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Address: 39 Daryacha, Hauz Khas Villege, New Delhi, India. e-Mail: , Website:


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)



4th December Friday

Dear Colleague,

Today is national hepatitis day. Main points to revise

1. There are 300 million carriers of the hepatitis B virus in the world
2. 500,000 dye annually from hepatitis B related liver disease.
3.  The virus spread by needle sharing during injection drug use or by unprotected sex, or from mother to infant during pregnancy or delivery.
4.  Any activity that transfers blood or body fluids beneath the skin can transmit the hepatitis B virus. This includes tattooing, acupuncture, ear piercing and needle sharing.
5.  Perinatal transmission usually occurs during or shortly after delivery.
6. There is no evidence that a cesarean delivery prevents maternal infant transmission, and breast feeding does not appear to increase the risk of transmission.
7. During pregnancy, all women should have HBsAg test. This marker indicates that the woman is currently or has previously been infected with hepatitis B.
8.  If the mother's HBsAg test is positive, the infant should receive an injection of hepatitis B immunoglobulin soon after birth. It temporarily helps to protect the infant from infection.
9. The infant should also receive the hepatitis b vaccine at birth, at 1 to 2 months, and at 6 months. The infant should have blood test for hepatitis B infection at 9 to 18 months of age; if the test is negative, a fourth dose of the vaccine should be given at that time.
10.  Hepatitis B can be spread through close personal contact. Infection most likely occurs when body fluids containing the virus enter tiny breaks in the skin or the mucous membranes of the eyes and mouth. This type of transmission can occur between children. Because the virus can survive outside the body for long periods of time, transmission can also occur by sharing household items that carry the virus, including toys, toothbrushes, and razors.
11.   In hospital setting, hepatitis B virus can be transmitted from patient to patient or from patient to health care provider through contaminated needles or instruments. Measures to reduce this risk include using gloves, eye protection, a face mask, and hand washing.
12.  Hepatitis B virus can be transmitted in donated organs.
13.  Symptoms of hepatitis B differ during acute hepatitis and chronic hepatitis.  Most infected people have no symptoms for many years. However, the absence of symptoms does not necessarily mean that the infection is under control.
14. Everyone with chronic hepatitis B is at increased risk of developing complications, including liver scarring and liver cancer.
15.  Symptoms of acute hepatitis B usually appear one to four months after becoming infected. The first symptoms may be non-specific, including fever, skin rash, and joint pain and inflammation. Some people have no symptoms at all.
16.  Acute hepatitis can be severe, with symptoms lasting for many weeks or months. Less commonly, acute hepatitis is life-threatening or "fulminant,". The only treatment for fulminant hepatitis is liver transplantation.
17.  The symptoms of acute hepatitis B usually resolve within three months. 
18.  Most people with acute hepatitis B recover uneventfully. However, in about 5 percent of adults the virus makes itself at home in the liver, where it continues to make copies of itself for many years. People who continue to harbor the virus are referred to as "carriers". Liver damage associated with longstanding infection is referred to as "chronic hepatitis."
19.  Chronic hepatitis B develops more commonly in people who are infected with the virus at an early age, such as at birth. This is a common event in southeast Asia where as many as 1 in 10 people have chronic hepatitis B infection.
20.  The symptoms of chronic hepatitis B can vary widely and can last for many years.
21.  About 10 to 20 percent of people with chronic hepatitis B develop complications. Inflammation of blood vessels and kidney disease are the two most common complications.
22. During acute hepatitis B, high levels of SGOT and SGPT signal ongoing liver inflammation.
23.  In most people with acute hepatitis, liver enzyme levels return to normal within one to four months. If SGPT levels remain high after six months, this suggests that the person is developing chronic hepatitis. Liver enzyme levels may fluctuate during the course of chronic infection.
24.  The diagnosis of acute hepatitis B is based upon the presence of the hepatitis B surface antigen (HBsAg) and hepatitis B core IgM antibody.
25. The diagnosis of chronic hepatitis B is based on the presence of the HBsAg marker for at least six months; hepatitis B core IgM antibody is usually negative.
26.  In acute hepatitis, HBsAg can be detected soon after infection; falling levels of this marker and the appearance of hepatitis B surface antibodies (HBsAb or anti-HBs) signal recovery.
27.  In chronic hepatitis, HBsAg can be detected for many years, and HBsAb may never appear.
28.  Hepatitis B e antigen (HBeAg) is present when the hepatitis B virus is actively multiplying. In acute hepatitis, HBeAg can be detected soon after infection; falling levels of this marker and the appearance of hepatitis B e antibodies (HBeAb or anti-HBe) signal recovery.
29.  In most patients with chronic hepatitis, HBeAg can be detected for many years. With time, the immune system may suppress the virus to such low levels that HBeAg is no longer detected and HBeAb is present. Loss of HBeAg and appearance of HBeAb (also called HBeAg seroconversion) is usually an indication that the virus is suppressed and the liver disease becomes inactive.
30.  Detection of hepatitis B virus DNA in a blood sample signals that the virus is actively multiplying. In acute hepatitis, HBV DNA can be detected soon after infection; falling levels of HBV DNA signal recovery, and levels usually become undetectable over time.
31.  In chronic hepatitis, levels of HBV DNA often remain high for many years and then decrease as the immune system gains control over the virus. In some patients, HBV DNA levels fluctuate due to alterations in balance between the immune system and the virus.
32.  Antibodies to Hepatitis B surface antibody is a marker of immunity or protection. People who develop immunity to hepatitis B after vaccination have anti HBs only while those who develop immunity after recovery from acute hepatitis B have anti HBs and a specific class of antibodies (IgM) directed against the hepatitis B core antigen (anti-HBc).
33.  There are two classes of this antibody (core IgG and core IgM). The IgM class appears first during the acute phase of hepatitis and then gradually switches to the IgG type.
34.  A liver biopsy is not routinely needed to diagnose hepatitis B. Liver biopsy is used for monitoring the progression of liver damage in people with chronic hepatitis, helping to decide if treatment is needed, and for detecting cirrhosis or liver cancer.
35.  The likelihood of a person with acute hepatitis progressing to chronic hepatitis largely depends on the person's age at the time of infection.
36.  Chronic infection develops in about 90 percent of children who are infected at birth, in 20 to 50 percent of children who are infected between the ages of 1 and 5 years, and in less than 5 percent of people infected with hepatitis B during adulthood.
37.  The risk of developing complications of chronic hepatitis B is influenced by how rapidly the virus multiplies and the immune system's ability to control the infection.
38.  Other factors to worsen the course of hepatitis include continued alcohol use and infection with other hepatitis viruses (hepatitis A or C).


Dr KK Aggarwal


Revisiting progeria (Amitabh Bachhan play the role of a progeria child)

1. In progeria, the skin changes typically develop during the first year of life. Lesions are characterized by thickened, bound-down skin on the abdomen, flanks, proximal thighs, and upper buttocks.
2.  Progeria (also known as "Hutchinson–Gilford progeria syndrome.
3.  It is an extremely rare, severe, genetic condition wherein symptoms resembling aspects of aging are manifested at an early age.
4.  The disease has a very low incidence and occurs in one per eight million live births.
5.  Those born with progeria typically live about thirteen years, although many have been known to live into their late teens and early twenties and rare individuals may even reach their forties.
6.  t is a genetic condition that occurs as a new mutation and is not usually inherited, although there is a uniquely inheritable form.
7.  The earliest symptoms include failure to thrive and a localized scleroderma-like skin condition. As the child ages past infancy, additional conditions become apparent. Limited growth, alopecia, and a distinctive appearance (small face and jaw, pinched nose) are all characteristic of progeria.
8. People diagnosed with this disease usually have small, fragile bodies, like those of elderly people. Later, the condition causes wrinkled skin, atherosclerosis, and cardiovascular problems.
9.  Diagnosis is suspected according to signs and symptoms, such as skin changes, abnormal growth, and loss of hair. It can be confirmed through a genetic test.
10. No treatments have been proven effective. Most treatment focuses on reducing complications (such as cardiovascular disease) with heart bypass surgery or low-dose aspirin.
11.  Children may also benefit from a high-calorie diet.
12.  Growth hormone treatment has been attempted.
13.  A type of anticancer drug, the farnesyltransferase inhibitors (FTIs), has been proposed, but their use has been mostly limited to animal models.
14.  There is no known cure. Few people with progeria exceed 13 years of age.
15. At least 90% of patients die from complications of atherosclerosis, such as heart attack or stroke.
16.  Mental development is not affected. The development of symptoms is comparable to aging at a rate six to eight times faster than normal, although certain age-related conditions do not occur. Specifically, patients show no neurodegeneration or cancer predisposition. They do not develop physically mediated "wear and tear" conditions commonly associated with aging, like cataracts (caused by UV exposure) and osteoarthritis (caused by mechanical wear).
17.  Although there may not be any successful treatments for Progeria itself, there are treatments for the problems it causes, such as arthritic, respiratory, and cardiovascular problems

Stroke Risk Associated With Positive Serologic Test Results
A Study, published in the November issue of Stroke (2009;40:3443), linked herpes zoster to stroke. The epidemiologic study suggested that infection increases the risk for ischemic and hemorrhagic events. It showed that the risk for stroke increased by 30% after a herpes zoster attack. The risk is even higher, approximately 4 fold, if the attack involves the eye (herpes zoster ophthalmicus).

High Triglycerides During Pregnancy Linked to Preeclampsia, Diabetes
Dr. Victor Novack of Harvard Clinical Research Institute, Boston, Massachusetts HAhas shown that the prevalence of preeclampsia or gestational diabetes increases with levels of triglycerides, from 7.2% in the group with low triglycerides (<25th percentile adjusted for the gestational month) to 19.8% in the group with high triglycerides (>75th percentile). Preeclampsia or gestational diabetes are not associated with high density lipoprotein levels.

Chest CT Angiograms to Diagnose Pulmonary Embolism Twice as Likely to Find Other Pathology
Small pulmonary nodules on chest CT scans could indicate bronchogenic carcinoma; however, these lesions are much more likely to be benign. William B. Hall, MD, from the University of North Carolina at Chapel Hill, and colleagues studied on prevalence and management implications of such incidental findings. Incidental findings of pulmonary nodules can be a source of great anxiety for patients and often generate multiple follow up radiographic studies and other diagnostic interventions.

Monofilament Testing Can Diagnose Peripheral Neuropathy
Monofilament testing is an inexpensive, easy to use, and portable test for assessing the loss of protective sensation, and it is recommended to detect peripheral neuropathy in otherwise normal feet.

Walking Speed Predicts CV Mortality in Older People
Dr Julien Dumurgier (INSERM, Paris, France) says a walking speed over 6 m in older people is predictive of cardiovascular mortality, with those in the slowest tertile three times more likely to suffer CV death over five years than those who walked faster. The old persons who walk slowly have an increased risk of death, in particular cardiovascular death.
Walking speed was measured by asking participants to walk at their usual speed and then asking them to walk, over 6 m down a corridor, at their maximum pace without running.

Analyses for specific causes of death showed that those with a low walking speed had about a threefold increased risk of cardiovascular death (HR 2.92) compared with participants who walked faster. There was no association between walking speed and cancer mortality (HR 1.03), however. Walking speed is an objective measure of physical fitness and should not be used in isolation to identify people at high risk of cardiovascular death. Measuring walking speed is an objective measure of physical performance, and it's far more accurate than asking a person how much regular exercise they do. It's a bit like the difference between asking a person how much they eat and weighing them.

Long Term Statin Use May Be Linked to Decreased Risk for Gallstone Disease and Cholecystectomy
Gallstone disease is a leading cause of morbidity in western countries and carries a high economic burden. Statins decrease hepatic cholesterol biosynthesis and may therefore lower the risk for cholesterol gallstones by reducing the cholesterol concentration in the bile. The analysis by Michael Bodmer, MD, from University Hospital, Basel, in Basel, Switzerland, and colleagues showed that patients with long term statins use have a reduced risk for gallstone disease and subsequent cholecystectomy vs patients without statin use. 

Antioxidant pills do not prevent metabolic syndrome
People who want to forestall heart disease and diabetes may do better by choosing antioxidant rich foods instead of antioxidant supplements. Researchers found that among more than 5,200 middle aged adults, antioxidant supplements had no effect on the risk of developing metabolic syndrome over seven plus years. The current findings, reported in the American Journal of Clinical Nutrition, suggest that taking antioxidants in capsule form may not thwart metabolic syndrome.

Population Movement Can Be Critical Factor In Dengue's Spread
Human movement is a key factor of dengue virus inflow in Rio de Janeiro, according to results from researchers based at the Oswaldo Cruz Foundation in Brazil.


High dose, short term folate may cut blood pressure
A short term, high dose supplementation period with folate may reduce blood pressure, and improve other cardiovascular measures, suggests a small study from Italy. Fifteen post menopausal women received a daily dose of 15 mg of 5 methyltetrahydrofolate, the naturally circulating form of folate, for three weeks, and experienced an average drop in systolic and diastolic blood pressure of 4.5 and 5.3 mmHg, respectively.
The results of the placebo controlled study are published in the European Journal of Clinical Nutrition.

Multivitamins may lower heart disease death risk
Long term regular consumption of a multivitamin may reduce the risk of dying from heart disease by 16 per cent, according to a new study from the US. Intakes of vitamin E over 215 milligrams per day over the course of ten years were also associated with a 28 per cent reduction in the risk of death from cardiovascular disease, according to findings published in the American Journal of Epidemiology. The news supports the use of multivitamins and particularly vitamin E, much maligned and linked to increased risk of all cause mortality in a controversial meta analysis in the Annals of Internal Medicine in 2004.

Multivitamins and biological age
Earlier this year, scientists from the National Institute of Environmental Health Sciences reported that the cells of multivitamin users may have a younger biological age than cells from non users. The study, published in the American Journal of Clinical Nutrition (June 2009, Vol. 89, pp. 1857 1863) was reported to be the first epidemiologic investigation of multivitamin use and telomere length.

New Canadian Cholesterol Lowering Guidelines Target Immediate Risk Group: Presented at CCC. In high risk groups in addition to the previous LDL goal of <2 mmol/L, the new guidelines recommend a 50% reduction in LDL from baseline. For some patients, this means bringing LDL substantially below the previous target.

The diagnosis of vitamin D deficiency is often missed because the signs and symptoms develop slowly or are nonspecific, such as symmetric low back pain, proximal muscle weakness, muscle aches, and throbbing bone pain. Diagnosis of suspected vitamin D deficiency or insufficiency is confirmed with measurement of 25 hydroxyvitamin D levels.   In older adults, vitamin D supplementation of 700 to 800 IU per day is associated with a lower risk for falls and fractures. Suggested treatment in patients with vitamin D deficiency is oral ergocalciferol, 50,000 IU per week for 8 weeks. Adults with vitamin D deficiency, except for those with malabsorption syndromes, should receive maintenance dosages of 800 to 1000 IU of vitamin D per day (DR.G. M. SINGH)


Following is a guidelines/recommendation for emedinews: From Dr Astha Gupta
Physicians should carefully prescribe anti cholinergic drugs (OTC cold and cough meds) to elderly people, (especially those with genetic risk of dementia), not only to avoid side effects of urine retention, constipation and dryness but due to  associated risk of short term cognitive effects and dementia in long term. [Longitudinal study published in Arch Intern Med 2009 Jul 27; 169:1317]

American Association for the Study of Liver Diseases, Boston, Oct 30-Nov 3, 09 excerpts
1.      A simple breath test, which measures exhaled CO2 following an early dose of isotopically labeled methacetin can provide a good overall measure of liver function in patients with chronic viral hepatitis and could help in evaluating liver transplant patients (Dr. Ghalazen)
 2.      Vitamin E and pioglitazone may become the first effective treatment for NASH (Dr. Arun Sangat University of Richmond).
3.  Most hepatitis C patients who are initially unresponsive to standard treatment will be able to achieve sustained biologic response with a new investigative drug Bocepreviv (Dr. Paul Kwo of Indiana Polis).
4.      People with BMI of more than 40 is not a contraindication for liver transplant (A J C Lamaffina).
5.   Antibiotics are the most common cause of drug induced liver failure. More than half of drug induced liver failures are caused by drugs belonging to anti-TB, anti-fungal, sulfa and other antibiotics. (Dr. A. Reupen of Santh Carolina)  
Other causes are herbal settlements anti-convulsants and statins.
6.      In patients with advanced liver diseases related to Hepatitis C, a course of PEG Interferon and Ribarvirin before liver transplant can prevent complications (Dr. G T Aveson, University of Colorado).
7.      A form of Hepatitis C infection is behaving like an STD in New York. It is rapidly damaging the liver and is transmitted primarily through sex with other man (Dr. D. Firer of Mt. Sinai Hospital)

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Emedinews: 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 We have crossed 700 registrations.

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Letters to the editor
1. Prasugrel vs clopidogrel after DES, which drug for which patient? DR G M singh
 Emedinews comments? Patients with unstable angina/non STEMI who are selected for an invasive approach should receive dual   anti platelet therapy, with aspirin at presentation and clopidogrel or prasugrel as the second agent.  A 60  milligram loading dose of prasugrel is now a recommended alternative to clopidogrel for patients with ST   elevation myocardial infarction (STEMI) who undergo primary percutaneous coronary intervention, according to updated guidelines.  The guidelines from the American College of Cardiology, American Heart Association, and Society for Cardiovascular Angiography and Interventions determined that the benefits of prasugrel outweighed its risk for bleeding and incorporated the drug into their recommendations. The FDA approved prasugrel in July, despite the same concerns.

2. Dear D. Aggarwal: I is always nice to read your emedinews. In this issue article on depression was good. It will sensitize physician and GPs and create awareness among them.
Regards. Dr. Rajesh Rastogi. HOD Psychiatry, Safdarjung Hospital

Interesting sites by Dr Manoj Aron

CDC Warns of Increasing Pneumococcal Disease Associated With H1N1 Flu

Long Term Statin Use May Be Linked to Decreased Risk for Gallstone Disease and Cholecystectomy (Dr Vivek Chhabra)


A waiter suddenly became ill and was rushed to the hospital emergency room. He was lying on the operation table in great pain when he saw an intern walk by. Doctor, you have to help me, the waiter pleaded. Sorry, the intern said. This is not my table.

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