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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; Chairman Ethical Committee 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 July, 2010, Wednesday

For regular emedinews updates follow at www.twitter.com/DrKKAggarwal

Measuring blood pressure (Part 1)

Measuring BP is an expert’s job. It’s not the job of quacks, paramedics or the patients to learn it as they invariably will default. Most often doctors default on this very essential part of examination. Accurate measurement of blood pressure (BP) is important not only to diagnose but treat high BP as well.

Even 2-5 mm variation can make a difference in the treatment. A 5 mm reduction in BP can reduce chances of heart attack by 21%.

Today, I discuss the significant aspects of this very basic but crucial technique of measuring blood pressure, which may be a revision for most of us.

  1. Correct measurement and interpretation of BP is essential.
  2. Proper machine calibration, training of personnel, positioning of patient, and selection of cuff size are essential.
  3. Most doctors do not follow correct steps leading to potential errors in diagnosis and management.
  4. Time of measurement: To diagnose high BP, multiple readings should be taken at various times throughout the waking hours. To monitor treatment, BP should be measured before anti BP drugs are taken. If BP is measured soon after a drug has been taken, it may be normal or even below normal; it will gradually increase to potentially hypertensive levels until the next dose is taken.
  5. Factors that influence BP, such as food intake, strenuous exercise (can lower the BP), smoking and caffeine, should be avoided in the 60 minutes prior to evaluation.
  6. Smoking transiently raises the BP. One may underestimate BP in a heavy smoker who has not smoked for more than 30 minutes before the BP is measured.
  7. Caffeine intake can raise the BP acutely in non habitual coffee drinkers.
  8. Measuring BP in a cool room (12ºC or 54ºF) or while the patient is talking can raise the BP value by 8 to 15 mm Hg.
  9. Type of BP instrument: Mercury sphygmomanometers are the most accurate. Aneroid instruments should be checked against a mercury device since the air gauge may be in error.
  10. Automated oscillometric BP measuring devices are now available. The readings are typically lower than BP obtained with the auscultatory method. The oscillometric method has a somewhat greater inherent error and requires a proper AC atmosphere. Proper timing, patient positioning, cuff size and placement are still necessary, as is evaluation of machine accuracy at periodic intervals.
  11. Cuff size: Use of a proper-sized cuff is essential. If too small a cuff is used, the pressure generated by inflating the cuff may not be fully transmitted to the brachial artery; in this setting, the pressure in the cuff may be considerably higher than the intra arterial pressure, which can lead to overestimation of the upper systolic pressure by as much as 10 to 50 mm Hg in obese patients.
  12. The length of the BP cuff bladder should be 80 %, and the width at least 40 % (46%) of the circumference of the upper arm. This is often difficult to achieve in obese patients.
  13. Appropriate cuff size for a designated arm circumference
    • Arm circumference 22 to 26 cm: 'small adult' cuff, 12 x 22 cm
    • Arm circumference 27 to 34 cm: 'adult' cuff, 16 x 30 cm
    • Arm circumference 35 to 44 cm: 'large adult' cuff, 16 x 36 cm
    • Arm circumference 45 to 52 cm: 'adult thigh' cuff, 16 x 42 cm
  14. A lack of manufacturing standards also results in designated cuffs differing by several cm in both width and length depending on the manufacturer.
  15.  Pseudohypertension: This is a condition of falsely elevated BP and is found in patients with stiff vessels due to marked arterial calcification. Here, compression of the brachial artery requires a cuff pressure greater than systolic. Pseudohypertension is characterized by systolic upper and diastolic lower pressures estimated from the sphygmomanometer that are ≥10 mm Hg above the directly measured intra arterial or oscillometric pressure.
  16.  Patient position: The BP should be taken in the sitting position with the back supported. Supine values are different, with the systolic pressure higher by 2 to 3 mmHg and the diastolic pressure lower by a similar degree.
  17. In the elderly, supine and standing measurements should always be taken to detect postural hypotension (fall of BP on standing).
  18. The arm should be supported at the level of the heart.
  19. Allowing the arm to hang down when the patient is sitting or standing will result in the brachial artery being 15 cm below the heart. As a result, the measured BP will be elevated by 10 to 12 mm Hg due to the added hydrostatic pressure induced by gravity. The opposite is true if the arm is above the level of the heart.
  20. The mercury manometer should be visible but does not have to be at the level of the heart.
  21. The patient should sit quietly for five minutes before the BP is measured. 

Dr KK Aggarwal
Editor in Chief
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Photo Feature (From HCFI file)

 BSNL Dil ka Darbar

Heart Care Foundation of India (HCFI) announced the dates of BSNL Dil ka Darbar, a unique one-day interactive public forum, at a press conference on August 26, 2009

 In this Photo: Acharya Dr Sadhna Ji Maharaj, Chairperson, World Fellowship of Religions; Famous model, Ms. Sonalika Sahay at the Press Conference. Also in the photo Padma Shri and Dr. B C Roy National Awardee Dr K K Aggarwal, President HCFI

Dr k k Aggarwal


News and views

Say NO TO STEROIDS when managing a case of Aplastic Anemia

(Dr Rahul Bhargava MD (Medicine), DM (Clinical Hematology), Consultant Hematology and Bone Marrow Transplant, Medanta Medicity)

  1. Aplastic anaemia is caused by the inability of bone marrow to produce its normal components.
  2. High index of suspicion is needed in a case of pancytopenia.
  3. Diagnose early by doing bone marrow aspiration and biopsy as early diagnoses is a key to better outcome
  4. Never use steroids in aplastic anemia because of two reasons.
    • It predisposes the patients to unprecedented infections.
    • One in 100 case of acute leukemia will be missed.

  5. Do not transfuse until it is absolute necessary as it causes alloimmunization.
  6. Transfusion guidelines in adults: Hb < 8.0 gm/dl, Platelets – 1 SDP or 6 RDP, No fever < 10000 cu/mm; With fever platelet < 20000 cu/mm
  7. Definitive treatments are: Allogenic Bone Marrow Transplant, Anti Thymocyte Globulin @ 40 mg/kg/day X 4 days + cyclosporine
  8. Early diagnoses, minimal transfusion and aggressive treatment are the key components in the successful management of aplastic anemia.

Albumin:creatinine ratio from firstvoid urine sample best predicts future renal events in diabetic nephropathy

In a study, the albumin:creatinine ratio from a firstvoid urine sample significantly outperformed other parameters for predicting future renal events in patients with diabetic nephropathy.The study findings are published in the Journal of the American Society of Nephrology

Adding azathioprine to corticosteroid treatment for IgA nephropathy offers no extra benefits

A study published online July 15 in the Journal of the American Society of Nephrology reports that administration of a low dose of the immunosuppressant azathioprinein patients with IgA nephropathy did not add any benefit to corticosteroid treatment.

Depressive symptoms may increase risk of cardiovascular events in men with ED

The presence of depressive symptoms increased the risk of cardiovascular events in men with erectile dysfunction, according to a study published in the Journal of Sexual Medicine.


Legal Column

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

What is conduct money for doctors?

Conduct money is the fee offered or paid to a medical witness in civil cases, at the time of serving the summons to meet their expenses to attend the Court. The exact amount of fee received by doctor as conduct money must be communicated to the honorable court. The amount of conduct money must be accepted with good intention as an ethical right and should never be in excess and unjustifiable. If the fee is not paid to the doctor who has been summoned by a civil court/or if he feels that the amount is less, the doctor can bring this fact to the notice of the Judge before giving evidence in the Court on the date of appearance or send his justified demand to the honorable court and request for another convenient date to appear in the court of law. The Judge will decide the amount to be paid to the doctor as conduct money.


Experts’ Views

Interesting Tips in Hepatology & Gastroenterology

(Dr. Neelam Mohan – Director Pediatric Gastroenterology, Hepatology and Liver Transplantation Medanta Medicity)

Gastroesophageal Reflux Disease in Children (cont…)

Management of GERD

Lifestyle changes/ Small frequent feeds

Many infants often can be treated effectively with small or more frequent feedings. Continuous infusions, either by nasal, gastric, or even postduodenal tubes, have been shown to be successful in getting adequate weight gain and may allow surgical intervention to be avoided in infants in whom the risk is unacceptably high.

Question of the Day

What are the indications for coronary angioplasty in patients of unstable angina? (Dr. Sudhir Vaishnav)

PCI is an effective means of reducing coronary obstruction, improving acute ischemia and improving regional and global left ventricular function in patients with unstable angina.
- High risk patients of unstable angina: includes those with prolonged ongoing (>20 minutes) chest pain, pulmonary edema or worsening mitral regurgitation, dynamic ST segment depression of 1 mm or greater, or hypotension.
- Patients of unstable angina at intermediaterisk include: angina at rest (>20 minutes) that is relieved with rest or sublingual nitroglycerin, angina associated with dynamic electrocardiographic changes, recent-onset angina with a high likelihood of CAD, pathological Q waves or ST segment depression <1 mm in multiple leads or age older than 65 years.

Among patients with borderline LVD (ejection fraction between 40 and 50%) and milder degrees of ischemia, PCI may provide adequate revascularization. Recent data in large trials with drug coated stents suggest that results of multivessel stenting are as good as CABG. Re-stenosis has significantly reduced following widespread usage of drugcoated stents in patients of multivessel disease with or without diabetes.

Presence of thrombus in a patient of unstable angina is associated with increased risk of acute complications, such as abrupt closure or MI (vs patients with stable angina or those without it). Thus, use of glycoprotein IIb/IIIa inhibitors in such patients is associated with improved PCI outcomes.


Public Forum (Press Release for use by the newspapers)

Chaturmas: Time to strengthen inner healing

The "Chaturmas" begins on the Ekadashi in the month of 'Ashadha' and ends with the Ekadashi in the month of 'Kartik.' It has both spiritual and health implications said Acharya Sadhvi Dr Sadhna Ji Maharaj, Maha Mandeleshwar Swamy Dayanand Sarswati and Padma Shri and Dr B C Roy National Awardee Dr KK Aggarwal, President Heart Care Foundation of India & MTNL Perfect Health Mela, in a press conference here today organized by World Fellowship for Religions and Heart Care Foundation of India.

Indian farmers depend on monsoon. Months of monsoon are synchronized with four holy months of the year. These four months, called ‘Chaturmas’ coincide with many festivals. Chaturmas beging with Guru Poornima, a festival to worship your teacher or an indication that for the next four months one will have a lot of time to learn because of rains.

Next is the month of ‘Sravana’, in which Mondays are worshiped for Lord Shiva. The Narali Poornima in this month marks the end of heavy rain; the throwing of the coconut in the sea appeases the sea and it calms down. Nag Panchami and Gokul Ashtami are part of this month. ‘Bhadrapad’ is the next month of festivals. The first half is dedicated to the worship of Ganapati, the Lord of removal of obstacles. The second half are the "Shradhs" when religious ceremonies are held in memory of the departed souls. The month of ‘Ashwin’ starts with the "Navratri", through Dusshera and Diwali. Kojagiri Poornima in this month is the most bright poornima. The last two days of Ashwin and the first two days of Kartik are usually the days of the Diwali festival.

‘Fasting’ is the main part of any religious festival. The Mondays in the month of Sravan, Gokul Ashtami and Ekadashi are all days of fast.

The days of monsoon are not usually healthy days. For doctors, it is healthy season as regards their practice, because they get a large number of patients.

Health implications

  • In the monsoon, all the three doshas (movement, metabolism and structure) are vitiated. Light diet and less oily food are advised, as digestive power is weak.Vata is in imbalance in the varsha ritu and pitta in the sharad ritu.
  • As digestive fire is weak in rainy season, stomach upsets are common.
  • Most ground worms come to the surface and contaminate underground and surface vegetables. Community feasts, marriages, social functions, gatherings are therefore prohibited in this season.
  • River water gets contaminated.
  • Snakes come out and snakes bites are common. Naga Panchmi represents not to kill them unnecessarily as most of them are not poisonous.
  • Green leafy vegetables are avoided in the month of ‘Sravan’, Curd in ‘Bhadrapad,’ Milk in ‘Ashwin.’ Pulses (split variety) and oils should be avoided during ‘Kartik.’ The reason is that in rainy season Vata dosha is aggravated (vegetables aggravate vata) and pitta is accumulating. Pitta producing foods are therefore avoided (curd and fermented foods in bhado). In Kartik, the kapha is accumulating and hence oils are restricted. In allopathy: vata is movement, pitta is metabolism and kapha is structural functions.
  • In general, one should abstain from tea, coffee, sugar, rice, wheat etc and avoid garlic and onion as they may cause unnecessary excitements and cause indigestion.
  • Chaturmas is the time to meditate, read spiritual scriptures, and strengthen inner immunity by meditation.

Commonwealth Medical Association 

Dr. S. Arulrhaj, MD., FRCP (Glasg), President 

Commonwealth Foundation: The functions of the Foundation will be:

  • To support attendance at conferences, seminars, symposia, workshops, short courses and other such activities.
  • To assist professional and other non–governmental bodies at the national, regional and Commonwealth level.
  • To facilitate advisory, exchange and study visits and training attachments.
  • To stimulate the flow of information between professional and other non–governmental bodies.
  • To stimulate and support any other activities which fall within the Foundation’s areas of interest by any other means that may be thought fit by the board.

An Inspirational Story (Dr Anupam Sethi Malhotra)

Bad by name: bad by nature?

During Nelson Mandela’s 19 years imprisoned on Robben Island, one particular commanding officer was the most brutal of them all:

"A few days before Badenhorst’s departure, I was called to the main office. General Steyn was visiting the island and wanted to know if we had any complaints. Badenhorst was there as I went through a list of demands. When I had finished, Badenhorst spoke to me directly.

He told me he would be leaving the island and added: ‘I just want to wish you people good luck’. I do not know if I looked dumbfounded, but I was amazed. He spoke these words like a human being and showed a side of himself we had never seen before. I thanked him for his good wishes and wished him luck in his endeavours.

I thought about this moment for a long time afterwards. Badenhorst had perhaps been the most callous and barbaric commanding officer we had had on Robben Island. But that day in the office, he had revealed that that there was another side to his nature, a side that had been obscured but still existed.

It was a useful reminder that all men, even the most seemingly cold-blooded, have a core of decency and that, if their hearts are touched, they are capable of changing. Ultimately, Badenhorst was not evil; his inhumanity had been foisted upon him by an inhuman system. He behaved like a brute because he was rewarded for brutish behaviour."

Source: "Long Walk To Fredom" by Nelson Mandela


IJCP Special

Dr Good Dr Bad

Situation: A female with past history of DVT needed a OC prescription.
Dr Bad: Start OC patch (transdermal).
Dr Good: You should not be on OCs.
Lesson: There is a possibility of an increased risk of venous thromboembolism in oral contraceptive patch users.

Make Sure

Situation: A patient with acute fever developed acute bleeding after aspirin was given.
Rection: Oh My God! Why was dengue not ruled out?
Lasson: Make sure that all patient with acute febrile illness are evaluated for dengue as low platelets count can precipitate bleeding in them, if aspirin is given to reduce fever.

Quote of the Day

" Nothing happens …………………………but first a Dream." Carl Sandburg

Are you fit to fly?


  1. Patients with significant comorbidities, pulmonary surgery, or postoperative anemia are at greater risk during flight and should be carefully assessed.

  2. General anesthesia is not usually a concern, but postspinal headache has been reported seven days after a spinal anesthetic, possibly because changes in cabin pressure induced a dural leak.

International Medical Science Academy Update (IMSA)

Physical abuse

In a retrospective review of 258 children younger than three years who had abuserelated fractures, 20 percent had at least one previous physician encounter for the fracture at which the possibility of abuse was not raised


  1. Ravichandiran N, Schuh S, Bejuk M, et al. Delayed identification of pediatric abuserelated fractures. Pediatrics 2010;125:60.

Drug Update

List of Approved drugs from 01.01.2010 TO 30.4.2010

Drug Name


DCI Approval Date

Ferrous ascorbate 100mg + Folic acid 1.1 mg tablet and Omega3fatty acid 200mg capsules combikit

For iron, folic acid & omega3fatty acid deficiency



Medi Finance

Q. Can a doctor claim any deduction on account of expenditure incurred on scientific research?

Ans. Yes, a doctor can claim deduction u/s. 35.


Lab Medicine (Dr Arpan Gandhi and Dr Navin Dang)

Tests measuring bone loss: help evaluate and monitor the rate of bone resorption and formation before treatment and again after treatment

  • Ctelopeptide (Cterminal telopeptide of type 1 collagen (CTx))
  • Deoxypyridinoline (DPD)
  • Pyridinium Crosslinks
  • Tartrateresistant acid phosphatase (TRAP) 5b

Lateral thinking

Read this…………


Ans: man overboard

okay, let’s see if now you’ve got the hang of it


Send in your answer to emedinews@gmail.com


Humor Section


A woman tells her doctor "I want a hysterectomy."
The doctor asks "Why Mrs. Koslowski, you're 77 years old?"
She tells him "I don’t want any grandchildren."

Medical bloopers on medical charts!

Exam of genitalia was completely negative except for the right foot.


Readers Responses

  1. Dear Dr Aggarwal, Why should we have a new symbol and not fight for the exclusive right of the prefix Dr as is everywhere for Medical doctors or PhD doctors only. The tendency for Dental physicians or Ayurvedic Vaidyas or Homoeopaths to use this should be stopped and rather they should have their symbols like Vaidya etc: Dr Pradeep Sharma MD,FAMS, Professor, RP Centre, AIIMS, New Delhi, India
  2. Dear Dr. K.K. Aggarwal, I have been getting emedinews and find it useful in providing practical answers to the medical situations practitioners face in their clinical practice. The initiative is laudable and I wish it a grand success for the benefit of medical fraternity as well as other readers. Congratulations and best wishes: Dr. DC Katoch

  3. Sir Namaskar, your e medicine is a welcome mail and helps us be updated and also relax our mind in between our busy OPD. Dr Bharathi Hassan

  4. Dear Dr. K.K.A: You are doing wonderful service to the Medical fraternity. I appreciate it. I feel that we are facing so many professional problems which need urgent attention. I feel you should include the professional issues along with academics. Some of my observation I want to share with you as below. IMA has to be vigilant against the encroachment by other paramedical on our profession. They want to be at par with or even a step ahead of MBBS course eg. Dr, Pharmacy course, Doctor Physiotherapists, clinical nurses, Optometrists, Doctor clinical psychologist, doctor clinical oncologists-- all wants to belittle doctors and they claim they are best in their field and demands right to practice as doctors. Unless IMA take up these issues, in near future doctors will become a bunch of technicians to diagnose illness and right for treatment will be vested on these groups. Most of the times, we forget our own professional interests and most concerned about public health which nobody cares for except the IMA. First include our professional Issues and then concentrate on other issues. If we don't act now, in near future MBBS will become obsolete. Regards Alex Franklin

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

26th September: BSNL Dil ka Darbar A day–long 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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