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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 & Dean Medical Education Moolchand Medcity; Chairman Ethical Committee Delhi Medical Council; Chairman (Delhi Chapter) International Medical Sciences Academy; National Vice President Elect Elect, Indian Medical Association; 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 & Hony. Visiting Professor (Clinical Research) DIPSAR

For updates follow at www.twitter.com/DrKKAggarwal     www.facebook.com/Dr KKAggarwal

    Health Videos…
Nobility of medical profession Video 1 to 9 Health and Religion Video 1 to 7
DD Take Care Holistically Video 1 to 15 Chat with Dr KK On life Style Disorders
Health Update Video 1 to 15 Science and Spirituality
Obesity to Towards all Pathy Consensus ALLOVEDA: A Dialogue with Dr KK Aggarwal
  Editorial …

30th January 2013, Wednesday

Always write the dose and duration of treatment in the prescription

The present case reminds me of a medical joke. A patient came to a doctor after six months and said I consulted you six month back for fever and you said do not take bath. Can I take it now?

Recently The National Consumer Disputes Redressal Commission has held a Delhi doctor guilty of "limited medical negligence" for verbally advising, instead of prescribing in writing, the use of eye drops to a patient who lost his vision following its prolonged application, reports TOI. The commission directed the doctor to pay the patient, compensation of Rs 50,000.

The commission said that the eye surgeon did not spell out in writing the "dosage and duration of the medicine". And at the same time, it blamed Gupta for not turning up for follow-ups and for continuing the drops despite being provided just one vial by the doctor. There was an element of "contributory negligence" by the patient and the same was considered as a mitigating circumstance while awarding the compensation.

In 1993, the patient had pterygium left eye. Post operatively he was prescribed local application of Mitomycin-C. He was verbally told to take it for no more than two weeks as this could harm but was not documented. But the patient continued the drops and over a period developed dry eye due to prolonged use of the drug.

The national commission observed that since the doctor had converted just one vial of Mitomycin-C injection into eye drops the indication was for its limited use for about two weeks and not several months.

Because of this the commission held the doctor guilty of only 'limited medical negligence' for not having put down in writing the dosage and duration of the medicine in the prescription slip.

The doctor was guilty of 'limited medical negligence' since he had failed to put in writing the dosage and duration of the medicine.

For More editorials…

Dr KK Aggarwal
Group Editor in Chief

    Constipation Update

Chronic idiopathic constipation or functional constipation is a common condition affecting the GI tract, with a prevalence of between 4% and 20% (Ford AC, Suares NC. Effect of laxatives and pharmacological therapies in chronic idiopathic constipation: systematic review and meta-analysis. Gut 2011;60:209-18).

Dr K K Aggarwal
    eMedinewS Audio PostCard

Stay Tuned with Padma Shri and Dr BC Roy National Awardee Dr KK Aggarwal on

Healthcare worker fatigue and patient safety

Audio PostCard
    Photo Feature (from the HCFI Photo Gallery)

Hands-only CPR 10 camp at St. Froebel Public School, Paschim Vihar.

Over 1000 school children were trained on the spot during the camp.

Dr K K Aggarwal
    National News

Invite: Hands-only CPR 10 Camp

Heart Care Foundation of India will be organizing a Hands-only CPR 10 Camp on 31st January, 2013 at Lady Reading Nursing Institute, Near Delhi Gate. Over 150 nurses will be trained on how to survive a person within ten minutes of death.

Dead rat in hostel meal, kids take ill

LUCKNOW: Some children took severely ill when a dead rat was allegedly found in dinner served at a government residential school in Hardauli village in Banda district on Sunday. The students started vomiting after which a team of government doctors was rushed to the school. The students are feeling better now reports TOI.

In this case it looks like the people vomited after they came to know about the rat and not because of the rat poisoning. If the rat is boiled and cooked in the food it cannot cause poisoning. If a dead rat is put in the boiled food again it is unlikely to cause poisoning. In any way if it was poisoning it was staph bacteria poisoning, which is self-limiting and causes no death.

One can classify food poisoning depending on the onset of symptoms as follows:

  • Rapid symptoms within 6-12 hours: are due to organisms that make a toxin in the food before the food is consumed. Symptom is predominantly vomiting. Examples are Staphylococcus aureus, Bacillus cereus emetic toxin and botulism.
  • Symptoms after 24 hours: are due to pathogens that make toxin once they have been ingested. They mainly cause diarrhea that may be watery (Vibrio cholerae or E. coli) or bloody (Shiga toxin-producing E. coli).
  • Symptoms after variable time: are due to microbes that cause pathology by either damaging the epithelial cell surface or by actually invading across the intestinal epithelial cell barrier. They can produce a wide spectrum of clinical presentations from watery diarrhea (Cryptosporidium parvum, enteric viruses) to inflammatory diarrhea (Salmonella, Campylobacter, Shigella) or systemic disease (L. monocytogenes).

Food poisoning can also be classified depending on the type of symptoms vomiting or diarrhea. A sudden onset of nausea and vomiting is likely due to the ingestion of a preformed toxin, such as S. aureus enterotoxin or B. cereus emetic toxin, or a chemical irritant. There is no risk of person-to-person spread.

When the poisoning presents with diarrhea, the organisms are V. cholerae, Clostridium perfringens, enterotoxigenic E. coli, B. cereus, rotavirus, astroviruses, enteric adenoviruses and Noroviruses, and the parasitic organisms, Cryptosporidium parvum and Cyclospora cayetanensis.

There are clinical clues that should increase suspicion that a food-borne microbe is causing inflammatory diarrhea. Such symptoms and signs include: Passage of diarrhea with blood or mucus; presence of severe abdominal pain and occurrence of fever. The most likely pathogens in patients with inflammatory diarrhea are Salmonella or Campylobacter.

About the author: Dr K K Aggarwal is Padma Shri and Dr B C Roy National Awardee, President Heart Care Foundation of India and National Vice President Elect IMA (blog.kkaggarwal.com)

Medical mistakes in Indian movies

Dear all, eMedinewS is starting a special series on ‘Medical mistakes in Indian movies’. We invite all our readers to share with us the following information:

  1. Scene/s where the image of the medical profession has been maligned in an unrealistic manner, or
  2. Scene/s where medical care and approach has been depicted incorrectly, or
  3. Scenes where the medical profession has been portrayed correctly.

Send us the clippings or description of the scenes. This would be a start to a special campaign to rebuild the image of the medical profession.

Certificate courses in 2D and 3D Echocardiography/Fellowship Diploma in non invasive cardiology Contact Dr KK Aggarwal, Moolchand Medcity, email: emedinews@gmail.com

    Be Human Stop Child Abuse (Team IMA for CMAAO)


Each year 1% of children are exposed to some form of sexual abuse

    Valvular Heart Disease Update

By echocardiography, although a bicuspid aortic valve with a raphe may appear similar to a tricuspid valve during diastole, the systolic opening shape of a bicuspid valve is elliptical rather than the triangular pattern of a tricuspid valve.

(Experts: Dr Ganesh K Mani, Dr Yugal Mishra, Dr Deepak Khurana, Dr Rajesh Kaushish, Dr K S Rathor, Dr Sandeep Singh and Dr KK Aggarwal)

    International News

(Contributed by Dr Monica and Brahm Vasudev)

Early breast Ca survival better with lumpectomy

In real-world practice, women with early-stage breast cancer were more likely to survive if they had a lumpectomy rather than mastectomy, a population-based registry study found. (Source: Medpage Today)

Early team-based extubation reduces pneumonia

An early-morning, multiprofessional extubation approach decreases the number of ventilator days and cuts the rate of ventilator-associated pneumonia (VAP) in half, according to a study presented here at the Society of Critical Care Medicine 42nd Critical Care Congress. (Source: Medscape)

Diuretic use lags in blacks with high BP

Blacks and Hispanics who are hypertensive may not be receiving adequate diuretic treatment, two studies indicated. (Source: Medpage Today)

ACIP issues 2013 adult immunization schedule and guidelines

The Advisory Committee on Immunization Practices (ACIP) of the Centers for Disease Control and Prevention has issued the 2013 adult immunization schedule. The updated guidelines, posted online January 28 in the Annals of Internal Medicine, include recommendations to increase adult vaccination rates, as well as changes to the tetanus, diphtheria, and acellular pertussis (Tdap); pneumococcal; and influenza vaccine schedules. (Source: Medscape)

Avastin wins new colorectal Ca indication

The FDA has approved a new use of bevacizumab (Avastin) as part of second-line combination therapy for metastatic colorectal cancer, the drug's manufacturer announced. (Source: Medpage Today)

    Twitter of the Day

@DrKKAggarwal:Is caffeine good for the health? 1. Caffeine is the most consumed stimulant in the world, 2. It is consumed in (cont) http://tl.gd/krv6io

@DrKKAggarwal: Your inner potential and cosmic potential are the same field. The field is you and the universe, just as the wave and ocean are one.

    Spiritual Update

(Dr KK Aggarwal, Group Editor in Chief, IJCP Group of Publications and eMedinews)

You look at people the same way as you are

Honest people look at everybody as honest and dishonest people look at everybody as dishonest. It all depends on the type of people you interact with. If you do not take bribe, nobody will come and offer bribe to you and you will feel everybody is honest. If you take bribe then everybody will come to you to offer bribe and you will feel that everybody in the society is dishonest.

For comments and archives

    Infertility Update (Dr Kaberi Banerjee, IVF expert, New Delhi)

What are some less common treatments for infertility?

Immunotherapy with Intravenous Immunoglobulin (IvIg) is a less common treatment that is becoming more recognized and utilized.

    Tat Tvam Asi………and the Life Continues……

(Dr. Neelam Mohan, Director, Dept. of Pediatric Gastroenterology, Hepatology & Liver Transplantation, Medanta – The Medicity, Gurgaon)

What about post liver transplant care?

Following liver transplant the patient requires immunosuppression usually for life-long (according to the present consensus). There are three drugs: tacrolimus, mycophenolate mofetil and steroids. Steroids are discontinued first followed by mycophenolate mofetil. Thereafter, patient is on one immunosuppressive drug, usually tacrolimus, which needs to be taken twice-daily every day. The patient needs to undergo regular blood tests to monitor the liver functions, kidney functions and immunosuppressive drug levels.

For comments and archives

    An Inspirational Story

When I got home that night as my wife served dinner, I held her hand and said, I've got something to tell you. She sat down and ate quietly. Again I observed the hurt in her eyes.

Suddenly I didn't know how to open my mouth. But I had to let her know what I was thinking. I want a divorce. I raised the topic calmly.

She didn't seem to be annoyed by my words, instead she asked me softly, why?

I avoided her question. This made her angry. She threw away the chopsticks and shouted at me, you are not a man! That night, we didn't talk to each other. She was weeping. I knew she wanted to find out what had happened to our marriage.

But I could hardly give her a satisfactory answer; she had lost my heart to Jane. I didn't love her anymore. I just pitied her! With a deep sense of guilt, I drafted a divorce agreement which stated that she could own our house, our car, and 30% stake of my company.

She glanced at it and then tore it into pieces. The woman who had spent ten years of her life with me had become a stranger. I felt sorry for her wasted time, resources and energy but I could not take back what I had said for I loved Jane so dearly. Finally she cried loudly in front of me, which was what I had expected to see. To me her cry was actually a kind of release. The idea of divorce which had obsessed me for several weeks seemed to be firmer and clearer now.

The next day, I came back home very late and found her writing something at the table. I didn't have supper but went straight to sleep and fell asleep very fast because I was tired after an eventful day with Jane.

When I woke up, she was still there at the table writing. I just did not care so I turned over and was asleep again.

In the morning she presented her divorce conditions: she didn't want anything from me, but needed a month's notice before the divorce.

She requested that in that one month we both struggle to live as normal a life as possible. Her reasons were simple: our son had his exams in a month's time and she didn't want to disrupt him with our broken marriage.

This was agreeable to me. But she had something more, she asked me to recall how I had carried her into out bridal room on our wedding day.

She requested that every day for the month's duration I carry her out of our bedroom to the front door every morning. I thought she was going crazy. Just to make our last days together bearable I accepted her odd request.

I told Jane about my wife's divorce conditions.

She laughed loudly and thought it was absurd. No matter what tricks she applies, she has to face the divorce, she said scornfully.

My wife and I hadn't had any body contact since my divorce intention was explicitly expressed. So when I carried her out on the first day, we both appeared clumsy. Our son clapped behind us, daddy is holding mommy in his arms. His words brought me a sense of pain. From the bedroom to the sitting room, then to the door, I walked over ten meters with her in my arms. She closed her eyes and said softly; don't tell our son about the divorce. I nodded, feeling somewhat upset. I put her down outside the door. She went to wait for the bus to work. I drove alone to the office.

On the second day, both of us acted much more easily. She leaned on my chest. I could smell the fragrance of her blouse. I realized that I hadn't looked at this woman carefully for a long time. I realized she was not young any more. There were fine wrinkles on her face, her hair was graying! Our marriage had taken its toll on her. For a minute I wondered what I had done to her.

On the fourth day, when I lifted her up, I felt a sense of intimacy returning. This was the woman who had given ten years of her life to me.

On the fifth and sixth day, I realized that our sense of intimacy was growing again. I didn't tell Jane about this. It became easier to carry her as the month slipped by. Perhaps the everyday workout made me stronger.

She was choosing what to wear one morning. She tried on quite a few dresses but could not find a suitable one. Then she sighed, all my dresses have grown bigger. I suddenly realized that she had grown so thin, that was the reason why I could carry her more easily.

Suddenly it hit me... she had buried so much pain and bitterness in her heart. Subconsciously I reached out and touched her head.

Our son came in at the moment and said, Dad, it's time to carry mom out. To him, seeing his father carrying his mother out had become an essential part of his life. My wife gestured to our son to come closer and hugged him tightly. I turned my face away because I was afraid I might change my mind at this last minute. I then held her in my arms, walking from the bedroom, through the sitting room, to the hallway. Her hand surrounded my neck softly and naturally. I held her body tightly; it was just like our wedding day.

But her much lighter weight made me sad. On the last day, when I held her in my arms I could hardly move a step. Our son had gone to school. I held her tightly and said, I hadn't noticed that our life lacked intimacy.

I drove to office.... jumped out of the car swiftly without locking the door. I was afraid any delay would make me change my mind...I walked upstairs. Jane opened the door and I said to her, Sorry, Jane, I do not want the divorce anymore.

She looked at me, astonished, and then touched my forehead. Do you have a fever? She said. I moved her hand off my head. Sorry, Jane, I said, I won't divorce. My marriage life was boring probably because she and I didn't value the details of our lives, not because we didn't love each other anymore. Now I realize that since I carried her into my home on our wedding day I am supposed to hold her until death do us apart.

Jane seemed to suddenly wake up. She gave me a loud slap and then slammed the door and burst into tears. I walked downstairs and drove away.

At the floral shop on the way, I ordered a bouquet of flowers for my wife. The salesgirl asked me what to write on the card. I smiled and wrote, I'll carry you out every morning until death do us apart.

That evening I arrived home, flowers in my hands, a smile on my face, I run up stairs, only to find my wife in the bed - dead. My wife had been fighting CANCER for months and I was so busy with Jane to even notice. She knew that she would die soon and she wanted to save me from whatever negative reaction from our son, in case we push through with the divorce -- At least, in the eyes of our son--- I'm a loving husband....

The small details of your lives are what really matter in a relationship. It is not the mansion, the car, property, the money in the bank. These create an environment conducive for happiness but cannot give happiness in themselves. So find time to be your spouse's friend and do those little things for each other that build intimacy. Do have a real happy marriage!

If you don't share this, nothing will happen to you. If you do, you just might save a marriage.

Many of life's failures are people who did not realize how close they were to success when they gave up.

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Photos and Videos of 4th eMedinewS – RevisitinG 2012 on 20th January 2013

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FDA warns of liver injury risk with Tolvaptan Read More

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    IJCP Special

Dr Good Dr Bad

Situation: A diabetic came with A1c 7.5%.
Dr Bad: It’s ok.
Dr Good: You need better control.
Lesson: A1c goal is <7% for most patients.

Make Sure

Situation: A patient on 10 units of insulin developed hypoglycemia with 11 units of insulin.
Reaction: Oh my God! Why was additional insulin given?
Lesson: Make sure that insulin dose is correct. The formula is 1500/total daily dose. The value will be the amount of sugar fluctuation with one unit of insulin.

  Quote of the Day (Dr GM Singh)

Talking and eloquence are not the same: to speak and to speak well are two things. A fool may talk, but a wise man speaks. Heinrich Heine

    Legal Question of the Day (Dr. M.C. Gupta, Former Professor and Dean)

Q. I am against the BSc (Community Health) course. I am relieved for the time being that the MCI has so far not taken any action to register such graduates. However, the course is already being started in some places and I am apprehensive that those graduating may move the Supreme Court and it may direct the MCI to register them. What are your comments?


  1. Your apprehension is unfounded. There is no way the MCI can enter the name of a BSc (Community Health) graduate in the Indian Medical Register. It is against law.
  2. There is no reason why a BSc in community health should be registered with the MCI? The concept of a degree course in Community Health to non-medical persons is nothing new. JNU has been giving the degree of MCH (Master of Community Health) for maybe 20 years or more. MCI has nothing to do with it. Similarly, there are hundreds of institutions in the world, including India, where non-medical persons can get an MPH degree and even a doctorate in public health. Persons possessing such degrees cannot and do not claim a right to be registered with the medical council.
  3. It is theoretically possible that a state medical council may create a new register for enrolling such graduates. States are competent to do that by amending the SMC Act. But I think it to be unlikely. If any state makes such a move, the state IMA or anybody else would be free to challenge the new law in the state HC.
  4. It is possible that BSc (Community Health) graduates may be registered with the state paramedical council. If that happens, I don’t see any objection to it.
  5. As a matter of fact, in consonance with the general convention that a master’s course is preceded by a bachelor’s course, it was an anomaly that there has been a master’s course in public health without a corresponding bachelor’s course. It is good that the anomaly has been corrected.
  6. It is likely that BSc (Community Health) graduates may go on to study at MPH/MCH and doctorate level. This will provide a much needed fillip to the discipline of Public Health in India. Hence, the introduction of a BSc (Community Health) in India should be welcomed.
    Mind Teaser

Read this…………………

A patient suffered a head injury 24 hours ago. During a routine hourly neurologic check, the nurse notes that the patient's speech has become slurred and that the patient now is disoriented to time and place. The nurse's first action is to:

A. Continue the hourly neurologic checks.
B. Inform the neurosurgeon of the patient's status.
C. Prepare the patient for emergency surgery.
D. Recheck the patient's neurologic status in 15 minutes.

Yesterday’s Mind Teaser: A patient received spinal anesthesia 4 hours ago during surgery. The patient has been on the unit for ½ hours and now reports severe incisional pain. The patient's blood pressure is 170/90 mm Hg, pulse is 108 beats/min, temperature is 99oF (37.2°C), and respirations are 30 breaths/min. The patient's skin is pale and the dressing is dry and intact. The most appropriate nursing intervention is to:

A. Call the physician and report the findings.
B. Medicate the patient for pain.
C. Place the patient in a high Fowler position and administer oxygen.
D. Place the patient in a reverse Trendelenburg position and open the IV line.

Answer for yesterday’s Mind Teaser: Medicate the patient for pain.

Correct answers received from: Prabha Sanghi, Dr PC Das, Dr Jella, Dr Thakor Hitendrsinh G,
Dr Bharat Bhushan Aggarwal, Dr Pankaj Agarwal, Dr Jainendra Upadhyay, Dr Arpan Gandhi, Dr Chandresh Jardosh, Dr Avtar Krishan.

Answer for 28th January Mind Teaser: D. Fluid and electrolyte monitoring

Correct answers received from: Dr Jayashree & Bitaan Sen, Dr Kanta Jain, Prabha Sanghi.

Send your answer to ijcp12@gmail.com

    Laugh a While

Embarrassing Traffic Stop

A police car pulled me over near the high school where I teach. As the officer asked for my license and registration, my students began to drive past. Some honked their horns, others hooted, and still others stopped to admonish me for speeding.

Finally the officer asked me if I was a teacher at the school, and I told him I was.

"I think you've paid your debt to society," he said with a smile, and left without giving me a ticket.

    Medicolegal Update

(Dr Sudhir Gupta, Additional Prof, Forensic Medicine & Toxicology, AIIMS)

What is contributory medical negligence?

The pregnant woman delivered a child with spina bifida; however, she failed to attend at the regularly advised dates for antenatal ultrasounds that would have identified this problem. The patient was found to be 100% at fault."

  • In a medical malpractice/maloccurrence case, medical negligence is the foremost ingredient to establish the liability of damage and dereliction in provided medical care. However, it is important to establish the difference between malpractice and contributory negligence when determining liability.
  • Contributory negligence means the patient/legal heirs/parties are partially to blame for the maloccurrence or medical untoward incident. For e.g., a patient is admitted to the emergency room for treatment and they fail to inform the doctor about a pre–existing condition e.g. any allergy to a drug. The patient is guilty of contributing to the negative outcome/damage of the treatment.
  • If the victim is found to be even one percent at fault, they will be unable to recover compensation for their injuries. However, comparative negligence is used to determine degree of liability of the doctor/medical care provider.
  • Contributory negligence will determine who will receive compensation for their losses and how much they may be entitled to receive in compensation for their injuries. Pure comparative negligence means that in case of an aggrieved patient, damages will be calculated and then reduced to reflect his or her contribution to the injury.

In India, the doctors take the defense against malpractice cases when determining how the parties involved are responsible. In US, 4 categories applied in compensation cases in many of its states: Pure Comparative Negligence/Pure Contributory Negligence/Modified Comparative Negligence—50% Bar Rule and Modified Comparative Negligence—51% Bar Rule. Twenty–one states that recognize the 51% bar rule which means that the party who is less than 51% liable can seek compensation; only 11 US states use the 50% bar rule, which means that if the damaged party is less than 50% responsible, they can collect damages.

For comments and archives

    Public Forum

(Press Release for use by the newspapers)

All hypertensive patients should keep their sugar lower than 90mg%

Hypertension is a risk factor for type 2 diabetes. If not properly managed, patients with hypertension are likely to end up with diabetes with subsequent high risk of kidney damage, said Padma Shri & Dr. B.C. Roy National Awardee, Dr. KK Aggarwal, President, Heart Care Foundation of India & National Vice President Elect IMA.

The results of the Anglo-Scandinavian Cardiac Outcomes Trial-Blood Pressure Lowering Arm (ASCOT-BPLA) study has shown that the major predictor of new-onset diabetes (NOD) in patients with hypertension is high baseline fasting plasma glucose levels of more than 90mg%. The risk increases by 5.8 times for each 18mg% rise above 90 mg%.

Other risk factors are higher weight, higher blood pressure and higher triglyceride levels. Also, hypertensive patients taking atenolol (beta-blocker drug) regimen with or without a diuretic are also at risk.

On the other hand, high BP patients on amlodipine (calcium blocker) ± perindopril (ACE inhibitor), with high good HDL cholesterol levels, moderate alcohol use, and age older than 55 years were protected from developing diabetes.

About HCFI: The only National Not for profit NGO, on whose mega community health education events, Govt. of India has released two National commemorative stamps and one cancellation stamp, and who has conducted one to one training on” Hands-only CPR” of 26134 people since 1st November 2012.

The CPR 10 Mantra is – “within 10 minutes of death, earlier the better; at least for the next 10minutes, longer the better; compress the centre of the chest of the dead person continuously and effectively with a speed of 10x10 i.e. 100 per minute.”

    Readers Responses

Dear Dr, KK Aggarwal , I am appending herewith my recent composition relating to self narration of a bidi smoker who left smoking after sustained and combined efforts of patient, physician and grace of God . Your comments, if any would be welcome. Regards: S Dwivedi

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