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

Dr K K Aggarwal

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




27th November Friday 

Dear Colleague,

Blood alcohol limits

 The 1994 Motor Vehicle Act has a provision for imprisonment for six months and or a fine of Rs. 2000 if a person is found drunk while driving. The definition accepted by the Courts is blood levels of more than 30 mg/dl which amounts to a blood alcohol concentration (BAC) of more than 0.030%.

With an alcohol concentration of less than 0.030%, the person behaves and reacts normally. In gradual manner, with the concentration is more than 0.030%, the person shows signs and symptoms starting from impaired judgment (BAC 0.030 to 0.06%),   impaired reasoning (0.060 to 0.10%); reduced reaction time (0.11 to 0.20%); motor impairment (0.21 to 0.29%); bladder disturbances (0.30 to 0.39%) and brain damage ( >0.40%).

An equivalent alcohol is present in 44ml of 80 proof (40% weight/volume) whisky, 355 ml (5% weight/volume) and 148 ml of wine (12% /weight/volume).

14 gm of alcohol (17.74 ml) will increase BAC by 0.20 to 0.05%. After drinking the BAC will normalize by 0.015% every hour. Therefore, after one peg of alcohol, it may take 1.5 to 3 hours for the blood alcohol levels to come back to Zero. When we are arranging alcohol party, we should nor serve more than 45 ml at a time and make sure that the person does not drive for the next three hours after a peg.

Excerpts of a talk by Dr. E. Camezind from Geneva, Switzerland at Max Hospital, Saket

1. There is no need to remember drug eluting stents as first generation, second generation and third generation. One should only remember them as Potent Stents and Weak Stents. Potent stents are sipher (sirolimus) and taxus (taxal stent).
2. Potent stents may give a better short term angiographic outcome but in the long run, they have more late (after six months) stent thrombosis, which may be up to 0.6% every year.
3. Late stent thrombosis depends on vascular factors (no or late reendothelisation), hemodynamic factors (luminal widening over time) and blood factors (inadequate anti platelet therapy, systemic inflammation, flu, dehydration and infection).
4. Compared to bare metal stent drug eluting stent are only 40% reendothelised  by six months.
5. Mortality of late thrombosis with drug eluting stent is 20 to 45%.
6. Late rethrombosis means more MI and more deaths.
7. Patient on potent stent should be on dual anti platelet therapy for life (75 mg aspirin and 75 clopidogel.
8. Patients on dual anti platelet therapy should continue their drugs when they go for any dental work. The harm of stopping anti platelet therapy is more than the risk of local bleeding which can be controlled by local compression. However, if the patient has received a week drug eluting stent or a bare metal stent, there is no harm in stopping one anti platelet drug for a few days while going for dental treatment.
9. In dengue fever, when the platelet count is low, it is a tricky situation whether or not to continue anti platelet therapy. Remember dengue is an inflammatory process and stopping anti platelet therapy in a patient with potent drug eluting stent may precipitate stent thrombosis. Individual decisions need to be taken in such a situation.
10. Patients on potent drug eluting stent and on dual anti platelet therapy, if they develop purpura refractory to treatment may require alternate day anti platelet therapy.
11. Drug eluting balloons combined with bare metal stent is a new concept in angioplasty but the drug eluting balloon is a potent balloon and hence will have more rethrombosis.
12. When choosing a drug eluting stent, one should not choose potent drug eluting stents unless they are specifically indicated. In fact, one should use a weak drug eluting stent which allows proper and effective vascular healing.
13. When choosing a drug eluting stent, one should be sure that there are no contra indications for anti platelet therapy for life.
14. It is worth trying hydroxyl chloroquine as an anti inflammatory agent to prevent stent late thrombosis.
15. The result of a stent depends on type of stent, a carrier matrix used and the drug used for eluting the stent. 


Dr K K Aggarwal




Letters to the editor

1. Regarding alcohol quantities, it is good for heart as per your research article in emedinews , but due to its high potential for addiction , I think one should avoid even small quantities , there are many good drinks like apple juice , orange juice and vegetable juices , why researches are not doing any research on that. Alcohol is a medicine , that should be used in making of drugs . Similarly is the case of caffeine and nicotine , that should also be used in the making of drugs. Anything which has a high addiction potential and is not good for health , should be avoided completely, because prevention is better than cure. (Dr Pankaj Budhiraja)

2. Please convey to Dr.Vivek Chhabra the following refrences for intracardiac adrenaline injection in the 21st . century
Harrison's Principles of Internal Medicine 17th edition(latest) Critical care medicine- cardiac arrest secondary to bradyarryhthmias and asystole is managed differently.Epinephrineand/or atropine are given intravenously or by an intracardiac route.
American Heart Association -Advanced Cardiac Life Support - In desperate clinical situations whne an iv cannot be started  or an endotracheal tube placed,Intracardiac injections can be used to administer epinephrine to treat ventricular fibrillation,asystole,or PEA. Anecdotal evidence suggest that intracardiac epinephrne may have been effective in restoring cardiac contractions in asystole or electomechanical dissaociation when IV epinephrine was ineffective. Whether the needle stick or drug itself was effective has not been resolved.
Transfusion reactions:Treatment&Medication-eMedicine Heamatology- In overt shock, epinephrine as a1:1000 aqueous solution may be administered as an intracardiac injection.
Epinephrine(PF)Inj:AHFS Detailed Mongraph-In exxtreme cardiac emergencies, diluted injections of epinephrine hydrochloride also may be given intracardiacally, via an endotracheal tube or by intraossous infusion.
JAMA vol.244no.10,september5,1980 -Intracardiac injections during cardiopulmonary resuscitation- a low risk procedure.
Interstingly the topic was discussed in a meeting of family physicians who said they would do nothing except refer a patient to hospital if he suffers cardiac arrest outside their clinic. They were at a loss as to what they will do if it happened in their clinic, as Iv would not be available, intubation is ruled out, monitor/defibrillatotrs are not available in clinics, now even long needles for intracardiac injections are also not available and the ambulance/ emergency services are pathetic and will not reach in time even if CPR is started.
An important point for IV drugs to be effective, after the Iv injection the iv line has to be flushed with 20-0ml saline and the CPR has to be effective to distribute the drug in the system. Vinay Bhasin

emedinews commnets: use intracardiac only when others routes are not available. Infact in clinic practice just only compression chest CPR is sufficient.

 News to use (Dr G M Singh)

1. Obesity is characterized by the accumulation of excess body fat and can be conceptualized as the physical manifestation of chronic energy excess. Using the analogy of oedema, the consequence of positive fluid balance or fluid retention, obesity can be seen as the consequence of positive energy balance or calorie retention. Just as the assessment of oedema requires a comprehensive assessment of factors related to fluid balance, the assessment of obesity requires a systematic assessment of factors potentially affecting energy intake, metabolism and expenditure. Rather than just identifying and describing a behavior (this patient eats too much), clinicians should seek to identify the determinants of this behavior (why, does this patient eat too much?).

2.  SPORT is a major study which compared outcomes after surgical vs non operative treatment of lumbar disk herniation in patients with lumbar radiculopathy. It consisted of randomized and observational patient cohorts. Surgery remained superior in these outcomes at 2 years, although there was some attenuation of the benefit associated with surgery.

3.  There is an intimate link between mental health disorders and depression, as more than 90% of people who have committed suicide have such disorders. Majority of these individuals are untreated for mental health disorders at the time of the suicide, although there has been some question as to whether treatment of psychiatric illness such as depression might actually increase the risk for suicide.

4. There are several steps that people with diabetes should take to fight against 2009 H1N1 flu. CDC recommends that all people with all types of diabetes who are 6 months through 64 years of age get vaccinated with the 2009 H1N1 and seasonal flu shot. People with diabetes also should talk with their health care provider about getting a pneumonia (pneumococcal) vaccine as part of their diabetes management plan.

5.  Hot flashes are reported by most perimenopausal and postmenopausal women, and night sweats are reported by half of them and may be associated with impaired sleep. Recent studies have suggested an adverse association between hot flashes and CVD mortality, suggesting that vasomotor symptoms may be a marker for a more hypoestrogenic state.

6. Dosing for morphine sulfate must be adjusted for each patient with consideration of factors such as age, body mass, physical status, prior experience with opiate analgesics, risk factors for respiratory depression, and medications to be coadministered before or during surgery. Caution is advised in elderly patients and patients with seizure disorders.

7.  Cyclosporine may increase the plasma concentrations of repaglinide and thereby increase the risk for hypoglycemia. Pharmacokinetic data suggest that concomitant use of cyclosporine increases the maximal and
total exposure to repaglinide by 1.8  and 2.4 fold, respectively. Caution and close monitoring of glucose levels are recommended.

8.  Post marketing cases of nephrolithiasis have been reported in patients receiving treatment with fosamprenavir calcium. Temporary interruption or discontinuation of therapy should be considered for patients in whom signs or symptoms of kidney stones develop. Fosamprenavir and ritonavir therapy has been linked to increases in triglyceride and cholesterol levels; regular monitoring is recommended.

9.  Heart failure is the leading cause of hospitalization in people older than 65 years in India. High coffee consumption may increase the risk for heart failure, and coffee consumption also increases risk for hypertension. However, coffee consumption has also been associated with a reduced risk for diabetes, so the 2 effects may neutralize one another.

10.  The CDC guidelines issued October 16, update those from September 22, 2009, aims to help clinicians prioritize use of antiviral medications for hospitalized patients and those at higher risk for influenza complications during the 2009 to 2010 season. Updates since the September 22, 2009, guidelines include the following: Expanded considerations for treatment and chemoprophylaxis in persons vaccinated with the 2009 H1N1 and seasonal influenza vaccines; a new recommendation that women up to 2 weeks postpartum or after a miscarriage should be considered to be at increased risk for complications from 2009 H1N1 influenza; additional oseltamivir dosing instructions for children younger than 1 year.

11. The new CDC guidelines contain dosing recommendations for antiviral treatment (for 5 days) or chemoprophylaxis (for 10 days) with oseltamivir for children younger than 1 year.  Because of limited data on use of oseltamivir in infants younger than 3 months, prophylaxis is not recommended in this age group unless the situation is judged to be critical. 

12. Both EPA and DHA are fish oils that have been used as supplements to reduce the risk for cardiovascular disease. A significant reduction in deaths from cardiovascular disease and all cause mortality rates has been shown in clinical trials, but it is uncertain if this reduction is because of a reduction in arrhythmias, although both types of fish oil have been proposed to stabilize membranes of cardiocytes.

13. Fish oil supplementation with EPA and DHA is associated with a reduction in the risk for cardiac death.

14. Individuals diagnosed with either type 2 diabetes or OSA should be screened for the other condition. Those with OSA should be routinely screened for metabolic syndrome and type 2 diabetes with inexpensive, easily performed screening tests, followed by a glucose tolerance test when these test results are positive.

15. Most diverticular bleeding is self-limited. Resuscitative measures and intravenous fluid replacement should be given urgently, as well as packed red cell transfusions in patients with ongoing bleeding. Colonoscopy is the initial diagnostic procedure of choice, and therapeutic maneuvers may also be performed if the bleeding source is visualized. Surgery is seldom required. To prevent progression of diverticular disease, patients should increase dietary fiber intake or take supplements, increase physical activity levels, and avoid aspirin and NSAIDs. Avoiding certain nuts, corn, or popcorn is no longer recommended.

16. Bullying refers to repetitive aggressive acts characterized by an imbalance of power and inability of the victims to defend themselves. Bullying and victimization have been linked to poorer family functioning, interparental violence, and parental maltreatment. Children who are both bullies and victims appear to be the most dysfunctional in outcomes. To date, however, no prospective, population-based study has evaluated predictive associations between childhood bullying behavior and long-term mental health outcomes in both boys and girls.

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Dr Good Dr Bad

Situation:   A patient with acute gouty arthritis needed NSAID.
Dr Bad:   Change to this NSAID
Dr Good:  Take any NSAID but start immediately

Lesson:  The most important determinant of therapeutic success lies not in which NSAID is chosen, but rather in how soon NSAID therapy is initiated.

A man has a heart attack and is brought to the hospital emergency room. The doctor tells him that he will not live unless he has a heart transplant right away. Another doctor runs into the room and says, "you're in luck, two hearts just became available, so you will get to choose which one you want. One belongs to lawyer and the other to a social worker".

The man quickly responds, "the lawyer's".

The doctor says, "Wait! Don't you want to know a little about them before you make your decision?"

The man says, "I already know enough. We all know that social workers are bleeding hearts and the lawyer's probably never used his. So I'll take the attorney's!"


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emedinews: revisiting 209

IJCP Group is organizing emedinews: Revisiting 2009, a day long conference on 10th Jan  2010 at Maulana Azad Auditorium. It will be attended by over 1500 doctors. Topics will be happenings in the year 2009. There is no registration fee however advanced registration is required.  Top experts will deliver lectures. CME will be followed by lively cultural evening, doctors of the year award, dance and dinner. For regiatration mail  emedinews@gmail.com. We have crossed 800 registrations.

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