emedinews
Head Office: 39 Daryacha, Hauz Khas Village, New Delhi, India. e-mail: emedinews@gmail.com, Website: www.ijcpgroup.com
FIRST NATIONAL DAILY eMEDICAL NEWSPAPER OF INDIA
eMedinewS is now available online on www.emedinews.in or www.emedinews.org
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


30th July, 2010, Friday

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

The new British Thoracic Society guidelines for
Community–acquired pneumonia

Community–acquired pneumonia (CAP) is common and predominantly affects the old and very young. It accounts for 5–12% of all cases of LRTI managed in the community with 22–42% of these needing admission. Mortality of patients treated at home is low at 1% but up to 14% in those admitted to hospital. Symptoms depend on the causative organism but generally include high fever, acute onset, dry cough, dyspnea, pleuritic chest pain and flu–like general malaise. Comorbidities like COPD, left ventricular failure and non–specific symptoms in the elderly may complicate the clinical picture. The presence of localizing signs in the chest – crackles – is helpful in diagnosis.

Guidelines

  1. Chest X–ray is unnecessary in routine suspected CAP unless the diagnosis is in doubt; progress following treatment for CAP is not satisfactory at review and the patient is at risk of other pathologies such as lung cancer.
  2. Radiological resolution often lags behind clinical improvement, especially in the elderly.
  3. Sputum culture is not routinely required.
  4. One should assess severity using the CURB65 score.
    • Confusion: New mental confusion
    • Urea raised above 7mmol/l: In hospitalized patients
    • Respiratory rate: Raised, above 30 per minute
    • Blood pressure: Low (systolic < 90mmHg and/or diastolic < 60mmHg)
      The risk of death from pneumonia increases with higher scores.
  5. An oxygen saturation of less than 92% indicates more severe infection.
  6. Treatment in the community should be with antibiotics. Amoxycillin 500mg thrice daily for a week or doxycyline or clarithromycin as alternatives are recommended.

Dr KK Aggarwal
Editor in Chief
drkkaggarwal Dr K K Aggarwal on Twitter
Krishan Kumar Aggarwal Dr k k Aggarwal on Facebook  

 

Photo Feature (From HCFI file)

 Press conference

Press conference held on May 27, 2009 organised by Heart Care Foundation of India to announce the dates of Perfect Health Parade.

In the photo: Ms. Shovana Narayan, Kathak Dancer and Padma Shri and Dr B C Roy National Awardee Dr. K K Aggarwal, President HCFI

Dr k k Aggarwal

 

News and views

Tissue Doppler E/E’ ratio is a powerful predictor of primary cardiac events in a hypertensive population

Patients with controlled hypertension are at risk of future cardiac events. However, it is difficult to predit first events. Results from the Anglo–Scandinavian Cardiac Outcomes Trial (ASCOT) substudy indicate that Tissue Doppler E/E’, a non–invasive estimate of left atrial filling pressure, independently predicts primary cardiac events in a hypertensive population and out–performed traditional echocardiographic measures in this moderately sized, well–treated hypertensive population. E/E’ therefore may be a simple, effective tool for assessing cardiac risk in a hypertensive population.

Pulse pressure and coronary atherosclerosis in asymptomatic type 2 diabetes mellitus

Elevated pulse pressure is a useful independent marker of presence and extent of pre–clinical coronary artery disease in an asymptomatic diabetic population. (Contributed by Dr E A Farooquee)

Chokeberry Extract Found to Regulate Weight Gain, Blood Glucose, and Inflammation in Rats

Drs. Bolin Qin and Richard Anderson from the US Department of Agriculture in Beltsville, MD evaluted the effects on prediabetic rats who were fed chokeberry extracts for an extended period of time. Chokeberry has high levels of anthocyanins (from the Greek anthos + kyanos meaning dark blue) antioxidants, which protect the chokeberry seed from sunshine–induced oxidative stress. Anthocyanins protect from range of harmful situations such as exposure to pollution and metabolically–derived free radicals including diseases ranging from cancer to obesity. The potent anti–inflammatory properties of anthocyanins may explain the health-promoting effects. Certain anthocyanins –– including those found in chokeberry –– have also been shown to improve blood sugar and the function of insulin.The results of their research were presented in April at the 2010 Experimental Biology meeting, Anaheim.

Prolonged Sitting May Increase Mortality Risk, Regardless of Daily Exercise

Women who spend over six hours a day sitting during leisure time (watching TV, playing games, surfing the web, reading) had 40 % greater chance of dying earlier compared to women who spend less than three hours sitting. Men have a 20 percent increased risk of death. Prolonged time sitting suppresses the immune system and may increase resting blood pressure and cholesterol levels. These were the results published in a study in the the American Journal of Epidemiology.

 

Legal Column

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

Should Doctors interact with the media?

The miraculous extension of life by high technology medical care, organ transplantation, mechanical substitutes, cosmetic surgery, cardiac interventions, newer antibiotics, and prosthetic products document the increase in powers of medical care delivery. At the same time, they have aroused public interest in health & health law including issues related to standard of medical care. This has compelled the Doctors/Hospitals/Medical forums/Associations/Government and has brought them more and more into unavoidable contact with media, both electronic and print. The same has now become an important ingredient in era of transparency and medical information in civilized democratic society in India. The registered medical professional should be aware of the ethics involved in dealing with media.

 

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

• No food or drink for 2 hours before bed-time.
• Elevate head of bed if nocturnal symptoms.
• Avoid foods (caffeine, chocolates, spicy or fatty foods, citrus foods, tomato, carbonated beverages).
• Weight loss, if overweight.

Question of the Day

How is an exposure to multidrug–resistant tuberculosis treated?
(Dr Neeraj Gupta, New Delhi)

Treatment of contacts to MDR cases is difficult. There are few published data concerning the composition, duration, or efficacy of preventive regimens for MDRTB. Potential regimens that have been suggested (based primarily on animal studies) include:

  • Pyrazinamide + ethambutol 
  • Pyrazinamide + a quinolone

With drugs given in the doses to treat active disease for 12 months in immunocompromised patients, and at least six months in patients who are immunocompetent. Therapy in persons with a high probability of having been infected with MDR-TB should be individualized on the basis of drug susceptibility pattern of the index case. Use two drugs to which the organism is assumed to be sensitive, for example, a combination of pyrazinamide (2530 mg/kg daily in adults and 1530 mg/kg/day; maximum 2 g in children) plus either ethambutol (1525 mg/kg daily in adults and 1520 mg/kg/day; maximum 1 g in children) or in adults, a fluoroquinolone with antituberculous activity (levofloxacin 5001,000 mg daily or moxifloxacin 400 mg twice daily).

Duration of treatment has not been studied but is usually recommended for six to 12 months.

Suggested reading

  1. Targeted tuberculin testing and treatment of latent tuberculosis infection. American Thoracic Society. MMWR Recomm Rep 2000;49:1.
  2. Management of persons exposed to multidrugresistant tuberculosis. MMWR Recomm Rep 1992;41:61.
 

Public Forum (Press Release for use by the newspapers)

Diabetes is a progressive disease

Diabetes is a progressive disease, said Padma Shri and Dr B C Roy National Awardee Dr KK Aggarwal, President Heart Care Foundation of India & MTNL Perfect Health Mela.

Dr Aggarwal said that an analysis from the United Kingdom Prospective Diabetes Study (UKPDS) found that 50 percent of patients originally controlled with a single drug required the addition of a second drug after three years. After nine years, 75 percent of patients need multiple therapies to achieve the target hemoglobin A1c (HbA1c) value which is the average blood sugar of the last three months.

After a successful initial response to oral therapy, patients fail to maintain target A1c levels (<7 percent) at a rate of 5 to 10 percent per year. That means that all diabetic patients will start with one drug and will invariably end up with three with or without the addition of insulin within ten years.

A1c should be done every three months until <7 percent and then at least every 6 months and should be preferred over the fasting sugar levels. A1c  should be kept lower than 7%.

Regardless of the initial response to therapy, the natural history of most patients with type 2 diabetes for blood glucose concentrations is to rise gradually with time.

Initial treatment of patients with type 2 diabetes mellitus includes education, with emphasis on lifestyle changes including diet, exercise and weight reduction when appropriate. Monotherapy with metformin is indicated for most patients and insulin may be indicated for initial treatment for some.

In the absence of contraindications, metformin is usually the initial therapy for most patients with type 2 diabetes.

 

Commonwealth Medical Association 

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

Commonwealth Foundation: The functioning of the foundation is as below:

- President – Executive Head of CMA 
- Secretary 
- Treasurer 
- Vice Presidents – Regional

• European Canadian / Caribbean
• South East Asian / Australian
• Central Asian
• West African
• Central Eastern & Southern African

- Company Secretary 
- Secretary to Present
- Liaison Officer

CMA Executive Committee has all the above members. CMA Council has one representative, usually Head of National Medical Association as its member.
The Executive Committee meets usually once in a year and Council meets once in 3 years during the Triennial Conference.

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An Inspirational Story

Wise Man

Ten people were going from one village to another. On the way they had to cross a river. After crossing they wanted to be sure all were there. Each one started counting but counted only nine. They were very distraught and began to cry for the loss of the tenth.

A wise man came along and asked them, "Oh my dear friends, why are you crying?"

"We were ten but now we are only nine," they replied.

The wise man saw they were ten, so he asked them to count. Each counted nine but left out himself. Then the wise man made them stand and count, and he said to the last person, "You are the tenth!"

And they all rejoiced for having regained the tenth.

Similarly the five senses and the four inner faculties (mind, intellect, memory, ego) all lament when they lose sight of the Self. Then the Master comes and shows you that You are the tenth!

Count, but never stop until you find the tenth. The joy is in finding the Ever Present.

With the knowledge of the Self inside, everything is truly joyful.

 

IJCP Special

Dr Good Dr Bad

Situation: A 45–yr–old male came with chest pain and normal ECG.
Dr Bad: Take antacids.
Dr Good: It seems to be a cardiac pain.
Lesson: ECG can be normal in the first six hours of acute heart attack.

Make Sure

Situation: The 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.

Quote of the Day

"Sometimes in the winds of change we find our true direction."

Mnemonic of the day (Dr Varesh Nagrath)

Mnemonic for Reversible Causes OF Dementia
DEMENTIA

Drugs :Any drug with Anticholinergic property
Emotions  :Depression. Pseudodementia
Metabolic  Hypothyroidism
Eye & Ear declining
Normal pressure hydrocephalus
Tumor /ICSOL
Infection :Syphilis / HIV
Anemia Vitamin B12 or folic acid deficiency.

Are you fit to fly?

Surgery

  1. Laparoscopic abdominal procedures are less often associated with ileus than open procedures. The carbon dioxide introduced into the peritoneum during the procedure rapidly diffuses into the tissues, and patients can usually fly the next day if they do not have bloating.
  2. Patients who have undergone a colonoscopy with polypectomy should wait at least 24 hours before flying because of the large amount of gas often present in the colon and the risk of bleeding or perforation at the polypectomy site.
 

International Medical Science Academy Update (IMSA)

HPV vaccine

The US Food and Drug Administration (FDA) approved the use of quadrivalent human papillomavirus vaccine in males. In January 2010, the Advisory Committee on Immunization Practices (ACIP) stated that "the quadrivalent vaccine may be given to males aged 9 through 26 years to reduce their likelihood of acquiring genital warts"

Reference

  1. Policy statement––Recommended childhood and adolescent immunization schedules––United States, 2010. Pediatrics 2010;125:195.
 

Drug Update

List of Approved drugs from 01.01.2010 TO 30.4.2010

Drug Name

Indication

DCI Approval Date

Dexamethasone Intravitreal Implant 0.7mg (in solid polymer drug delivery system)

For the treatment of macular edema following branch retinal vein occlusion (CRVO)

16Jan10

 

Medi Finance

Q. How can a doctor define the inventory of a hospital in simple words?

Ans. Stock of various consumables such as medicines, injections and other vaccines.

 

Lab Medicine (Dr Arpan Gandhi and Dr Navin Dang)

Mycoplasma pneumoniae IgG and IgM

Blood tests for antibody to M. pneumoniae are done:

• To determine if Mycoplasma pneumoniae is the cause of a respiratory tract infection.

• To help diagnose a systemic infection that is thought to be due to mycoplasma.

 

Lateral thinking

Now Read this…………

r

road
……
a
……
d

Send in your answer to emedinews@gmail.com

The answer for yesterday's puzzle:  “Reading between the lines”

Correct entries received from:
Dr Simran Singh, Dr.Srikumar.S, Dr Vivek Vijjan

Correct answers received for 28th July 2010 Puzzle from:
Dr Anurag Jain, Dr Manoj Kr Saini, Dr Sumit Batra, Doctor Anjani, Dr Joshi Sachin, Dr Vinay Nambiar

 

Humor Section

Jokes

Conversation between two small boys in the children’s ward of a hospital: "Are you medical or surgical?"
"Gee, I don't know what you mean by that."
"Well, were you sick when you came in, or did they make you sick after you got here?"

Medical bloopers on medical charts!

Recovery Room………Place to do upholstery

 

Readers Responses

  1. Dear Dr Aggarwal, this is regarding case of Dr Manocha. People at higher level who frame laws are not doctors and they cannot understand the real situations doctors are facing, in this case although Dr Manocha has been fined I think he should consider himself lucky because if he had tried to treat that patient the media and court may have slapped criminal charges on him that why did he touch him when he was a pediatrician. It can be called just bad luck for him that he was standing there and tried to gave the best possible instructions.
    Dr Puneet Wadhwa, Pediatrician, Faridabad.

  2. Hon’ble Sir, this is in continuum to readers query by Dr. Satish Chugh. TRITON–TIMI 38 trial has revealed that Prasugrel has 60% more incidence for solid tumours. "In a new report in the June 29, 2010 issue of the Archives of Internal Medicine, Drs James Floyd (University of Washington, Seattle) and Victor Serebruany (Heart Drug Research Laboratories, Towson, MD) present data from an analysis of the Trial to Assess Improvement in Therapeutic Outcomes by Optimizing Platelet Inhibition with Prasugrel (TRITON–TIMI 38) and show that use of prasugrel was associated with an increase in cancer risk, particularly a 62% increase in the rate of new and worsening cancers." Should we use prasugrel? My second concern is that a few mails are arriving wherein the relatives of deceased patients with pacemakers are approaching docs to sell the pacemakers. What should be a regulated step towards this? Thirdly, there is no standard protocol so as to check the quality assurance of the stents deployed in patients. An oral drug can be checked by patients for expiry date. But what about the expiry date of DES?. Pharma principals are same for medicines & DES regarding the shelf lives. And we all know a DES when expired becomes useless economically, ethically & medically. Regards: Dibendujoy Verma

  3. Regarding some odd facts about blood pressure; I have seen doctors going for MBBS, MD and DNB final exams fail on the matter of taking or discussing BP like
    •  Silent gaps
    •  Phase–4 or phase–5 to be the diastolic pressure
    •  How will one take BP in a fibrillating or irregularly beating heart?
    •  Do we really take the cuff readily available for lower limb BP?
    •  How will a doctor go with absent brachial pulse/s?

      If we people are not comfortable enough in these situations, how can a common man deal with locally available other system practitioners/quacks, god only knows (GOK) Regards: Udaya S Sharma

  4. Dear Sir, Thanks for enlightening all on medicolegal issues. It is true that conduct money is paid to a medical witness by court. However in today’s time when junior doctors working in Emergency are relocating to different areas, many a times they are called from different states, involving expenditure on air tickets and loss of revenues on account of absence from their work, especially in private practice. Most of the courts reimburse only the minimum fare by train/bus. In these cases what is the solution to minimize losses? Dr. Sandeep Jain

  5. Dear Doctor K.K. Aggarwal, I am thankful to you for taking and publishing the case of Dr A.K.Manocha, The comments of doctors from all over India show that emedinews is making its own place in the daily life of doctors. I wish the medical association takes up this case of Dr Manocha to its logical conclusion.

  6. Dr A..K.Shrsivastva's comments in today's emedinews needs special mention. This voice comes from the heart of every doctor. Already Supreme Court has given some protection to doctors. But fears remain. The only solution is restoring the faith. The doctors have to communicate and community has to interact. The media can help. So let us set our own house in order first. Your efforts are appreciated. Sincerely
    Dr .R.S.Bajaj, Consulttant Paediatrician, Sector 13 Rohini,Delhi -110085, Editor : Chikitsak - A bulletin of IMA Rohini

  7. Dear Dr KK Aggarwal, I am in USA on vacation. I am an ardent fan of your very informative emedinews. I must read it everyday. I would like to know the comparison between CT Angio and angiography since many corporate hospitals ask for CT Angio instead of angiography these days. Is it because they have imported these costly machines or
    otherwise. Regards. Prof RV Koranne. Ex -Prof and HOD -Dermato-Venereology. Lady  Hardinge Medical College, Delhi. Ex-student -GRMC-Gwalior-1961-1966
    eMedinewS responds: CT angio is helpful in doubtful cases when TMT is borderline positive; in ER triad to differentiate between MI embolism and dissection, in follow up after CABG, follow up of CAD patients on lifestyle regression therapy etc
 

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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