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  From the Desk of Editor–in–Chief
Dr KK Aggarwal

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

  Editorial …

28th January, 2011, Friday                                eMedinewS Presents Audio News of the Day

View Photos and Videos of 2nd eMedinewS – Revisiting 2010

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

Exercise for stronger knees and hips

Strength in the muscles around a damaged knee or hip can help support that joint by taking over some of its responsibilities. For example, your hips have to do less work to support your body weight if your quadriceps, gluteals, hamstrings, and abdominal muscles are stronger.

A strong quadriceps can take over the shock–absorbing role usually played by the meniscus or cartilage in the knee.

The proper balance of strength in the muscles can hold the joint in the most functional and least painful position. With any knee or hip problem, the first muscles to lose strength are the largest antigravity muscles, the quadriceps and gluteals, so an exercise plan for any injury is likely to focus on these.
Muscles work in pairs — one contracts while the opposing one relaxes. For example, when you straighten your knee, your quadriceps on the front of your thigh contracts, and the hamstrings on the back relax. Imbalances in the function of paired muscles can cause joint problems and invite injury. If your hamstrings are tight, your quadriceps can’t contract fully and may weaken, so exercise the quadriceps and hamstrings (the opposing muscles) equally. Flexibility exercises (to stretch and relax specific muscles) are an important part of an exercise plan to improve joint function.

Closed–chain exercising. Physical therapists have emphasized the distinction between open–chain and closed–chain exercises. The chain referred to is a series of body parts, such as a hip, knee, ankle, and foot.

In an open–chain exercise, the body is stationary while the limb moves. In closed–chain exercise, the limb is stationary while the body moves. For example, a squat is a closed–chain exercise because your feet stay stationary while your quadriceps do the work. In contrast, a seated leg extension is an open–chain maneuver, because your seated body is still, but your leg moves as you extend it.

Open–chain exercises may be more effective for particular therapeutic goals such as increasing quadriceps strength after ACL injury. But over all, physical therapists are incorporating more closed–chain exercises into rehabilitation programs and recommending them for people with painful joints because these exercises involve more muscles and joints and help to create stability around a joint. If you have had a knee or hip replacement, gait retraining helps you relearn to stand up straight (the tendency is to lean toward your operated leg) and use both legs evenly. Gait retraining may begin in the pool, where the water’s buoyancy takes weight off the joint, makes it easier to stand up straight, and reduces the fear of falling. (Harvard News Letter)

Dr KK Aggarwal
Editor in Chief
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  eMedinewS Audio PostCard

  2nd eMedinewS Revisiting 2010

Revisiting the year 2010 with Dr KK Aggarwal
Delhi Bug – NDM1

Audio PostCard
  SMS of the Day

(By Dr GM Singh)

Pleasant words are a honeycomb, sweet to the soul and healing to the bones.

    Photo Feature

Healthcare industry salutes excellence

The Arab Health 2011 Awards winners.

(Contributed by Nilesh Aggarwal)

Dr K K Aggarwal
    National News

Certificate courses in 2D and 3D Echocardiography/Fellowship Diploma in non invasive cardiology

Contact Dr KK Aggarwal, Moolchand Medcity, email: emedinews@gmail.com

DCGI to take call on Nimesulide

Nimesulide may be suspended from paediatric use in India too. The Drug Controller General of India (DCGI) Dr Surinder Singh will take a final call on the fate of the drug on Thursday after a meeting with the stakeholders. The DCGI had earlier recommended a ban on the drug to the Union Health Ministry after the sub–committee of the government’s chief advisory body — the Drug Technical Advisory Board (DTAB) — had recommended it. The Ministry, however, had asked the DCGI to have a meeting with the stakeholders so as to hear their side of the story. The DCGI will now alert the Ministry again after the meeting with the manufacturers. (Source: Indian Express, Jan 27 2011)

    International News

(Contributed by Nilesh Aggarwal)

Health Authority - Abu Dhabi to Regulate Antidote Stock Levels in Healthcare Facilities

The Health Authority – Abu Dhabi (HAAD), the regulatory body of the healthcare sector in the Emirate of Abu Dhabi, announced the introduction of the Antidote Stocks standard in Healthcare Facilities. The standard is a guide to healthcare providers to ensure continuous, safe access to and uses of antidotes, used to counteract poisoning, are maintained in all Healthcare Facilities.

Inadequate hospital stocking and the unavailability of essential antidotes is a worldwide problem with potentially disastrous for poisoned patients. Dr. Yasser Sharif, Section Head of Medication & Medical Product Safety and Head of Poison and Drug Information Center, said: "The timely use of antidotes is potentially lifesaving in certain poisonings, maintaining a sufficient stock of antidotes is the responsibility of any facility that provides emergency care. If a poisoned patient requires an antidote that is not stocked at a particular hospital, then either the patient must be transferred or the antidote must be obtained from another hospital."

The new standard is set to maintain a minimum stock amount of each antidote at the ER that is sufficient to treat a 70 kg adult for the first 24 hours of admission for treatment. Under the new standard healthcare facilities will be required to

  • Report to HAAD the antidote stocks level on a monthly basis using the specified reporting form.
  • Establish policies and procedures for effective sharing of antidotes during stock shortages, with other healthcare facilities;
  • Ensure that licensed healthcare professionals are responsible for prescribing and administering antidotes

The standard will act as an interim advisory guide for a period of six month and will become mandatory on 1 June 2011.For more information, please refer to


(Contributed by Rajat Bhatnagar, International Sports & Fitness Distribution, LLC http://www.isfdistribution.com)

Exercise helps to lower risk of death from prostate cancer

In men with prostate cancer, physical activity is associated with lower overall mortality and prostate cancer mortality. Researchers from the Harvard School of Public Health and Brigham and Women’s Hospital found that a modest amount of vigorous activity such as biking, tennis, jogging or swimming for 3 or more hours a week may substantially improve prostrate specific survival. In the study, published in the Journal of Clinical Oncology, researchers tracked the physical activity of 2,700 men who had been diagnosed with prostrate cancer after 1990. The researchers found that the more active patients – doing either vigorous or non–vigorous exercise had the greatest chance for survival.

(Dr Monica and Brahm Vasudev)

Nearly 70% Of people with hepatitis C will develop chronic liver disease

According to the US Centers for Disease Control and Prevention, nearly 70% of people with the hepatitis C virus will develop chronic liver disease.

Studies demonstrate speedy impact of rotavirus vaccines

Studies published in a supplement to the January Pediatric Infectious Disease Journal show that countries that vaccinate babies against rotavirus have reduced the number of children hospitalized with the disease considerably. Data from the United States, Australia, Mexico and El Salvador, where rotavirus vaccines have recently become part of routine childhood immunizations, show sharp and speedy decline in the number of children under age 5 becoming ill with the virus. Data also show large decrease in rotavirus disease among older, unvaccinated children, suggesting that vaccination of babies may provide herd immunity.

Breast calcifications may reflect cardiovascular risk in kidney disease

According to Valerie Duhn, MD, and colleagues, routine mammography may disclose an important, but difficult to detect, marker of possible cardiovascular risk in women with end–stage renal disease (ESRD). women with ESRD were significantly more likely to have breast arterial calcification vs control group of women without ESRD. Unlike the atherosclerotic plaques commonly associated with cardiovascular disease, which occur in the arterial intima, breast arterial calcification develops in the medial layer of the arterial walls. The findings are published online in January 20, 2011 issue of the Clinical Journal of the American Society of Nephrology.

    Infertility Update

Dr. Kaberi Banerjee, Director Precious Baby Foundation

What are the symptoms and complications of pelvic inflammatory disease (PID)?

Symptoms of PID

The infection may be subclinical (occurring without any symptoms), or there may be fever, chills, or pelvic pain indicating inflammation of the entire pelvic area.

Complications of PID

  • Severe or frequent attacks of PID can eventually cause scarring, abscess formation, and tubal damage that result in infertility. About 20% of women who develop symptomatic PID become infertile. The severity of the infection, not the number of the infections, appears to pose the greater risk for infertility.
  • PID also significantly increases the risk of ectopic pregnancy (fertilization in the fallopian tubes). A small US study suggests, however, that even mild Chlamydia infection that occurs in the upper genital tract may cause a higher proportion of ectopic pregnancies than previously thought.

For queries contact: banerjee.kaberi@gmail.com

    Pediatric Update

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

What are the usual indications for head CT scan in pediatric head injury?

An unenhanced head CT scan is usually the test of choice for pediatric patients who have moderate–to–high risk of injury after head trauma, as this test reveals both hemorrhage and bony injury pattern. The indications for head CT in children mostly include GCS of less than14, progressive headache, decline in level of consciousness, seizure, unreliable history, persistent vomiting, amnesia, signs of skull fracture or facial injury, penetrating skull injury, suspected inflicted TBI, or focal or abnormal neurology. The initial head CT may also include visualization of the craniocervical junction so that atlanto–occipital dislocation, rotatory subluxation of C1 on C2, and other craniocervical disruptions can also be evaluated.

    Medicolegal Update

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

What is the declaration of Oslo in abortion?

  • In 1970 the World Medical Association drew up a statement on Therapeutic Abortion known as the Declaration of Oslo.
  • The first moral principal imposed upon the doctor is respect for human life as expressed in a clause of the Declaration of Geneva: ‘I will maintain the utmost respect for human life from the time of conception’.
  • Circumstances which bring the vital interests of a mother into conflict with the vital interests of her unborn child create a dilemma and raise the question whether or not the pregnancy should be deliberately terminated.
  • Diversity of response to this situation results from the diversity of attitudes towards the life of the unborn child. This is a matter of individual conviction and conscience which must be respected.
  • If the doctor considers that his convictions do not allow him to advise or perform an abortion, he may withdraw while ensuring the continuity of (medical) care by a qualified colleague.
  • This statement, while it is endorsed by the General Assembly of the World Medical Association, is not to be regarded as binding on any individual member association unless it is adopted by that member association.
    Legal Question of the Day

(Contributed by Dr MC Gupta, Advocate)

Q. When a patient gets treatment at a hospital, he is the consumer of the services provided by the hospital. The consumer complaint should lie against the hospital, not the treating doctor. Why do the consumer courts allow the patient to file a consumer complaint against an individual doctor?

A. Many reasons can be given as to why the doctor should be made a party.

  • It has been held in court judgments that a doctor cannot be held guilty at his back. He must be given a chance to defend himself. Courts have therefore directed that the treating doctor must be made a party.
  • The treatment to an individual is directly given by the doctor, not by the aggregate body called the hospital. If the doctor is protected by professional indemnity insurance, there is no reason why the compensation awarded should be paid by the hospital and not by the insurance company providing the cover to the doctor. The insurance company would pay only when there is a court judgment against the doctor.
  • Some hospitals may preferably employ those consultants who are covered by insurance. The insurance company would pay only when there is a court judgment against the doctor.
  • There may be confusion as to whether the hospital is the service provider or not while there may be no controversy regarding the role of the doctor as the service provider. The patient cannot be made to suffer in the legal procedural wrangle about determining the role and status of the hospital as service provider.
  • When the complainant alleges medical negligence, it is inevitable that even if the hospital alone is made the respondent, the hospital will have to ask the concerned doctor to explain his stand. The doctor may choose not to respond to the hospital’s request and, in the interest of justice, summons may have to be issued to the doctor to testify in the court. This will entail avoidable delay and also harassment to the doctor. At present, doctors have rarely to be present themselves in the consumer court.
  • The legal nature of the hospital as an entity may be unclear. Some are corporate hospitals; some are government hospitals; some are small hospitals that may not even be registered. Only a few states have nursing home acts or clinical establishment acts. The ownership and management etc. of a hospital may be unclear. All this may delay the legal process at the "service stage" itself. (Service here means the act of serving the court summons upon the opposite party.)
  • The same doctor may treat a patient partly as a hospital patient and partly as his private patient in his private clinic. When he alleges negligence in treatment, the treatment cannot be artificially separated into private clinic treatment and hospital treatment.
  • The consumer courts have been established to dispense speedy justice as summary proceedings by avoiding arguments and delays related to procedure. Justice would be speedy when the doctor is a party.
  • Please also note that till today, probably no treating doctor has pleaded as to why a case has been filed against him and not against the hospital alone. Your question is, hence, merely a hypothetical/theoretical question.
Our Contributors
  Docconnect Dr Veena Aggarwal
  Docconnect Dr Arpan Gandhi
  Docconnect Dr Aru Handa
  Docconnect Dr Ashish Verma
  Docconnect Dr A K Gupta
  Docconnect Dr Brahm Vasudev
  Docconnect Dr GM Singh
  Docconnect Dr Jitendra Ingole
  Docconnect Dr. Kaberi Banerjee
  Docconnect Dr Monica Vasudev
  Docconnect Dr MC Gupta
  Docconnect Dr. Neelam Mohan
  Docconnect Dr. Naveen Dang
  Docconnect Dr Prabha Sanghi
  Docconnect Dr Prachi Garg
  Docconnect Rajat Bhatnagar
  Docconnect Dr Sudhir Gupta
    Rabies Update


Author of "RABIES – the worst death"

Do rat bite cases require rabies vaccination?

In India, most rodents, rats, squirrels, rabbits, birds and bats have been found to be free of rabies. However, following exposure to bandicoots and mongoose, PEP is recommended. Rat bite cases do not require rabies vaccination but this is a right opportunity to start pre–exposure vaccination.

    Lab Update

(Dr Arpan Gandhi and Dr Navin Dang)

BUN:creatinine ratio

  • BUN:creatinine ratio is usually >20:1 in prerenal and postrenal azotemia, and <12:1 in acute tubular necrosis.
  • Other intrinsic renal disease characteristically produces a ratio between these values.
    Medi Finance Update

Indirect Tax


  • Additional banking licenses to private sector players may be granted.
  • Non Banking Financial Companies could also be considered, if they meet the RBI–seligibility criteria.
    Drug Update

LIST OF APPROVED DRUG FROM 01.01.2010 TO 31.8.2010

Drug Name
DCI Approval Date
Lipid Based Amphotericin–B Gel 0.1%
Indicated in the treatment of cutaneous and mucocutaneous mycotic infections caused by candida (Monilia) species.
    IMSA Update

International Medical Science Academy (IMSA) Update

Artemisinin resistance and P. falciparum

Results of malaria blood smears performed three days after treatment initiation may be used as a screening tool for artemisinin resistance. Artemisinin resistance is highly unlikely if the proportion of patients with parasite density <100,000 parasites/microL following a three–day course of therapy with an artemisinin combination regimen is <3%.

(Ref: Stepniewska K, et al. In vivo parasitological measures of artemisinin susceptibility. J Infect Dis 2010;201:570).

    IJCP Special

Dr Good Dr Bad

Situation: A patient with chronic kidney disease (CKD) needed a diuretic.
Dr. Bad: Take OD dose.
Dr. Good: Take TDS dose.
Lesson: Diuretics are to be given every 6–8 hours in CKD.

Make Sure

Situation: A patient missed her last dose of hepatitis B vaccine as she was out of station at 6th month.
Reaction: Oh my God! Why was the vaccine not given between 4–6 months?
Lesson: Make sure that all patients are given the complete vaccine regimen. The correct regimen is 0, 1–2 months and 4–months.

    Lighter Side of Reading

An Inspirational Story
(Contributed by Dr. Prachi Garg)

Great Value in Disaster

Thomas Edison’s laboratory was virtually destroyed by fire in December 1914. Although the damage exceeded $2 million, the buildings were only insured for $238,000 because they were made of concrete and thought to be fireproof. Much of Edison’s life’s work went up in spectacular flames that December night. At the height of the fire, Edison’s 24–year old son, Charles, frantically searched for his father among the smoke and debris. He finally found him, calmly watching the scene, his face glowing in the reflection, his white hair blowing in the wind. "My heart ached for him," said Charles.

"He was 67 – no longer a young man – and everything was going up in flames. When he saw me, he shouted, "Charles, where’s your mother?" When I told him I didn’t know, he said, "Find her. Bring her here. She will never see anything like this as long as she lives."

The next morning, Edison looked at the ruins and said, "There is great value in disaster. All our mistakes are burned up. Thank God we can start anew."

Three weeks after the fire, Edison managed to deliver his first phonograph.

— — — — — — — — — —


Read this…………………

A 25–year–old homeless male is brought to the emergency room by the police who found him unresponsive on the pavement. Patient is intubated for airway protection. He is afebrile and blood pressure is normal. Remainder of the physical examination is unremarkable too. Laboratory data is consistent with a severe anion gap metabolic acidosis with a pH of 7.0 and an acute kidney injury. Ethanol was undetectable in his blood. Serum betahydroxybutyrate and lactate were undetectable. Which of the following is the next best step in the management of this patient.

A. A sepsis workup including chest x ray and culture of blood, sputum and urine.
B. A lumbar puncture to rule out meningo–encephalitis.
C. Urine sediment exam for oxalate crystals and serum methanol and ethylene glycol assay.
D. A stat head CT to rule out catastrophic intracranial bleeding.

Contributed by Ashish Verma MD

Yesterday’s Mind Teaser: ie.
Answer for yesterday’s Mind Teaser:
That is besides the point

Correct answers received from: Dr Chandresh Jardosh, Dr Anil Bairaria

Answer for 26th January Mind Teaser: Pair o’ DOX (paradox)
Correct answers received from: Dr K.Raju, Dr (Maj. Gen.) Anil Bairaria

Send your answer to ijcp12@gmail.com

— — — — — — — — — —

Laugh a While
(Contributed by Dr Prabha Sanghi)

A man driving home late at night in his Volkswagen beetle car was stopped by by policemen on patrol. The police asked the man to produce his car document. When they could not fault the document, the next question to the man was: "My friend, do you realise that you committed a criminal offence by driving alone in this car at late night?" The man became angry and responded: "How could you say that? God the father, the son and holy spirit, prophet Elijah and Angels Micheal and Gabriel are all with me in the Car." The policeman replied: "You mean, all these people are in this small car? I charge you for overloading!"

    Readers Responses
  1. Dear Sir, Emedinews is an extremely informative newsletter. Regards Dr Anupam
    Public Forum

(Press Release for use by the newspapers)

February: the month of detecting heart blockages before they cause symptoms.

Starting 1st February a month–long campaign by Moolchand Medcity Department of Cardiology will be organizing to create awareness about the early detection of heart blockages before they cause symptoms or become the reason for heart attack, paralysis or sudden death. Heart blockages become symptomatic only after they block 70% of the heart arteries. Patients with blockages of less than 70% may have absolutely no symptoms. The treadmill test may be negative with blockages of less than 70% and a stress echo may be negative with blockages of less than 60%. Coronary angiography may also miss blockages of less than 40%. The blockages in the heart arteries can only be correlated with very early thickening of neck artery wall. A test called IMT (intima media thickness) which is done by a high resolution colour Doppler ultrasound of the neck carotid artery is now available.

Giving the details, Dr. KK Aggarwal, Padma Shri and Dr. B.C. Roy National Awardee and Senior Consultant Moolchand Medcity said that IMT should be measured in childhood or young age as the process of heart blockages begins at that age.

Dr. Aggarwal said that in women with chest pain and normal neck artery morphology, one may practically rule out need for coronary angiography and a carotid wall thickness of less than 0.55mm and thoracic aorta wall thickness of less than 3mm practically rules out heart blockages.

  • In asymptomatic patients, a mean neck artery wall thickness of more than 1.15 mm correlates to 94% chances of having heart blockages.
  • A neck artery wall thickness of more than 0.75mm in asymptomatic population suggests significant blockages in the heart.
  • A neck artery wall thickness of more than 1.5 mm is also associated with family history of premature heart death.

Only 2% of patients with a neck artery wall thickness of less than 1mm have blockages in all three arteries of the heart and patients with thickness of more than 1.5 mm have 95% chances of having significant heart blockages.

The increased neck artery thickness and presence of plaque calcification in the neck artery are strong indicators of underlying heart blockages.

Neck artery wall thickness is also associated with thickness in the leg artery wall. Leg artery wall thickness is associated with more chances of heart attack and undergoing bypass surgery. Neck artery plaques are associated with non–fatal heart attacks and leg artery plaques are associated with more chances of bypass surgery.

Intima media thickness ultrasound test with or without stress test can practically detect chances of future attacks. Other tests which can predict heart attacks are high sensitivity C Reactive Protein and abnormal lipid profile.

Special facilities will be offered by Moolchand Medcity for Intima Media Thickness test for the general public. The test will be available at a nominal cost of Rs. 1000/–. The campaign is being started by Moolchand Medcity in association with Heart Care Foundation of India, IMA New Delhi Branch and eMedinewS.

    Forthcoming Events

eMedinewS Events: Register at emedinews@gmail.com

Conference Column

Workshop on Fetal and Paedatric Echocardiography Pre and perinatal management of heart disease
13th February 2011, Sunday, Moolchand Medcity

  1. Fetal Echocardiography- How to get it right: Dr Vandana Chaddha
  2. Fetal Cardiac Spectrum- abnormal cases with interactive session: Dr Vandana Chaddha
  3. Neonatal Cardiac Cases- Hits and misses inetractive session: Dr Savitri Srivastava
  4. Intima Media Thickness and Plaque Volume, New Marker for Atherosclerosis Regression: : Dr KK Aggarwal

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