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Dr KK Aggarwal

From the Desk of Editor in Chief
Dr B C Roy National Awardee,

Dr KK Aggarwal
President, Heart Care Foundation of India; Sr Consultant and Dean Medical Education, Moolchand Medcity; Member, Delhi Medical Council; Past President, Delhi Medical Association; Past President, IMA New Delhi Branch; Past Hony Director. IMA AKN Sinha Institute, Chairman IMA Academy of Medical Specialities & Hony Finance Secretary National IMA; Editor in Chief IJCP Group of Publications & Hony Visiting Professor (Clinical Research) DIPSAR

Dear Colleague,

28th January, Thursday 2010

 Practice Changing Updates: Dabigatran in atrial fibrillation
Over the past few years certain new guidelines have come which has changed our practice. We will publish them one by one.

In atrial fibrillation with a CHADS2 score of 2 or greater, and difficulty with monitoring or controlling the INR on acitrom or warfarin, one should use dabigatran, if available, rather than aspirin plus clopidogrel.

In a trial  Dabigatran at a dose of 110 mg was equally effective in preventing stroke and systemic embolization as warfarin, while having a lower rate of major bleeding. At a dose of 150 mg daily, dabigatran was more effective than warfarin and equally safe. (1)
CHADS score or CHADS2 score is a clinical prediction rule for estimating the risk of stroke in patients with nonrheumatic atrial fibrillation (AF), a common and usually benign heart arrhythmia. It is used to determine the degree of anticoagulation therapy required since AF can cause stasis of blood in the upper heart chambers, leading to the formation of a mural thrombus that can dislodge into the blood flow, reach the brain and cause a stroke. A high CHADS2 score corresponds to a greater risk of stroke, and vice-versa.
In CHADS2 scoring, on point each is given for presence of Congestive heart failure, Hypertension more than 160 mm Hg or on treatment, Age more than 75 yrs and Diabetes. Tow points are given for the presence of Stroke or TIA in the past.

The risk of stroke as a percentage per year is 1.9% (score 0), 2.8% (score1), 4% (score2), 5.9% (score3), 8.5% (score4), 12.5% (score 5) and 18.2% (score 6).

Reference : Connolly, SJ, Ezekowitz, MD, Yusuf, S, et al. Dabigatran versus warfarin in patients with atrial fibrillation. N Engl J Med 2009; 361:1139.

Dr KK Aggarwal
Chief Editor

Women living with partners may be more likely to gain weight
A study in the Jan. issue of the American Journal of Preventive Medicine has found evidence that women who live with a mate put on more pounds than those who live without one.

Age important factor in determining risk for abdominal surgery
According to a study published in the Dec. issue of the Archives of Surgery, common abdominal surgery like removal of the uterus or the gallbladder may pose a greater risk to older patients than generally reported.

Medical community still at odds regarding breech deliveries
The issue has recently come under limelight following a decision last June by the Society of Obstetricians and Gynaecologists of Canada to reverse past opposition to natural deliveries and suggest that planned vaginal delivery is reasonable in selected women.
The American College of Obstetricians and Gynecologists, however, remains firmly opposed to vaginal deliveries of breech babies, warning of the dangers of the head becoming trapped inside the mother; of neck injuries and paralysis, if the baby is extracted incorrectly and of pressure on the umbilical cord that could shut off blood supply to the baby.

Smoking cessation may increase type 2 diabetes risk
Former smokers have a greater risk of developing diabetes than smokers or nonsmokers, according to a study published in the Jan. 5 issue of Annals of Internal Medicine.

IOM calls for educating public, medical community about hepatitis B and C
A paper appearing in the National Academy of Sciences reveals that hepatitis B and C remain serious threats to public health. Most of the estimated 3-5 million people with chronic hepatitis B or C do not know they have the disease, and by the time they start to show symptoms, they may have developed scarring of the liver or liver cancer and may be close to death. Investigators at the Institute of Medicine also predict that in the next 10 years, these two liver damaging infections will kill about 150,000 people in the US alone.

Spine immobilization double trauma patients' mortality risk
Johns Hopkins researchers maintain that the mortality risk doubles for trauma patients who have been immobilized to prevent paralysis.

Psychiatrist questions effectiveness of antidepressants
Psychiatrist Richard A. Friedman, in the Journal of the American Medical Association, questioned the effectiveness of antidepressants, saying that for most patients with mild to moderate cases of depression, the most commonly used antidepressants are generally no better than a placebo.

Time spent watching TV linked to increased risk of death
According to a study published in the journal Circulation, every hour of daily TV watching increases the risk of dying from any cause by 11 percent. For cardiovascular diseases, the increased risk was 18 percent, and for cancer it was nine percent. When compared with those who watched TV for less than two hours per day, those who watched TV for more than four hours each day had an 80 percent increased risk of dying early from cardiovascular disease and a 46 percent increased risk of dying from any cause.

Readers Responses
1. Dear K K Aggarwal: Please accept my heartiest congratulations.You have made all the doctors of DMA proud.
Dr Narender Saini. President (elect) DMA

2. heartiest congratulations dr.agarwal on the national award. we are all happy for you.sushil dutt salwan

3. Dear Dr Aggarwal, Heartiest Congratulations for receiving the prestigious PADMA SHRI AWARD.
You are doing excellent work in updating the knowledge of your numerous readers. DR Hozie Kapadia. Hon State Sec IMA Mah State

4. Respected Dr. K K Agarwaal: Heartiest congragulations to you for getting the Padmashri.Peple like you really deserve it. I think you should be given some award for your medical journalism as well.I am an ardent follower of e medinews and have introduced many of my colleagues to this daily.All the best.Continue the good work for all of us. Warm regards. Dr. Suchanda B. Neurosurgeon, Hyderabad.

5. Dear dr.kk heartiest congratulations may  god give you strength and good heaith to continue your endeavours  and achieve more such laurels. Ravi Bindra

6. Dear Sir,Heartiest congratulation on your getting PADAMSHREE Award. Wish you all the more in future.Thanx for being a milestone in Doctor's community. Dr. Suman Kumar Baranwaal

7. Dr KK Aggarwal, Cogratulations  for being awarded Padmashree. R. M. hattar

8. Dear Dr K.K. Heartiest congratulations to you for being conferred with Padmashree award. Keep it up, best of luck. Dr. V. K. Jain

9. Congratulatins Dr KK : You made us proud, Humility and Hard work are some thing to learn from You. From where do you get so much positive  energy and attitude. Dr S K Gupta

10. Respected Dr. KK, Padamshri is not an honour for U only but for our proffession too. Dr. Ashok Gupta.

11. Dear Dr. K.K: Kindly accept our heartiest congratulations for receiving the Padma shri award on the occasion of republic day.  It was long overdue but it is never too late.  We wish that you get the highest award of the country next year.  Hard work never goes waste and you have proved it.  God bless you and give you enough strength to continue the good work you are doing  for the medical fraternity in particular and for the general public.  Regards. DR. Asha Ahooja, Ashok Ahooja

12. Heartiest congratulations,u r the real gem, v r proud of u; Satish Chetal

13. Dear dr kk aggarwal. Mny congratulations and best wishes. Keep it up.T R Bedi

14. Heartiest Congratulations for the prestigious award. Trying to recognise the issue and problem of health in totality,followed by seeking the solutions and spreading the message not only to medical fraternity but to masses to the maximum possible extent single handedly requires the type of tremendous efforts exercised by you,Sir. Thanks very much for your contribution to the society as a whole and thanks to government for this recognition. Warm regards and best wishes for many more contributions and recognitions. Dr.Uma Pant.

15. Respected Sir,Congratulations for the Padama Shri award.You dedicated your life as an esteemed teacher making so many students,spreading medical education by journals & above all reaching the community by social activities. you have been only the one to put in all your energy & talent with full force of volunteers to organize HEALTH MELA every year WITH Delhi administration.No one else could have been so persistent.Thanks for keeping us updated with 2009 Revisting by webcasting. With due Regards. Dr dibendujoy verma

16. congratulation to Dr. KK  for getting such unique award making doctor profession proud. Dr O P Jain

17. Hard work does get recognised.  may you get more accolades. Dr Yashoda Lohia

18. Dear Dr Aggarwal, Please accept my heatiest congratulations on your well desrved award of Padma shri. You are bringing good tidings and knowledge to a very large no. of doctors through the medium of the E-medinews. Please keep it up because there is no better task that distributing good knowledge. We all as a family facilitate and congratulate you on this happy occassion and wishing you many more honoursa nd awards. Wirh best regards,Dr SC MARWAHA, Mrs Sarita Marwaha, Dr Ashwin Marwaha, Dr Pooja Bhatia Marwah, And most of all Our 7 weeks old ADITI Marwaha

19. Dear K.K. Heartiest congratulations!! You made it. Dr. Shekhar Agarwal

20. Dear Dr Aggarwal: Heartiest Congratulations on recieving Padma Shri Award.You have made all of us proud sir. Regards, Dr I V B Raju

21. Dear Dr. Aggarwal: Congratulations on the well deserved Padma National award.
God bless. John dayal



24. Heartiest congratulations sir for PADAMSHREE, Dr chandan choudhary, Urologist, Stone and prostate clinic

25. Dear KK, Congratulations! You truly deserve PadmaShree for your dedication, committment and alll round contribution to Medical profession n cause of Humanity.It is just a milestone in your life; I know you are destined n deserve to go far.Dr Anil K Yadava

26. Dear Dr KK Aggarwal: Vanakkam, Hearty Congrats for a well deserved honour, We feel proud of your May God Bless you with many more laurels, LET IMA'S LIGHT ALWAYS SHINE, Sincerely DR L V M Moorthy

27. Sir, kindly receive my heartiest congratulations on being honoured with The Padama award. Dr A K WAHAL,         Anaesthetist, Hindu Rao Hospital

28. Hearty congratulations to DR.K.K. AGGARWAL for padamshree award,and i know you deserve many more DR. UMESH K. MALHOTRA. VICE PRESIDENT. I M A -WESTOWN

29. Respected Sir, Heartiest congratulations.It's a great news indeed. Regards. Dr. Neeraj Gupta.

30. congratulations on being conferred padma sri set still higher goals. Dr Ram Prasad

31. Sir, Heartiest Congratulations on getting the prestigious award.Dr Rajnish Gupta

32. Hi Dr K K Aggarwal, HEARTIEST CONGRATULATIONS, you are great.Dr Raj Kumar Ahuja

33. Dear Dr K K, Heartiest Congratulations for Padma Shree. We are delighted. Rgds, Dr. Varesh Nagrath, Deora Sadar, UP

34. Dear Dr. Aggarwal,Please accept my heartiest congratulations on being awarded PADMASHRI. Regards, Dr.Brijender  Mehta and Dr.Shashi Mehta


36. CONGRATS DEAR KK, YOU desrve this, all best, DR VKA/sushma

Punjab & Sind Bank
Central Bank of India
Our HIP's

Question of the Day: What are prognostic indicators in malaria?
The major indicators of a poor prognosis in children and adults with severe malaria are listed below.

Clinical indicators:
Age under 3 years
Deep coma

Witnessed or reported convulsions
Absent corneal reflexes
Decerebrate/decorticate rigidity or opisthotonus
Clinical signs of organ dysfunction (e.g., renal failure, pulmonary edema)
Respiratory distress (acidosis)
Circulatory collapse
Papilloedema and/or retinal edema

Laboratory indicators :
Hyperparasitemia (>250 000/Ál or >5%)
Peripheral schizontemia
Peripheral blood polymorphonuclear leukocytosis (>12 000/Ál)
Mature pigmented parasites (>20% of parasites)
Peripheral blood polymorphonuclear leukocytes with visible malaria pigment (>5%) Packed cell volume <15%
Hemoglobin <5 g/dl
Blood glucose <2.2 mmol/l (<40 mg/dl)
Blood urea > 60 mg/dl
Serum creatinine > 265 Ámol/l (>3.0 mg/dl)
High CSF lactic acid (>6 mmol/l) and low CSF glucose
Raised venous lactic acid (>5 mmol/l)
More than 3-fold elevation of serum enzymes (aminotransferases)
Increased plasma 5'-nucleotidase
Low antithrombin III levels
Very high plasma concentrations of TNF
(Source: A Practical Handbook 2nd Edition, WHO Geneva 2000)

Dr Good Dr Bad
Situation:A patient was to undergo GI endoscopy.
Dr Bad: Take bacterial prophylaxis.
Dr Good: There is no need to take any antibiotics.
Lesson: The AHA recommends that antimicrobial prophylaxis be given only to patients with high-risk heart valve lesions that are predisposed to the development of endocarditis if they undergo procedures that are likely to result in a bacteremia with a microorganism that has the potential ability to cause endocarditis. They no longer consider any GI procedure high risk and, therefore, do not recommend the routine use of infective endocarditis (IE) prophylaxis even in high risk patients.

Make Sure
A 70-year-old male with antibiotic-associated diarrhea and TLC of 24000 per cu mm died.
Reaction: Oh my God! Why was surgery not considered in this case?
Make sure that urgent surgical evaluation is done in patients with acute gastroenteritis who are =65 years and have a white blood cell count =20,000 cells/microL and/or a plasma lactate between 2.2 and 4.9 mEq/L.

Formulae in Imaging
A small pneumothorax can be more easily detected in the lateral decubitus view. In this position, as little as 5 ml of pleural gas is visible on the non-dependent side (Source: Radiology 1992;183:193)

Mistakes in Critical Care
Never write 5.0 mg as it can be read as 50 mg. Instead, write as 5 mg.

ENT Facts
The preferred antibacterial drug for the patient with acute otitis media (AOM) must be active against S. pneumoniae, H. influenzae and M. catarrhalis.

Emedinews Try this It Works
To differentiate between a systolic cardiac outflow murmur, a proximal carotid bruit, and a proximal left subclavian bruit

Place a blood pressure cuff on left arm of the patient and inflate it past his or her systolic pressure. The maneuver attenuates an ipsilateral subclavian bruit (by reducing blood flow, and thus turbulence, through that vessel); augments an ipsilateral carotid bruit (by shunting more blood to that vessel) and does not appreciably affect a cardiac outflow murmur.

Milestones in Neurology
Camillo Golgi was an Italian physician and scientist who discovered the Golgi's method which is a nervous tissue staining technique in 1873. It was initially called the black reaction (reazione nera) by Golgi, but later became better known as the Golgi stain or method. He also discovered a tendon sensory organ that bears his name Golgi receptor.

Laughter the Best Medicine
Did you hear about the baby born in the high tech delivery room? It was cordless!

SMS Anemia
Abnormal cells mean nucleated RBCs, blasts, atypical mononuclear cells and/or abnormal increases or decreases in absolute counts for granulocytes, lymphocytes, monocytes, or platelets.

What will be the consequence of non-compliance of provisions of Income Tax Act?
In such a case, the doctor will be liable to penalties. But if he gives reasonable cause for the default made, then he may not be liable to penalties.

Prayer is the soul's sincere desire, uttered or unexpressed; the motion of a hidden fire, that trembles in the breast. (James Montgomery)

BRSM Debate Continues : Open letter to the Health Minister
To, Honorable. Shri Gulam Nabi Azad, Union Minister for Health & Family Welfare Sub: Offering Safe Rural Health
Respected Sir, Warm Greetings from Commonwealth Medical Association, UK.
I am happy to know your concern to uplift the health of Rural Masses of India. It is a timely move and a necessity for our country towards creating a 'strong India'. As a senior physician practicing at a semiurban / Rural area in Tamil Nadu and President Commonwealth Medical Association, I submit to your goodself that 'Government must offer only safe Health Care to Rural or urban citizen of our Nation' Rural lives or urban are same and equal as per constitution The Proposed BRMS course will create chaos, confusion, litigations and compromised Health Care to the Rural Indians. Moreover the laws necessary to make, to violate and modify are much more and also the financial provisional needed is large.
If you can implement the following three suggestions we donĺt need legal tampering or huge financial implications:
1. Add 25 seats in the District Medical Colleges and reserve as quota for rural children.
2. Two years of Rural service is essential to apply for Post Graduate Education either in Government / Private Medical Colleges.
3. Offer support and Tax benefits for setting up clinics in Rural areas. BRMS will offer compromised health workers only after 4 years.
The above solutions will offer safe and equal health care to the Rural Indians tomorrow itself. You are well aware of the failures of short-term medical courses and Health workers, like Barefoot Doctors, Nurse practitioners both in India & overseas. I request you to create healthcare, which is friendly to the Profession and Rural citizens of India. I learn that you are organizing a meeting of 'Custodians of Medical Education in India' on 4th & 5th February 2010 at New Delhi. Kindly include me in the list of Invitees & permit me to hear the wisdom of our Medical Educationists which will help me to takeup health issues effectively both in India & WHO. (Dr. S. Arulrhaj, MD. President Commonwealth Medical Association, UK)

Dr Kunal Saha MD, PhD: Hello all, We have filed an intervention petition at the Delhi High Court in the pending PIL (seeking to allow the short-term medical course to produce more doctors for Indian villages). As our petition shows, the idea for a 3-year new medical course under the guise of helping the rural people was created with a vested interest. We must stop it. This matter will come up for hearing on Wednesday (Jan. 27). (President, People for Better Treatment (PBT), Columbus, Ohio, USA, Tel: 614-893-6772)

Dr R V Asokan: Dear All, this is regarding a PIL before Hon. High Court of Delhi. The considered opinion of MCI for the PIL will evoke surprise. What MCI has done is breach of trust and amounts to treason. (Dean Hospital, Punalur 691305, Kerala, India)

(Advertorial section)

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eMedinewS-revisiting 2010

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