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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

28th May, 2010, Friday

Metformin Associated With Decreased B12 Levels

Dear Colleague

Patients on metformin may have a higher risk of decreased levels of vitamin B12 and increased homocysteine levels, according to research published in the May 20 issue of BMJ. In the study Dr Jolien de Jager, of the Academic Medical Center in Amsterdam, the Netherlands, and colleagues randomized 390 patients with type 2 diabetes receiving insulin to either 850 mg metformin or placebo three times daily over 4.3 years and found that metformin was associated with a mean decrease of 19 percent in B12 concentration compared to placebo. The absolute risk of B12 deficiency was 7.2 percentage points higher in the metformin group, the absolute risk of low B12 was 11.2 percentage points higher in the metformin group, and the mean levels of homocysteine were inversely correlated with B12 levels. The conclusion of the study was that long–term treatment with metformin increases the risk of vitamin B12 deficiency, which results in raised homocysteine concentrations. Regular measurement of vitamin B12 concentrations during long–term metformin treatment should be strongly considered.

Medical education to remain under Health Ministry

The Health Ministry has rejected the proposal of Ministry of HRD to bring the medical education under the proposed National Council for Higher Education and Research (NCHER). Medical education cannot be separated from the Health Ministry, said Union Health Minister Ghulam Nabi Azad said. The health ministry has proposed to set up a National Council for Human Resources in Health (NCHRH) as an overarching regulatory body to reform the current regulatory framework and enhance the supply of skilled personnel in the health sector. A task force was formed in June for setting up the NCHRH and the task force submitted its report in July 2009.  The report and draft Bill was circulated to the states for their comments and 13 states have already responded.

Azad has also advised the newly-constituted panel replacing the dissolved MCI to work fairly without fear. Azad asked them to judiciously take all decisions and maintain transparency, honesty and integrity.The new panel would be an autonomous body with double powers. It will include the powers of the MCI and the Health Ministry.  As used to happen earlier where the Ministry had a final say, now the panel’s decision will be considered final. (Source ENS)

Request by DMA

DMA has requested all members to inform DMA Office by email delhimedicalassociation@yahoo.com, or  telephonically 01123271726, 01123285727 or to Dr. Ashwini Dalmiya, Hony. State Secretary (9811542055) alongwith their complete addresses and branch number, in case they are not getting DMA news bulleting published fortnightly.


Dr KK Aggarwal
Padma Shri Awardee and Chief Editor


Photo Feature (From HCFI file)

Promotion of Healthy Habits during Festivities

During festivals, weddings and other celebrations, people tend to damage their own health. Heart Care Foundation of India (HCFI) has regularly educated community about simple measures that can be taken up all through the revelries to avoid the unnecessary burden of illness and prevent from ruining the festive mood.

Dr k k Aggarwal
 Ms. Shibani Kashyap, singer and youth icon and Dr. K. K. Aggarwal, President HCFI, promoting use of herbal colors for Holi.

International Medical Science Academy Update (IMSA): New FDA Drug Update


US FDA has approved telavancin for treatment of complicated skin and skin–structure infections in adults. Although it is at least as effective as vancomycin in clinical studies, telavancin has a higher rate of toxicity and substantially higher cost. (http:// www.astellas.us/ docs/ us/ VIBATIV_PI_Final.pdf).


Mnemonic of the Day (Dr Prachi Garg)

Endotracheal intubation: Differential diagnosis of poor bilateral breath sounds after intubation – DOPE

  • Displaced (usually right mainstem, pyreform fossa, etc.)
  • Obstruction (kinked or bitten tube, mucuous plug, etc.)
  • Pneumothorax (collapsed lung)
  • Esophagus

News and Views

Lenalidomide significantly prolongs progression–free survival in multiple myeloma

In a trial, maintenance therapy with lenalidomide doubled the rate of progression–free survival, compared with placebo for multiple myeloma patients who had completed autologous stem cell transplantation and a lenalidomide consolidation phase. In lenalidomide-treated patients, the 3–year progression–free survival rate until relapse was 68% vs 34% for patients who received placebo. According to the authors of the study, this difference translates into a 54% reduction in multiple myeloma progression (hazard ratio 0.46). The study findings will be presented at the American Society of Clinical Oncology annual meeting on June 6.

GERD patients on PPIs find it impossible to discontinue therapy

A new Danish study suggests that patients become "addicted" to acid suppression and it is not an easy task to wean off patients with GERD on PPIs. According to the authors of the study, PPIs are nearly impossible to discontinue, even for patients who lack a formal indication for their use. Long term PPIs could be discontinued only in a small number of patients and that most patients who experienced relapse of their symptoms after stopping the drug had no abnormal findings on endoscopy. Rapid recurrence of typical reflux symptoms was the main reason for restarting therapy. Esomeprazole given for 7 days was of help, regardless of the normal findings on endoscopy. The results were presented at Digestive Disease Week.

New fathers too go through postpartum depression

A meta–analysis in the May 19, 2010, issue of JAMA reports that about 10% of new fathers are affected by prenatal and postpartum depression. Studies that reported depression in fathers occurring between the first trimester of pregnancy through to the first postpartum year were reviewed. The estimated rate of paternal depression was 10.4%. The rate was highest during the 3– to 6–month postpartum period, 25.6%; and lowest during the first 3 months postpartum, 7.7%.

Effective Antibiotic Prescribing (Dr. GM Singh)

Top 10 Tips

  1. Start antibiotic treatment immediately in patients with life–threatening infection.

  2. Prescribe in accordance with local policies and guidelines avoiding broad spectrum agents.

  3. Document, in clinical notes, indication(s) for prescribing antibiotics.

  4. Send appropriate specimens to the microbiology lab draining pus and removing foreign bodies if indicated.

  5. Use antimicrobial susceptibility data to de–escalate/ substitute/ add agents and to switch from intravenous to oral therapy.

  6. Prescribe the shortest antibiotic course likely to be effective.

  7. Always select agents to minimize collateral damage (i.e. selection of multi–resistant bacteria / Clostridium difficile).

  8. Monitor antibiotic drug levels when relevant (e.g. vancomycin).

  9. Use single dose antibiotic prophylaxis wherever possible.

  10. Consult your local infection experts

Quote of the day (Prakash Rajpal)

Learn to talk to each other instead of talking about each other.

Question of the Day

How can giardiasis be prevented?

  • Drink only water that has been treated in established treatment facilities.

  • If there is any doubt about the adequacy of the treatment of water, boil the water or filter it through a filter with a pore size of <1 micrometer, which will remove trophozoites and cysts.

  • Do not drink from fresh water streams or lakes without boiling or filtering the water.

  • Do not use ice or drink beverages made from tap water that may be contaminated.

  • Do not brush teeth with tap water that may be contaminated.

  • Do not eat uncooked or unpeeled fruits or vegetables grown in conditions in which Giardia contamination might occur.

  • Wash hands before eating food; after changing diapers; using the bathroom, or touching pets.

  • Avoid oral/anal sex.

Liver Fact

SGPT may be normal in patients with severe alcoholic liver disease.

World No Tobacco Day 31st May

Roman Catholic: His Holiness Pope John Paul II in his Bull of Indiction of the Great Jubilee Year 2000 called for all Christian men and women on goodwill to abstain from consuming tobacco products for a day with the provision that monetary equivalents of one day smoking be donated to the efforts to control the HIV AIDS epidemic and to assist those affected by this epidemic.

eMedinewS Try this it Works

Simple test for sensory loss

In patients with neuropathy, nylon monofilament can be used to administer a simple test of sensory loss. The end of the monofilament is touched against the bottom of the foot and moved toward the foot until the monofilament buckles, thus ensuring that a known and consistent force has been applied. Patients who cannot feel a pricking sensation from the monofilament have increased risk of neuropathic foot injury.

Dr Good Dr Bad

Situation: A diabetic patient developed depression.
Dr Bad: Its ok to have mild depression in diabetics.
Dr Good: You need treatment.
Lesson: Depression has been associated with poor glycemic control and with accelerated rates of coronary heart disease in diabetic patients (Arch Intern Med 2007;167:1137).

Make Sure

Situation: A patient of filariasis presenting with left leg swelling seeks a treatment.
Reaction: Oh my God! Why did you prescribe only ivermectin.
Lasson: Make sure to prescribe DEC in patients of filariasis because it is still the treatment needed to kill the adult worm. Ivermectin in a single dose is a potent microfilaricide.

IMANDB Joke of the Day


A shopkeeper, with no conscience, put by his door a box with a slit in the cover and a label reading, "For the Blind." A month later, the box disappeared. When some one inquired concerning it, the shopkeeper chuckled, and pointed to the window.

"I collected enough," he explained. "There’s the new blind."

Formulae in clinical practice

Oxygen Extraction Ratio (O2ER)
Formula: O2ER = {1 – (Vo2/Do2)} × 100
Normal value = 22–32%.

Milestones in Gastroenterology

1843–1918: Ludwig G. Courvoisier was a pioneer in biliary tract. He developed the operation of cholecystectomy and was one of the first surgeons to remove a common bile duct stone. The well–known ‘Courvoisier’s law’ for cancer head of pancreas is named after him

Lab Test (Dr Arpan Gandhi and Dr Navin Dang)

Fine Needle Aspirate Cytology– Reactive Lymphadenopathy: This is a non–neoplastic enlargement in response to antigenic stimuli. It can be caused by proliferation of normal lymph node follicles (lymphoid hyperplasia), or distortion of lymph node.

List of Approved drugs from 1.01.2009 to 31.10.2009

Drug Name


DCI Approval Date

Methyl Phenidate ER Tablet 10/20/30mg

For the treatment of Attention Deficit Hyperactivity Disorder (ADHD)




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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)

Tobacco Products in Urine - A Marker of Passive Smoking

In house holds where either of the parents smoke, infants have 5.5 times higher levels of nicotine by product, called cotinine, in their urine than infants of non-smokers, said Padma Shri and Dr B C Roy National Awardee Dr KK Aggarwal, President Heart Care Foundation of India.

Dr. Aggarwal said that cotinine is created as the body tries to get rid of the nicotine in inhaled smoke.

Quoting a British study published in the Archives of Diseases in Childhood, Dr. Aggarwal said that sleeping with smoker parents is a known risk factor for sudden infant death syndrome. One of the reasons for the same could be the infant proximity to parents clothing or other objects contaminated with smoke particles.

The study included of 104 twelve-week old infants. Seventy-one of them had one of the parents who smoked and 33 had no smoker parents.

The study showed that if the mother smoked, the chances of infant’s urine containing nicotine products was four times higher. If the father smoked, the chances of having nicotine products in the urine of the infant was two times than of a non smoking parent.

The study also showed that sleeping with smoker parents or sleeping in lower temperature rooms was associated with increased nicotine products in the urine of the infants.

Higher levels of nicotine by products in the urine were also observed during colder times of the year indicating more closed door smoking during this period of the year.

Readers Responses

  1. Thank You Dr. KKA, I am regularly going through your medinews. It very good for doctors and also for GPs. You are doing a yeoman service to doctor community. Congratulations and my good wishes. Adding feather to your cap is the article you added about professional and MCI issues: Dr. Alex Franklin

  2. This is with reference to emedinews dated 26th May, 2010, Wednesday and I shall like to add that as per section 21,22.23 and 27 (Reproduced below) of THE INDIAN MEDICAL COUNCIL ACT, 1956

    21(1) The Council shall cause to be maintained in the prescribed manner a register of medical practitioners to be known as the Indian Medical Register, which shall contain the names of all persons who are for the time being enrolled on any State Medical Register and who possess any of the recognised medical qualifications.

    21(2) It shall be the duty of the Registrar of the Council to keep the Indian Medical Register in accordance with the provisions of this Act and of any orders made by the Council, and from time to time to revise the register and publish it in the Gazette of India and in such other manner as may be prescribed.

    21(3) Such register shall be deemed to be public document within the meaning of the Indian Evidence Act, 1872 and may be proved by a copy published in the Gazette of India.

    22. Each State Medical Council shall supply to the Council six printed copies of the State Medical Register as soon as may be after the commencement of this Act and subsequently after the first day of April of each year, and each Registrar of a State Medical Council shall inform the Council without delay of all additions to and other amendments in the State Medical Register made from time to time

    23. The Registrar of the Council, may, on receipt of the report of registration of a person in a State Medical Register or on application made in the prescribed manner by any such person, enter his name in the Indian Medical Register, Provided that the Registrar is satisfied that the person concerned possesses a recognised medical qualification.

    27. Subject to the conditions and restrictions laid down in this Act, regarding medical practice by persons possessing certain recognised medical qualifications, every person whose name is for the time being borne on the Indian Medical Register shall be entitled according to his qualifications to practice as a medical practitioner in any part of India and to recover in due course of law in respect of such practice any expenses, charges in respect of medicaments or other appliances, or any fees to which he may be entitled.

    The link to IMR database has been provided on MCI website and one can browse as per details given below. What is needed is not a new system but proper implementation of existing procedures and rules. For example it has details of only 5081 DMC registered doctors where as actual number is around 25000.

    As far as practising any where in the country is concerned, it is allowed as per section 27 but not agreed upon by DMC. (Dr Kamlesh Kanodia)

    eMedinewS Responds: I agree. But the present system is not effective. It should be mandatory.

  3. Dear all, For Your Urgent Attention and to pass on to your dear and near ones (Sudha)
    I cannot stop myself from sharing this with all of you. It all started when I received a call from someone claiming that he was from my mobile service provider and he asked me to shutdown my phone for 2 hours for 3G update to take place. As I was rushing for a meeting, I did not question and shutdown my cell phone.

    After 45 minutes I felt very suspicious since the caller did not even introduce his name. I quickly turned on my cell phone and I received several calls from my family members and the others were from the number that had called me earlier – 3954380.

    I called my parents and I was shocked that they sounded very worried asking me whether I am safe. My parents told me that they had received a call from someone claiming that they had me with them and asking for money to let me free. The call was so real and my parents even heard ‘my voice’ crying out loud asking for help. My parents were at the bank waiting for next call to proceed for money transfer. I told my parents that I am safe and asked them to lodge a police report. Right after that I received another call from the guy asking me to shutdown my cell phone for another 1 hour which I refused to do and hung up. They keep calling my cell phone until the battery had run down. I myself lodged a police report and I was informed by the officer that there were many such scams reported. MOST of the cases reported that the victim had already transferred the money! And it is impossible to get back the money.

    Be careful as this kind of scam might happened to any of us!!! Those guys are so professional and very convincing during calls. If you are asked to shut down your cell phone for updates by the service provider, ASK AROUND! Your family or friends might receive the same call.

    Be Safe and Stay Alert!

    Please pass around to your family and friends!

  4. Dear Dr. Aggarwal, For Papillary Carcinoma , We should not leave Total/ Near Total Thyroidectomy or delay b'cause the results of t/t vs no t/t are comparable . It must be done to avoid metastasis by lymphatics as the secondarily involved nodes can be far larger than the the primary in thyroid. Usually Pap. Thyroid carcinomas are multifocal and /or multicentric so Only one or two parathyroid should be saved and whole thyroid should be removed----- it's easy to replace by thyroxine even for life time. However, it's recommended to be performed by experts only as chances of Rec. Laryngeal injuries are greater in Total Thyroidectomy. But I know few surgeons in New york are agaist it citing the example " If you walk on the roads of New York in the evenings , your chances of retuning home alive is only 95%". I told them "if you walk in Lagos after 5 pm, your chances of returning home alive is only 80% so surgeons should avoid doing cancer surgery there accordingly!!!!". There was no answer to that. To my experience Providone Iodine are supirior to Chlohedine Alcohol. Infact we put Alcohol in addition to Prov. Iodine. Fazl ur Rahman MS FRCS FACS FICS.