AND LET ANOTHER MAHABHARATHA BE THERE. Be SURE VICTORY WILL BE ON THY SIDEH Shri Krishan Yogeshwar Jahan, Arjun Dhanurdhari Jahan VAIBHAV VIJAYA SRI NEETI sab mat se hamare hai WAHAN… So LEAD UD ALL TO CLEANSE OUR SACRED PROFESSION…GUIDE US ADVICE US AND TRUST US… God Bless, Dr.N.K.Bhatia

  3. Sir. Most of the time insurance companies do not include cumulative bonus to sum insured while calculating upper limit of room charges i.e. 1% for rooms and 2% for ICU in individual mediclaim policies: Dr K K Kanodia
 

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5th September: 3 PM to 5 PM A dialogue with His Holiness Dalai Lama at Parliament Street Annexe in association with Acharya Sushil Muni Ahimsa Peace Award Trust

12th September: BSNL Dil ka Darbar A daylong interaction with top cardiologists of the city.
8 AM – 5 PM at MAMC Auditorium, Dilli Gate.

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29th October, Friday: Divya Jyoti Inter Nursing College/ School Competitions/ Culture Hungama

30th October, Saturday: Medico Masti Inter Medical College Cultural festival from 4 PM to 10 PM

31st October, 2010, Sunday: Perfect Health Darbar, An interaction with top Cardiologists

eMedinews Revisiting 2010

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