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Address: 39 Daryacha, Hauz Khas Villege, New Delhi, India. e-Mail: drkk@ijcp.com , Website: www.ijcpgroup.com

Dr K K Aggarwal

Dr KK Aggarwal
Dr BC Roy Awardee
Sr Physician and Cardiologist,
Moolchand Medcity
President, Heart Care
Foundation of India
Gp Editor-in-Chief,
IJCP Group
Delhi Medical Council
Director, IMA AKN Sinha Institute (08-09)



2nd December Wednesday

Dear Colleague,

 emedinews revisited 2009 (top happenings of the year)

1. Outcomes with chlorthalidone are as good as with amlodipine. Patients who are started on a thiazide diuretic for hypertension should be treated with chlorthalidone rather than hydrochlorothiazide (HCTZ). A large randomized trial of combination therapy for hypertension in patients at high risk for cardiovascular complications has shown that in patients receiving an ACE inhibitor, cardiovascular event rates were lower with amlodipine compared with HCTZ. (1)

2.  The JUPITER trial, a randomized trial of rosuvastatin therapy in healthy men (aged 50 and older) and women (aged 60 and older) with an LDL C level below 130 mg/dl (3.4 mmol/l) and a C reactive protein (CRP) level of at least 2.0 mg/l, has shown a large reduction in the primary composite cardiovacular end point (hazard ratio 0.56).(2)

3.  A large randomized trial found that vitamin C supplementation in primary prevention had no effect on major cardiovascular events or all cause mortality.3 There is no benefit to supplementation with vitamins C, E or beta carotene in preventing cancer.(4-6)

 4.  A large randomized trial has shown that ginkgo is ineffective in preventing progression to dementia in elderly adults with normal cognition or mild cognitive impairment. (7)

5.  A large randomized trial with more than seven years of follow up found that a B vitamin supplement with a high dose of folate (2.5 mg) had no effect on the risk of cancer.(8)

6.  The United States Preventive Services Task Force (USPSTF) has issued revised guidelines for colorectal cancer screening.(9-12) Three screening options were recommended for adults age 50 -75 years:  Annual fecal occult blood test (FOBT) with a high sensitive test, Flexible sigmoidoscopy every five years, with high sensitive FOBT every three years ; Colonoscopy every 10 years

7.  Over diagnosis of breast cancer by mammographic screening was suggested by a Norwegian study in which the incidence of invasive breast cancer was compared between groups of women who had regular mammograms and women who did not undergo mammography until the end of a six year period.(13) The incidence of breast cancer was 22% higher in the group who underwent regular screening.

8.  A meta analysis performed for the US Preventive Services Task Force found that, each increase in homocysteine level of 5 Ķmol/l increased the risk of CHD events by approximately 20%.(14) Independent of Framingham risk factors.

9.  The Infectious Diseases Society of America has published guidelines for fever evaluation in nursing home patients.(15) Infection should be suspected with development of confusion, incontinence, decreased intake or behavior change. These guidelines suggest: Lower parameters for defining fever than in younger individuals; Urinalysis and urine culture should not be performed for asymptomatic residents; Chest radiography should be ordered when hypoxemia is present (oxygen saturation <90%) or suspected and Blood cultures are rarely indicated.

10.  A meta analysis of 33 randomized trials of beta blocker therapy evaluated outcomes in over 12,000 patients, of whom over 8,000 were from POISE.(16) Beta blocker therapy appeared to reduce the risk of MI by one third while more than doubling the risk of stroke, and had no statistically significant effect on either all cause or cardiovascular mortality.

11.  A large case control study in patients receiving clopidogrel after a myocardial infarction (MI) found an association between use of proton pump inhibitors (PPIs) and recurrent MI.(17) Similar associations had been seen in other studies, and there is evidence that PPIs may reduce the effectiveness of clopidogrel in inhibiting platelet function.(18)

12.  Angiotensin II receptor blocker therapy does not improve outcomes in patients with diastolic heart failure. In a large randomized trial, treatment of patients with symptomatic HF and a preserved ejection fraction, irbesartan did not improve the primary end point of death from any cause or hospitalization for a cardiovascular cause.(19 )

13.  In a randomized trial in 1791 patients with longstanding poorly controlled type 2 diabetes, there was no difference in the occurrence of any cardiovascular outcome between the intensive (achieved A1C 6.9%) and standard (A1C 8.4%) groups.(20)

14.  In a trial of patients with type 2 diabetes randomly assigned to a low glycemic index or a high cereal fiber diet, there was a modest difference in A1C decline from baseline favoring the low glycemic index group.(21)

15.  Oral bisphosphonates have been linked to esophageal adenocarcinoma and squamous cell carcinoma according to a post marketing Food and Drug Administration (FDA) letter.(22) The FDA recommends against using oral bisphosphonates in patients with Barrett's esophagus.

16.  A meta analysis that included 10 studies involving 1,193 patients undergoing surgery found that N acetylcysteine, compared with placebo, failed to provide any benefit in preventing acute kidney injury.(23)

17.  The largest double blind trial evaluating the treatment of Bellís palsy confirmed that early oral glucocorticoid treatment was effective, while antiviral therapy was not.(24)

18.  A meta analysis found that in patients with COPD, inhaled glucocorticoids increase the risk of pneumonia by about 30%.(25)

19.  Smoking prevalence fell among men and women from 1975 to 2006. (26). This was accompanied by a decline in the death rate for lung cancer among men and a leveling off of the death rate for lung cancer among women.

1.  N Engl J Med 2008;359(23):2417 28.
2. N Engl J Med 2008;359(21):2195 207.
3. JAMA 2008;300(18):2123 33.
4. JAMA 2009;301(1):52 62.
5. JAMA 2009;301(1):39 51.
6. J Natl Cancer Inst 2009;101(1):14 23.
7. JAMA 2008;300(19):2253 62.
8. JAMA 2008;300(17):2012 21.
9. Am J Respir Crit Care Med 2008;178(9):956 61.
10. Ann Intern Med 2008;149(9):627 37.
11. CA Cancer J Clin 2008; 58(3):130 60.
12. Ann Intern Med 2009;150(1):1 8.
13. Arch Intern Med 2008;168(21):2311 6.
14. Mayo Clin Proc 2008;83(11):1203 12.
15. Clin Infect Dis 2009;48(2):149 71.
16. Lancet 2008;372(9654):1962 76.
17. CMAJ 2009;180(7):713 8.
18. Am Heart J 2009;157(1):148e 1 5.
19. N Engl J Med 2008;359(23):2456 67.
20. N Engl J Med 2009;360(2):129 39.
21. JAMA 2008;300(23):2742 53.
22. N Engl J Med 2009;36(1):89 90.
23. Am J Kidney Dis 2009;53(1):33 40.
24. Lancet Neurol 2008;7(11):993 1000.
25. JAMA 2008;300(20):2407 16.
26. J Natl Cancer Inst 2008;100(23):1672 94.

Dr KK Aggarwal



News and Views

 1. As per a study published in November issue of Cancer Epidemiology Biomarkers & Prevention there has been significant decline in the rates of atypical ductal hyperplasia, known risk factor for breast cancer. The decline correlates with the declining use of HRT in women.

2. 2.2 crores affected by swine flu in US : At least 2.2 crore American have come down with H1N1 swine flu since the virus first surfaced in April and approximately 3900 people have died including 540 children.

3. As per a report published in the Journal Pediatric, more than 53% of children with kidney stones do not have classical symptoms like painful bloody urination.

4. Tadelafil has been approved by US FDA in May 2009 for the treatment of pulmonary arterial hypertension.

5. Pitavastatin was approved by the US FDA in August 2009 for the treatment of primary hyper mixed Dyslipidemia.

6.  Dronedarone has been approved by US FDA in July 2009 for the treatment of paroxysmal or persistent arterial fibrillation or atrial flutter.

Failed thrombolysis
The optimal management of ST elevation myocardial infarction patients with failed fibrinolysis has been uncertain.  The REACT trial randomly assigned 427 patients with STEMI and failed fibrinolysis to conservative medical therapy, repeat fibrinolysis, or rescue percutaneous coronary intervention (69 percent with stenting) [1,2].
At more than four years of follow up, rescue angioplasty was associated with a lower rate of all cause mortality compared to repeat fibrinolysis or conservative therapy.

Rescue or salvage angioplasty is defined as angioplasty done within 12 hours of failed fibrinolysis in patients with evidence of continuing or recurrent myocardial ischemia.
If rescue angioplasty is performed, it should be undertaken quickly.

That means one should do urgent angio at 45 to 60 minutes following fibrinolysis. Go for angioplasty or bypass with less than TIMI grade 3 flow, defer intervention in patients with TIMI 3 flow who are hemodynamically stable. However, observational data suggest that even patients with TIMI 3 flow have reduced mortality if PCI is performed.

1. Gershlick, AH, Stephens Lloyd, A, Hughes, S, et al. Rescue angioplasty after failed thrombolytic therapy for acute myocardial infarction. N Engl J Med 2005; 353:2758.
2. Carver, A, Rafelt, S, Gershlick, AH, et al. Longer term follow up of patients recruited to the REACT (Rescue Angioplasty Versus Conservative Treatment or Repeat Thrombolysis) trial. J Am Coll Cardiol 2009; 54:118.


 Myths about Depression

Depression is hurtful but not a major medical condition. MYTH
Depression is not simply a temporary case of the blues. It is a common, serious medical condition that can disrupt daily functioning. At the extreme, people with depression may harm themselves. Brain imaging research shows that the brains of people with depression function differently than those of non depressed people. In depressed people, brain areas that regulate mood, behavior, thinking, appetite and sleep seem to function abnormally. Also, important brain chemicals called neurotransmitters appear to be out of balance.

If your parent and grandparent had depression, you are sure to get it eventually. MYTH.
Because depression can run in families, scientists suspect that genes play a role. You are three times more likely to develop depression if your parents suffered depression. But it is not inevitable that you will get the illness, too. Scientists believe the risk of developing depression results from a combination of genetic, biochemical, psychological, and environmental factors.

Only emotionally troubled people become depressed. MYTH
Depression affects people from all walks of life, not just people with previous emotional troubles. Depression can strike after the loss of a loved one, trauma, or other stressful situations like the loss of a job.

Most people with depression never go to a mental health professional. FACT
Only 39% of people with severe depression see a mental health professional. People with depression often see their primary care doctor. Also, many depressed patients remain undiagnosed or undertreated. Some cases of depression are tough to treat. But the vast majority of cases are highly treatable with antidepressants and talk therapy. The earlier treatment begins, the more effective it is.

Depression is most common in elderly people. MYTH
People assume the elderly suffer depression most often. In fact, middle aged people 40 to 59 have the highest rates of depression. Depression is not a normal part of aging. However, ill health, medication side effects, social isolation, and financial troubles can trigger depression in elderly people. Older people belong to a generation that often feels ashamed to admit to feelings of sadness and grief. But it's crucial that they seek help, especially because white men 85 and older have the highest suicide rate.

Depression causes physical pain. FACT
Depression causes emotional symptoms such as anxiety, irritability, and hopelessness. But it can also cause physical symptoms such as chest pain, queasy or nauseated sensations, dizziness or lightheadedness, chest pain, sleep problems, exhaustion, and changes in weight and appetite. It can also worsen back and joint pain and muscle aches.

Talking about depression only makes it worse. MYTH
Different types of psychotherapy, or talk therapy, have been proven effective in treating depression. For example, cognitive behavioral therapy (CBT) teaches people new ways of thinking to replace negative thoughts and behaviors that contribute to depression. In another approach, interpersonal therapy (IPT) helps people to understand troubled relationships and find ways to work through the difficulties.

Being optimistic can cure depression. MYTH
Depression is debilitating. Most people with the disorder will require treatment to get better. Few can will themselves to get well through positive thinking. Depressed people may need medication to normalize brain chemicals.



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Humor (Dr Shirish Dhande Nagpur)
Love story of a doctor

I wan in 12th.                           She was in 12th
I got MBBS                               She got Bsc
I was doing MBBS,                     She Got MSc
I completed MBBS                      She got a doctorate
She got married.                        I was preparing for PG Entrance
She is the mother of 2 children.   I am doing my MD
Her child is 1st standard             I Completed my MD
Her son passed tenth.                I just finished my DM and started practice

The greatest irony   
I got engaged today and              She went for her tubectomy


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emedinews is the first daily emedical newspaper of the country. One can advertise with a singe insertion or 30 insertions in a month. Contact drkk@ijcp.com.

medinews: revisiting 2009

IJCP Group is organizing emedinews: Revisiting 2009, a day long conference on 10th Jan  2010 at Maulana Azad Auditorium. It will be attended by over 1500 doctors. Topics will be happenings in the year 2009. There is no registration fee however advanced registration is required.  Top experts will deliver lectures. CME will be followed by lively cultural evening, doctors of the year award, dance and dinner. For regiatration mail  emedinews@gmail.com. We have crossed 700 registrations.

You can gift emedinews to some one just write to emedinews@gmail.com  

Also if you like emedinews you can FORWARD it to your email addresses


WHO issues new AIDS  treatment guidelines?
1.In its directive, the Who wants people to start anti retroviral therapy once their CD4 cell count, drops to 350. Currently, patients are put on ART when their CD4 cell count drops to 200.

2.To prevent mother to child transmission, HIV positive pregnant women should start using the drugs at 14 weeks of pregnancy instead of the previously recommended 28 weeks.

Letters to the editor

1.Sir I have become a fan of yours, forever thanks for emedinews. Dr Arnav bansal
2. Very informative, I am getting addicted to reading it. Congratulations for such an initiative. Please mention the post exposure prophylaxis regimen(s) for HIV and their availability. I wish to gift emedinews to
drpraveengupta@gmail.com. drpraveengupta123@yahoo.co.in. Do you wish to involve people to actively contribute (writing) for emedinews? If yes How? DR S K GUPTA
emedinews comments: please see tomorrow's edition, it will have detailsm in my edit column.




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