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FIRST NATIONAL DAILY eMEDICAL NEWSPAPER OF INDIA
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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 June, 2010, Monday

Connection between obesity, salt sensitivity & high blood pressure

Georgia doctors have identified how obese people become salt sensitive and hypertensive.

They’ve documented a chain of events in which excess inflammatory factors resulting from excess fat cause the body to retain more sodium and, consequently, more fluid and higher blood pressure. According to Dr. Yanbin Dong, geneticist and cardiologist at MCG’s Georgia Prevention Institute, their findings point to a biomarker in the urine that could one day help physicians identify the most effective therapy for these patients.

Obesity increases inflammation, salt sensitivity and high blood pressure. The process start with fat producing more inflammatory factors, such as interleukin–6, or IL–6.

In the study, mouse kidney cells were exposed to IL–6. Increased production of prostasin, a protease, was found, which typically inhibits a protein’s action by cutting it. But when prostasin cut fellow protein ENaC it increased its activity and so salt reabsorption. ENaC, or epithelial sodium channel, is the last of many kidney channels that determines how much sodium to excrete. Although ENaC calls the shots on a relatively small amount of sodium, it’s significant in a system that is all about balance. In cells fed IL–6, ENaC gets activated and the cells take in more sodium. 

It appears that measuring prostasin in the urine, may be a way to gauge ENaC activity in humans. Doctors are now measuring its levels in obese people with and without hypertension as well as normal–weight individuals. They are hopeful that a simple urine test could one day help identify those at risk for or experiencing this type of inflammation–based hypertension.

Statins and angiotensin antagonists are known to block some aspect of inflammation. Angiotensin antagonists, block production of angiotensin II, which constricts blood vessels and increases IL–6 production. There may be a good reason to prescribe these types of drugs to obese people.

Dr KK Aggarwal
Padma Shri Awardee and Chief Editor

 

Stop Press: Former Medical Council of India President Dr  Ketan Desai, in judicial custody, and was admitted to AIIMS for treatment of a bacterial infection on 11th June was discharged from the hospital on Sunday and sent back to Tihar.

 

 

 

Photo Feature (From HCFI file)

 

Planet Earth Greener Cleaner and Healthier

 

was an initiative from the Heart Care Foundation of India (HCFI) to mark the World Environment Day in 2008.

 

Dr k k Aggarwal

Renowned Kuchipudi exponents Raja Reddy, Radha Reddy and Kaushalya Reddy promoting the cause of Green Planet on World Environment Day. Also in the photo: Padma Shri & Dr BC Roy Awardee Dr K.K. Aggarwal, President HCFI


 

News and views

Car crash trauma often under-detected in elderly (Dr G M Singh)

A study reported in the January issue of the Journal of Emergency Nursing states that elderly people involved in motor vehicle crashes are often undertriaged and inappropriately treated for injuries that go undetected.

Slow–release NSAIDs pose greater risk of GI bleeding (Dr Varesh Nagrath)

A study conducted at the Spanish Centre for Pharmacoepidemiological Research revealed that the risk of gastrointestinal complications due to use of NSAIDs varies according to specific NSAID administered and also by dosage. NSAIDs with a long half–life or slow-release formulation are associated with a greater risk of GI bleeding or perforation. [June issue of Arthritis & Rheumatism.]

Lanreotide may help patients with acromegaly to control their disease
(Dr Monica and Brahm Vasudeva)

A research presented at the Endocrine Society’s 2010 annual meeting finds that in most patients with acromegaly who failed to respond to surgery or radiotherapy, their disease was controlled by treatment with the somatostatin analog lanreotide (Somatuline Depot).

Rheumatoid arthritis patients face double the risk of suffering heart attack

Rheumatoid arthritis patients face a 2fold increased risk of suffering a myocardial infarction vs the general population, which is comparable to the increased risk of MI seen in diabetes patients. [Annual Congress of the European League Against Rheumatism in Rome, Italy].

 

Legal Column

DMC Decision: Error of judgemnt is not a crime

As per DMC/DC/F.14/Comp.563 DATED 12th April, 2010, the Delhi Medical Council examined a complaint of Smt. K forwarded by Directorate of Health Services, alleging medical negligence on the part of Dr. PS, in the treatment administered to her at MA Hospital.

Complainant: Hysterosalpingography report dated 13th August, opined that complainant’s tubes were blocked. She went for IVF treatment, and inspite of her tubes being blocked, the treating doctor treated her with IUI.

Defence: The treating doctor stated that the complainant, during consultation with her, told her verbally that there was no blockage in her tubes. The complainant had never shared with her the Hysterosalpingography report. She also had made it clear and counseled both the husband and wife that due to poor egg formation she was canceling the IVF oocyte pickup procedure, as she had little chances of success if follicle formation is less than 2. She did IUI with good intention of making the complainant pregnant as the doctor was under the impression that her tubes were fine. She only tried to save complainant’s money and invasive procedure and opted for IUI with elaborate discussion with complainant under consent.

The Council observed that the patient went for treatment of infertility. As per the records available, the bilateral fallopian tubes of the patient were blocked. In the event of Bilateral blocked tubes, IUI is not beneficial at all. Such patients require IVF. Patient has signed the consent for IUI procedure despite knowing about her Bilateral blocked tubes. As per the statement of Dr she was told by the patient that her tubes were fine. Doctor should not go by verbal statements of patient. Dr. should have insisted for the report or should have advised fresh tube testing before starting the treatment of infertility. The decision of the Delhi Medical Council was that Dr. P S made an error in judgement albeit with the best of intentions. The Delhi Medical Council, therefore, issued a warning to Dr. PS.

eMedinewS Comments: the warning was not justified as error of judgment is not a lapse. The patient at the most could have gone to the court for compensation.

Forensic Column

Dr Sudhir Gupta, Associate Professor, Forensic Medicine & Toxicology, AIIMS

Legal aspects of Emergency Medicare/Consent to emergency treatment

Section 92 of Indian Penal Code provide legal immunity/protection for a doctor to proceed with appropriate treatment  / medical care with good intention even without the consent of the patient in an emergency situation when the victim is incapable of understanding the nature of the treatment or when there are no legal heirs to sign the consent. It provides for exemption for acts done in good faith. When the patient requires amputation, major surgical intervention the opinion of other doctors, if present, can be obtained.

There are certain situations seen in hospital that the patient is conscious and refuses treatment without which that person might endanger his/her life and the doctor by virtue of being medical professional having the knowledge of the same, then the surgeon/physician/hospital should inform the judicial magistrate/police and get the sovereign power of guardianship over persons for immediate but limited medical/surgical intervention required to save the life under disability means parens patriae.1

In Dr Thomas v Elisa2, it was held that in case of emergency operation the doctor cannot wait for the consent of his patient where the patient is not in a fit state of mind to give consent or to give a conscious/oriented answer regarding consent or where the patient is a minor/mentally ill/insane. However, in K Gracekutty V Dr Annamma Oommen3, even though consent was not taken, it was considered only as a routine procedure lapse, which does not constitute medical negligence in emergent circumstances of the case which needs immediate medical/surgical, diagnostic or/and therapeutic intervention in the imminent interest of patient health and life.

1. AIR 1990 SC 1480
2. AIR 1987 Ker 52(1986) Ker LT 1026(DB)
3. 1992 1 cpr 251 Kerla SCDRC

 

Experts’ Views

Interesting tips in Hepatology & Gastroenterology

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

Manifestations (Coeliac Disease)

Symptomatic disease is just the tip of the iceberg but, because of the availability of new serological tests, we are exploring the hidden CD groups in India. Based on clinical presentation, celiac disease (CD) is broadly classified as diarrheal and nondiarrheal celiac disease (NDCD). Diarrhea is the commonest manifestation in children with CD. The stools are large not well formed and foul smelling. This is usually associated with abnormal distension, pallor and failure to thrive (not gaining weight +/- height). There is usually a delay of 3-6 years from the age of onset of symptoms to the age at diagnosis which is mainly due to lack of awareness among parents and doctors alike.

Because of its protean and subtle symptoms, NDCD can remain undiagnosed for a long period. Use of serologic tests for the diagnosis of CD has further widened the spectrum of NDCD by recognizing silent cases, referred to as potential and latent CD. Thus, in a recent study from the US, only 55% of patients with CD had diarrhea at presentation. Clinical features associated with NDCD are variable. Children often have growth retardation with or without refractory anemia. In a study from India the sole atypical presentations were short stature in 47%, anemia in 65%, constipation in 31%, and rickets in 3% of patients. Common associations observed in children were IgA deficiency in 6%, asthma in 2%, type 1 diabetes in 1.5%, autoimmune hepatitis in 1.5%, seizures in 1.5%, juvenile rheumatoid arthritis in 0.7%, Down syndrome in 0.7%, and nephrotic syndrome in 0.7% of patients.

In adults, refractory anemia, usually iron-deficiency type, and metabolic bone disease are common. Other extraintestinal manifestations include peripheral neuropathy, seizures, ataxia, amenorrhea, infertility, autism, dermatitis herpetiformis, and growth hormone deficiency, and less commonly, epilepsy, Plummer-Vinson syndrome, and recurrent oral ulcerations.

 

Dr k k Aggarwal

 Question of the Day

What care should be exercised by parents when they are giving a pacifier to their baby?

Dr. Swati Bhave & Dr. Alok Gupta

Pacifiers can interfere with establishment of proper lactation. Hence, unless lactatation is well-established one should not start a pacifier.

  • When a baby is hungry it should be fed and not comforted by a pacifier. If a baby is crying, first check all other causes of crying, like hunger, boredom etc before giving a pacifier.

  • If a child continuously has a pacifier in its mouth for the whole day, it will cause malocclusion and also delay speech development.

  • It is better to have a commerciallymade safe pacifier. Homemade pacifiers made out of various things may lead to choking.

  • The pacifier should be kept clean and properly sterilized to prevent infection.

  • They should not be dipped in honey or sweeteners as they can cause caries and infection.

  • Tying the pacifier around the neck has the risk of strangulation. It is better to buy a pacifier with a cover and use a safety clip to fasten to the child’s clothing.

  • If a pacifier is put into the mouth immediately after medicines it can crack. If the child chews on the pacifier it can also crack. These pose a risk of choking. Hence pacifiers should be checked for cracks and thrown away. They should be replaced periodically

How to wean off the child from a pacifier: If proper care is not exercised, pacifier addiction can be as bad as thumb sucking and will need the same principles to stop.

Mental exercise to prevent dementia: Dr Anupam Sethi Malhotra

How did the pear get inside the brandy bottle? It grew inside the bottle. The bottles are placed over pear buds when they are small, and are wired in place on the tree. The bottle is left in place for the entire growing season . When the pears are ripe, they are snipped off at the stems.

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Public Forum (Press Release for use by the newspapers)

Monsoon fever can be deceptive

Any episode of fever during monsoons should not be taken lightly as many diseases can cause fever. The commonest being viral, malaria, dengue or chikungunya. However, fever can also be due to viral jaundice or typhoid. This was stated by Padma Shri and Dr B C Roy National Awardee Dr KK Aggarwal, President Heart Care Foundation of India.

The Heart Care Foundation of India has released following tips for the benefit of the public:

  1. Unless there is clinical suspicion of typhoid, no antibiotics are required.

  2. Viral fever will have cough, eye redness or nasal discharge.

  3. Dengue will have fever with rash and pain in eye movements.

  4. Chikungunya is a triad of fever, rash and joint pain. Typically the joint pain will increase on compression of the wrist joint.

  5. Malaria fever typically will have chills and rigors and will have normal phase in between two episodes of fever.

  6. Fever in the case of jaundice will disappear once the jaundice starts.

  7. Typhoid fever is often continuous with relatively low pulse rate and with toxic feeling.

Precautions

  • No antibiotics are required unless there is a feeling of toxemia.

  • Antibiotics in sore throat are only required if associated with pain in the throat while swallowing food or red, angrylooking tonsils.

  • Except for Paracetamol or Nimesulide, other anti fever medicines should not be used indiscriminately as they can reduce platelet count.

  • Most diseases are selflimiting and take 4 to 7 days to resolve.

  • The basic precaution involves proper hydration, especially on the days when fever is subsiding.

Warning Signals
Any fever with associated comorbid conditions should not be ignored and a doctor should be consulted
.

 

IJCP Special

Dr Good Dr Bad

Situation: A patient with laryngopharyngeal reflux wanted to know whether he could eat chocolates
Dr Bad: You can take.
Dr Good: No, you cannot take.
Lesson: There are caffeine–like substances within chocolates and peppermint that stimulate acid production and weaken the upper esophageal sphincter.

Make Sure

Situation: A patient was denied rheumatic prophylaxis as IM penicillin was under short supply
Reaction: Oh my God! Why was he not given oral penicillin?
Lesson: Make sure that all such cases are not denied oral penicillin V.

Mistakes in Clinical practice

Do not write "TIW" for three times a week: it can be mistaken for "three times a day" or "twice" a week

Mnemonic of the Day (Dr.Varesh Nagrath M.D.)

Causes of Reversible cardiomyopathy

APT PACTS

Alcoholic Cardiomyopathy
Peri partum cardiomyopathy
Thyrotoxicosis
Phosphate deficiency (Chronic)
Addiction (Cocaine)
Calcium deficiency (Chronic)
Tachycardia-induced cardiomyopathy
Selenium deficiency

 

International Medical Science Academy Update (IMSA)

In 2010, the US Centers for Disease Control and Prevention’s Advisory Committee on Immunization Practices expanded the recommendation for influenza vaccination to include all individuals 6 months of age and older (CDC's Advisory Committee on Immunization Practices (ACIP) recommends universal annual influenza vaccination. http://www.cdc.gov/media/pressrel/2010/r100224.htm. (Accessed May 16, 2010). This represents a change for adults from previous guidelines, which recommended influenza vaccination for individuals over age 50 and for those at increased risk of influenza complications and close contacts of such individuals.

Drug Update

List of Approved drugs from 1.01.2009 to 31.10.2009

Drug Name

Indication

DCI Approval Date

Chlorthalidone Tablet 6.25mg

For the treatment of mild to moderate hypertension.

03.10.09

Medifinance

A discount of 10% may be granted on the gross premium under the Family Package Cover.

Lab Medicine

Tests for Asthmatics

Allergy blood testing:blood tests that are specific for the allergen(s) suspected to be causing symptoms, such as dust mites, mold, pet dander, and pollens. May be ordered to help determine asthma triggers. Blood gases: an arterial blood sample is collected to evaluate blood pH, oxygen, and carbon dioxide. May be ordered when a patient is having an asthma attack. CBC (Complete Blood Count): to evaluate blood cells Sputum culture: to diagnose lung infections caused by bacteria .

Other tests:
AFB smear and culture:
to diagnose tuberculosis and nontuberculous mycobacteria (NTM)
Lung biopsy:
to evaluate lung tissue for damage and for cancer;
Sputum cytology: occasionally ordered to evaluate cells found in the lungs. Eosinophils and neutrophils, two types of white blood cells, can be increased with inflammation in some asthma patients.

 

Humor Section

IMANDB Joke of the Day

Stock Broker Patient: Doctor, what should I do if my temperature goes up five more points?

Intensivist: Sell!

Funny Definitions

Coma…………………A punctuation mark

Medical bloopers on medical charts!

On the second day the knee was better and on the third day it had completely disappeared.

 

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

The true spiritual warrior is never afraid to look at what he doesn’t want to see.

 

Readers Responses

1. Sir, your work is so good that there are many who will be jealous, continue with positive outlook and not as saddened man, we are with you: Dr Manvir Gupta, Kotkapura

2. Dear Dr Aggarwal: I highly appreciate ur "never say die" spirit u are really a fighter ,cheers to your efforts in making our system transperent. Thanks. Dr Puneet Wadhwa, Pediatrician, Faridabad.

 

Forthcoming Events

eMedinews Events: Register at emedinews@gmail.com

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.

17th MTNL Perfect Health Mela 2010 Events: Venue: NDMC Ground Laxmi Bai Nagar, New Delhi

24th October, Sunday: Perfect Health Darbar, Interaction with top Medical experts of the city from 8 AM to 5 PM

30th October, Saturday: eMedinewS Update from 8 AM to 5 PM

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

The 2nd 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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