eMedinewS
5th December 2014, Friday

Dr K K AggarwalPadma Shri, Dr B C Roy National Awardee and National Science Communication Awardee. Limca Book of Record Holder (CPR). Gold Medalist

Dr KK Aggarwal

President, Heart Care Foundation of India; Senior Consultant Physician, Cardiologist & Dean Medical Education Moolchand Medcity; Editor in Chief IJCP Group, Senior National Vice President, Indian Medical Association; Member Ethics Committee Medical Council of India, Chairman Ethical Committee Delhi Medical Council, Hony. Visiting Professor (Clinical Research) DIPSAR; Limca Book of Record Holder in CPR, Chairman (Delhi Chapter) International Medical Sciences Academy (March 10–13); 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);
For updates follow at :  www.twitter.com/DrKKAggarwal, www.facebook.com/Dr KKAggarwal

Winter Asthma

Any breathlessness after the age of 40, appearing for the first time in winter, is cardiac asthma unless proved otherwise. Such patients should immediately have their blood pressure check-up done and if high needs immediate medical attention. First-onset breathlessness can also be an indication of angina or heart attack. However, the more common is winter asthma or acute exacerbation of winter COPD (chronic bronchitis).

Asthma is reversible airway obstruction and COPD is irreversible airway obstruction. Sudden exposure to cold, humidity, pollution at lower levels in atmosphere can precipitate asthma in susceptible individuals. Winter is the time to increase the dose of asthma medicines.

If a person can speak a full sentence, the asthma attack is mild; if a person speaks broken sentences the asthma attack is moderate and if the person is able to speak only words then the asthma attack is severe. Severe attack of asthma needs immediate hospitalization.

An attack of asthma is due to inflammation, narrowing and collection of fluid in the wind pipe and needs medicines to widen the wind pipe and reduce the inflammation.

The need of asthma medicines can be intermittent and/or permanent. The ‘Formula of ‘2’t becomes handy in such situations. A person who consumes more than two canisters of inhalers in a year or consumes asthma medicines more than twice in the night time in a month or more than twice in a day in a week, then he or she needs continuous asthma and anti inflammatory medicines. Inhalers are the best choices.

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66th Annual Conference of Cardiological Society of India (CSI) -2014 conference newsletter day 1

66th Annual Conference of Cardiological Society of India (CSI) -2014

Dr. Dayasagar Rao V

 Dr.Dayasagar Rao.V, DM (Cardiology), FRCP (Canada), FRCP (Edinburgh).,  Senior Consultant Interventional Cardiologist, Krishna Institute of Medical Sciences (KIMS) Hospital, Hyderabad, Andhra Pradesh, India. What would be the prevalence of iron deficiency (ID) in AHF and CHF?

The prevalence of iron deficiency increases with the severity of heart failure. As per the published data, about 50% of heart failure patients have some form of iron deficiency with and without anemia.

Why are chronic heart failure (CHF) patients at risk of developing ID?

Iron deficiency is a common comorbidity in HF is associated with increased disease severity and may contribute to a worse outcome. The mechanism through which anemia contributes to adverse outcome in chronic HF patients is complex and multifactorial. Important factors that may lead to gradual depletion of iron stores (absolute ID) due to low iron intake, GI blood loss, or iron malabsorption. Chronic inflammation, commonly observed in chronic HF, may also play a role. Inflammation causes reduced iron absorption and availability of iron recycled in the reticuloendothelial system (functional ID).
How does ID impact CHF patients?

Iron deficiency contributes to cardiac and peripheral muscle dysfunction. It is associated with poorer clinical outcomes and a greater risk of death, independent of Hb level. The reason why iron may have an effect of HF patients irrespective of the Hb, that supplies oxygen to the cells, is that iron is also an essential constituent of myoglobin which is found in the cytoplasm and avidly binds and releases the oxygen. Iron also prevents structural abnormalities in the cells. Mitochondrial function needs iron as it is a cofactor for hemeproteins - involved in catalase and peroxidase activity - which are important for antioxidation. Iron is also important in T cell function, thus affecting immune mechanisms, and in enzymes involved in synthesis and degradation of proteins, lipids, RNA and DNA.

Therefore, iron deficiency emerges as a new comorbidity and a therapeutic target of CHF in addition to chronic renal insufficiency, anemia and diabetes.

What are the different types of ID and which form of ID is common in CHF? ID in CHF can be classified as absolute or functional. Absolute iron deficiency implies depleted iron stores, functional iron deficiency means that iron is present in human body, but it cannot be mobilized to fulfill its functions. Absolute iron deficiency in patients with HF may be present once serum ferritin is <100 µg/L and functional iron deficiency may be present with serum ferritin is <300 µg/L with TSAT <20%. Functional iron deficiency is more common in patients with CHF.

What is the role of hepcidin in the progression of iron deficiency in CHF?

Iron deficiency is a complication of chronic diseases irrespective of concomitant anemia due to raised level of various inflammatory markers such as IL 6 and TNF-a. Systemic iron metabolism is controlled by mechanisms involving hepcidin and its receptor (ferroportin). In chronic disease such as CHF, hepcidin plays an important regulatory role by inhibiting iron absorption. Hepcidin is a small peptide hormone synthesized mainly by hepatocyte. The circulating hepcidin interacts with its specific transmembrane receptor (ferroportin) on target cells, which causes: 

• Reduced expression of proteins involved in transmembrane iron import to enterocytes, • Internalization of ferroportin, the only protein able to export intracellular iron. Hence, hepcidin blocks intestinal absorption of iron, and diverts iron from the circulation into the reticuloendothelial system

Decreased intestinal iron absorption together with its accumulation in the reticuloendothelial stores reduces the availability of iron to target tissues.
What are the ESC guideline recommendations for the diagnosis of iron deficiency in CHF?
The 2012 guidelines of the European Society of Cardiology for HF state that all patients should be screened for iron deficiency, a class I recommendation. Iron deficiency was defined as ferritin level <100 µg/L or serum ferritin 100 to 299 µg/L in combination with a TSAT <20%. The recent guidelines also suggest that IV iron therapy may now be considered as an acceptable treatment option for CHF patients.

What is your opinion regarding ESA (Erythropoietin Stimulating Agents) usage for treatment of iron deficiency/anemia in CHF?

Two clinical trials, RED-CHF and TREAT have been done using ESA for treatment of iron deficiency/anemia and both trials have shown higher incidence of stroke and thromboembolic events after ESA. Possible causes include worsening of hypertension, increased release of endothelin and increased prothrombic state.

What is your opinion on blood transfusion/ EPO vis-à-vis IV iron therapy in CHF patients

Although all interventions have definite benefits as per the indication at which a patients has been presented, but as per the AACP 2013 guideline the only intervention that has proven to be effective in improving QOL and NHYA class was with IV iron therapy. In a series of placebo-controlled, randomized studies in patients with HF and iron deficiency, IV iron had a favorable effect on exercise capacity, functional class, LVEF, renal function and QOL.

Moreover, according to the latest trial CONFIRM HF, ferric carboxymaltose (available as Ferinject) has significantly reduces the rate of first hospitalization by 61%. 

Dr. Santanu Guha

An Interview with: Dr. Santanu Guha, Kolkatta

How has your practice changed after the new ACC/AHA guideline of dyslipidemia management?
Statin therapy for chronic ischemic heart disease patient has changed. I now routinely use 40 to 80 mg of atorvastatin in such patients. My threshold for giving statin has perhaps been little lowered in primary prevention.
How important are non-statin therapies in managing your patients?
I consider the use of fibrates and ezetimibe quite important in the management in those patients with atherogenic dyslipidemia where LDL is not very high but non HDL cholesterol is significantly elevated, after attaining the LDL goal with statin therapy, I use fibrates to bring down the non HDL cholesterol if it still remains elevated. I mostly encounter this scenario in patients with diabetes and metabolic syndrome. Ezetimibe is useful in high risk patients, where LDL remains elevated despite statin therapy.

The pcsk9 inhibitors hold promise as data suggest, what are your added expectations from it?

The pcsk9 inhibitors are very powerful LDL lowering agents and I believe they will be very helpful in statin intolerant patients and in FH having very high baseline LDL level.

In the midst of setbacks to HDL enhancement therapies what is your opinion on HDL goals in your patients?

Now days, we are less bothered about the HDL level. However, functionality of HDL is more important. HDLs cholesterol efflux capacity is perhaps much more important than the level of HDL. Particularly in statin treated patients, perhaps, there is no role of pharmacotherapy to raise HDL level.

News Around The Globe

  • Diabetes in midlife is associated with an increased rate of cognitive decline over a 20-year follow-up, suggests a new study published online December 2 in Annals of Internal Medicine.
  • The US Food and Drug Administration (FDA) has granted marketing clearance for an injectable microchip neuromodulation device, the Stimwave Freedom Spinal Cord Stimulation (SCS) system, for the relief of chronic back and leg pain.
  • Cabozantinib monotherapy leads to skin problems in most patients with metastatic, progressive urothelial carcinoma, suggests new research published online in JAMA Dermatology.
  • Treatment with low-dose budesonide for one year keeps most patients with collagenous colitis in remission, reported a new randomized, placebo-controlled trial published online in Gut.
  • When women with rheumatoid arthritis being treated with tofacitinib experience an unplanned pregnancy, newborns are healthy in about half of all cases, suggests an analysis of a large clinical trials database. This suggests that tofacitinib should be used during pregnancy only if the potential benefit justifies potential risk to the fetus. The data were presented at the American College of Rheumatology 2014 Annual Meeting.

Dr KK Spiritual Blog

Why Spirituality is Happiness Friendly

  1. What you believe in can have a big impact on health and longevity. People with high levels of religious beliefs or spirituality have lower cortisol responses. Cortisol is a hormone the body releases in response to stress.
  2. Positive thinking produces nearly a 30 percent drop in perception of pain.
  3. Spirituality and the practice of religion is associated with a slower progression of Alzheimer’s disease.
  4. Those who regularly attend organized religious activities may live longer than those who don’t. Regular participation lowers mortality rate by about 12 percent a year.
  5. People undergoing cardiac rehabilitation feels more confident and perceive greater improvements in their physical abilities if they have a strong faith.
  6. Increased levels of spirituality and religious faith may help substance abusers kick their habit.
  7. Spirituality stimulates the relaxation response. When the body is relaxed, your heart rate, blood pressure and breathing rate all go down, which decreases the body’s stress response.
  8. Spirituality can affect immune-system function. Spirituality, faith, church attendance improves immune function in ways that can be measured, like an increase in white blood cells.
  9. Prayer heals the heart. Positive talking and thinking in the ICU produces better results.
  10. Spirituality is what brings you peace and safety. It can be achieved through God or Goddess, nature, a beautiful sunset, a meditation, Pranayama, religious meeting, chanting, mind body relaxation, etc. Spirituality is something that can help all the way from promoting wellness to helping with recovery.

Inspirational Story

Believe in Yourself

Believe in yourself and you can achieve, things you never thought possible, Believe in yourself and you can discover talents new, that lie away hidden

Believe in yourself and you can reach, new heights that you thought unscalable, Believe in yourself and you can solve, problems that defy any solution

Believe in yourself and you can conquer, any situation, however difficult, Believe in yourself and you can make, the most complicated things seem simple

Believe in yourself and you can learn, the skills of gaining knowledge from experience, Believe in yourself and you can enjoy, the beauty in nature's abundance

Believe in yourself and you can perceive, new depths your senses can apprehend, Believe in yourself and you can perform way beyond your expectations

Believe in your goal and work towards it with determination and dedication, Believe in yourself and output enhance by contributing to a given situation

Believe in yourself and you'll feel blessed, as God's very own special creation.

Rabies News (Dr A K Gupta)

What are the myths about rabies in India?

The following myths about rabies are very prevalent in India:

  • In India, there are many myths and wrong practices concerning the management of an animal bite. People apply turmeric, salt and sometimes ghee over the wound area. Chilies, hydrogen peroxide and cow dung are some other wrong practices followed, mainly in the rural parts of India.
  • Some herbal extracts will cure rabies.
  • In rural areas, people also resort to witchcraft and religious practices.
  • Washing of wound(s) can cause hydrophobia.
  • Dietary changes can cure, i.e., shift from vegetarianism to non-vegetarianism or vice versa; stopping consumption of white things etc.
  • A single dose vaccine will prevent rabies.
  • Vaccines are more effective if taken on empty stomach.
  • One should not bathe or eat meat and eggs during vaccination.
  • Gems and stones have magical properties against rabies.

Cardiology eMedinewS

  • Breathing secondhand marijuana smoke may be just as damaging to the heart and blood vessels as inhaling secondhand cigarette smoke, suggests a small study presented recently at the American Heart Association (AHA) 2014 Scientific Sessions.
  • For patients with diabetes, even mild coronary artery disease can increase the risk for death, points new research from the CONFIRM Registry. The analysis of data from the registry was presented at the Radiological Society of North America 100th Annual Meeting.

Pediatrics eMedinewS

  • Breastfed babies may sometimes suck on their own arms to the point of bruising themselves and the injuries should not be confused with signs of child abuse, suggested a new case report. Authors said that where there is clear evidence of the baby sucking on their arm prior to a feed then it may result in linear suction bruises. The report was published online in Archives of Disease in Childhood.
  • A new study published in the BMJ has stated that risk of infant mortality is increased among mothers who are overweight or obese during early pregnancy.
emedipicstoday emedipics

Health Check Up and CPR 10 Camp at Sarvodaya Kanya Sec. School, Pushp Vihar on 7th November 2014

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19th-Nov-CSI.jpg

video of day
press release

FDA OKs first drug-eluting stents for use in MI

Sameer Malik Heart Care Foundation Fund

The Sameer Malik Heart Care Foundation Fund is a one of its kind initiative by the Heart Care Foundation of India instituted in memory of Sameer Malik to ensure that no person dies of a heart disease because they cannot afford treatment. Any person can apply for the financial and technical assistance provided by the fund by calling on its helpline number +91 9958771177 or by filling the online form.

Madan Singh, SM Heart Care Foundation Fund, Post CAG

Kishan, SM Heart Care Foundation Fund, Post CHD Repair

Deepak, SM Heart Care Foundation Fund, CHD TOF

Total CPR since 1st November 2012 – 101090 trained

cpr10 Mantra The CPR 10 Mantra is – "within 10 minutes of death, earlier the better; at least for the next 10 minutes, longer the better; compress the centre of the chest of the dead person continuously and effectively with a speed of 10×10 i.e. 100 per minute."

CPR 10 Success Stories

Ms Geetanjali, SD Public School
Success story Ms Sudha Malik
BVN School girl Harshita
Elderly man saved by Anuja

CPR 10 Videos

cpr 10 mantra
VIP’s on CPR 10 Mantra Video

Hands–only CPR 10 English
Hands–only CPR 10 (Hindi)

 

IJCP Book of Medical Records

IJCP Book of Medical Records Is the First and the Only Credible Site with Indian Medical Records.

If you feel any time that you have created something which should be certified so that you can put it in your profile, you can submit your claim to us on :

 

Dr Good and Dr Bad

Situation: A heart patient wanted to know if he could meditate under a pyramid.
Dr Bad: You cannot do it.
Dr Good: Go ahead.
Lesson: The effect of meditation under a pyramid as twice as strong as meditating outside the pyramid.

Make Sure

Situation: A diabetic patient with BP of 130/90 developed acute heart pain.
Reaction: Oh my God! Why was his BP not kept below 120/80.
Lesson: Make sure that all patients with diabetes should have a goal BP of less than 120/80.

eMedinewS Humor

I'll trust you that you paid

A man walks into a bar and has a couple of beers. Once he is done the bartender tells him he owes $9.00.

"But I paid, don't you remember?" says the customer.

"Okay," says the bartender, "If you said you paid, you did."

The man then goes outside and tells the first person he sees that the bartender can't keep track of whether his customers have paid.

The second man then rushes in, orders a beer and later pulls the same stunt.

The barkeep replies, "If you say you paid, I'll take your word for it."

Soon the customer goes into the street, sees an old friend, and tells him how to get free drinks.

The man hurries into the bar and begins to drink high-balls when, suddenly, the bartender leans over sand says, "You know, a funny thing happened in here tonight. Two men were drinking beer, neither paid and both claimed that they did. The next guy who tries that is going to get punched right in the nose."

"Don't bother me with your troubles," the final patron responds. "Just give me my change and I'll be on my way."

Twitter of the Day

Dr KK Aggarwal: Cause and cold does not require antibiotics

Dr Deepak Chopra: My Thanksgiving Message: Let us be grateful, humble, have reverence and love for all existence.

Quote of the Day

  • Luck is what happens when preparation meets opportunity. ~ Seneca

Wellness Blog

Heart Attack Symptoms in Women and elderly are Different

Winter is the month for heart attacks and the symptoms in women and the elderly may be different,

  • Chest pain is still the most common sign of a heart attack for most women but women are more likely than men to have symptoms other than chest pain or discomfort when experiencing a heart pain. In a study published in Archives of Internal Medicine researchers examined 35 years of research that yielded 69 studies and found that, between 30 and 37 percent of women did not have chest discomfort during a heart attack. In contrast, 17 to 27 percent of men did not experience chest discomfort.
  • Older people are also more likely to have heart attack without chest discomfort. Absence of chest discomfort is a strong predictor for missed diagnosis and treatment delays.
  • Women are also more likely than men to experience other forms of cardiac chest pain syndromes, such as unstable angina, and they appear to report a wider range of symptoms associated with acute coronary syndrome (ACS). They are more likely to report pain in the middle or upper back, neck, or jaw; shortness of breath; nausea or vomiting; indigestion; loss of appetite; weakness or fatigue; cough; dizziness; and palpitations.
  • Women are, on an average, nearly a decade older than men at the time of their initial heart attack. Coronary heart disease is the leading cause of death among U.S. women, and affects one in 10 women over the age of 18.

ePress Release

Stay cautious and make this winter a healthy one for your heart

The winters now seem to have taken a good grip all over the northern part of the country. However, such pleasant weather brings with it few health related concerns for the people as well. Keeping in mind the lowering temperature in the season, viral infections are seen on a rise. Patients suffering from heart ailments need to be extra careful during winters as most heart attacks in the world occur during this season.

Commenting on the precautions and cautions to be considered during this season, Padma Shree and National Science Communication and Dr. B.C. Roy National awardee Dr. K K Aggarwal, President Heart Care Foundation of India said, “Missing heart attacks during this period in the early hours of the morning can lead to spurts in number of cases of sudden cardiac death. In the emergency room heart attacks can be both over and under diagnosed. 10% of heart attacks are over diagnosed and equivalent number can be missed, as the ECG can be normal in the first six hours after a heart attack. Every effort should be taken to reduce the number of false positive or false negative diagnosis of heart attack in winter.”

Winter not only brings in the cold and chilly winds but also few festivities. Christmas and New Years Eve are the two occasions when people are in their full swing to celebrate these two days. However, heart patients should take few precautions so that the festivities don’t end up affecting their heart health. Dr. Aggarwal, elaborating on the precautions that need to be taken during these times said, “During Xmas most senior doctors maybe on vacation making the situation further bad for the common man. In winter season, the outdoor pollution especially the PM2.5 (particulate matter) is high in the environment and this can precipitate a heart attack. The blood pressure is also higher by 5 mm Hg during wintertime. Therefore, all the heart patients should be very careful during this time of the year and should also visit their doctors for those extra precautionary measures that will help them staying fit during the winters.”

eMedi Quiz

A vitreous aspirate has been collected in an emergency at 9 pm what advice you like to give to the staff on duty regarding the overnight storage of the sample. 

1. The sample should be kept at 4° C.
2. The sample should be incubated at 37°C.
3. The sample should be refrigerated deep freezer.
4. The sample should be refrigerated for the initial 3 hours and then incubated at 37°C.

Yesterday’s Mind Teaser: A 60 year old male presented to the emergency with breathlessness, facial swelling and dilated veins on the chest wall. The most common cause is:

1. Thymoma
2. Lung Cancer.
3. Hodgkin's lymphoma.
4. Superior vena caval obstruction.

Answer for yesterday’s Mind Teaser: 4. Superior vena caval obstruction.

Correct answers received from: Dr K V Sarma, Raju Kuppusamy, Dr Pankaj Agarwal, Manu Shankar, Dr Rakesh Sharma.

Answer for 3rd December Mind Teaser: 3. Bone erosions.

Correct answers received from: Dr Rakesh Sharma, Dr Avtar Krishan, Dr ABDUL GAFAR Dabawala, Dr Jainendra Upadhyay.

Send your answer to email

medicolegal update
  1. Dear Sir, Very Informative. Regards: Dr Karan

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