6th November 2014, Thursday

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

No antibiotics without advice if you are a heart patient

Trimethoprim-sulfamethoxazole when combined with ACE inhibitor or ARB can end up with sudden death

Trimethoprim-sulfamethoxazole may increase risk for hyperkalemia in the elderly

New Delhi: In a study published in BMJ, the risk of sudden death went up by more than a third in older patients taking ACE inhibitors (ACEIs) or angiotensin-receptor blockers (ARBs) who were also put on the antibacterial agent cotrimoxazole (sulfamethoxazole and trimethoprim), compared with those who were instead given amoxicillin.

The elevated risk was likely caused by its capacity for raising serum potassium, which became fatal on top of other medications known for causing hyperkalemia.

Patients on ACEIs or ARBs are at risk for hyperkalemia, should not take any antibiotic without medical supervision. If they need to be given:

  • They should be given at the lowest dose and for a minimum period of time
  • And keep a watch on potassium.

Diabetics are vulnerable

  • Patients with type 2 diabetes have a tendency for hyperkalemia because of silent kidney involvement.
  • Heart failure patients on potassium-sparing spironolactone are also at risk
  • Patients with both reduced left ventricular function and diabetes have the greatest risk.

The risk depends on the dosage and duration of use of the antibiotic. Ten days of Trimethoprim-sulfamethoxazole may be risky while three days not.

In the study data from patients aged 66 or older who received ACE inhibitors or ARBs in Ontario from 1994 to 2012, identified outpatients who died of sudden death within 7 days of being prescribed Trimethoprim-sulfamethoxazole, amoxicillin, ciprofloxacin, norfloxacin, or nitrofurantoin. Those 1027 cases were matched to 3733 controls alive within that time frame relative to the antibiotic prescriptions, based on, among other things, age, sex, chronic kidney disease, and diabetes.

The adjusted odds ratios (95% CI) for sudden death within 7 days of an antibiotic prescription on top of an ACE inhibitor or ARB, by antibiotic, relative to amoxicillin (which does not pose a hyperkalemia risk itself or prolong the QT interval) were: 1.38 for Trimethoprim-sulfamethoxazole; 1.29 for ciprofloxacin; 0.74 for norfloxacin and 0.64 for nitrofurantoin.

Ciprofloxacin can predispose to sudden death by prolonging the QT interval.

News Around The Globe

  • The Infectious Disease Society of America (IDSA) recommends that culturing and antibiotics should be avoided in treating DFUs that show no clinical signs of infection.
  • Patients receiving chronic hemodialysis may be at a significantly higher risk for death if they are prescribed beta blockers with a high dialyzability (atenolol, acebutolol, or metoprolol) compared with beta blockers with a low dialyzability (bisoprolol or propranolol) as reported by Matthew A. Weir, MD, from University Hospital in London, Ontario, Canada, and colleagues in the Journal of the American Society of Nephrology.
  • The American College of Physicians (ACP) has issued new, evidence-based guidelines on the comparative efficacy and safety of dietary and pharmacologic strategies to prevent recurrent kidney stones in adults. The updated recommendations are published in the November 4 issue of the Annals of Internal Medicine.
  • Events during surgery, especially intraoperative awareness, can lead to post-traumatic stress disorder (PTSD), suggests a new study presented at the Anesthesiology 2014 from the American Society of Anesthesiologists (ASA).
  • Clinicians must weigh the risks and benefits of selective cyclooxygenase 2 (COX-2) inhibitors when treating inflammatory bowel disease patients with rheumatological manifestations in order to avoid disease exacerbation and other adverse effects, says a report released by The Cochrane Library.

National news

Shri Ravi Shankar Prasad, Honorable Minister of Communications and Information Technology, and Minister of Law and Justice released a commemorative stamp to celebrate the 15th anniversary of India’s first successful liver transplant at the Apollo Hospitals, New Delhi. This prestigious honour has been approved and made available by the Department of Posts, Philately Section in recognition of the contribution of the program to the progress in the field of transplantation in the country.

Dr KK Spiritual Blog

Do not give health advice unless you are an expert

Once a foreigner visited India and when he returned back, somebody asked him to tell three things about India. He said – All time is tea time; all behave like doctors and every street wall can be used as a urinal.

Out of these three, the second one is very important and must be understood by all of us. In India, every person acts like a doctor and is ready to give an advice.

In the West, when a person is sick, nobody is supposed to visit him or her except for close relatives, but in India, not visiting a sick person is considered bad manners.

Everybody who visits, comes with an advice; an advice to change the doctor, hospital or the pathy. They will start giving examples of their experiences and try to influence the patient and the family. Neem Hakeem Khatraye Jaan is an old saying. No two patients are same and no two diseases behave in the same direction.

Changing medicines or pathy can be dangerous. When you go to another doctor for a second opinion, by default he or she has to disagree with the previous doctor, even if they do not need to. If they cannot find anything wrong in the prescription of the previous doctor, they will change the brand of the drugs or do minor modifications in the medicine.

In judicial practice when you go for review of judgment, you always file review petition before the same judge. Why can’t the similar happen in medical science? If you are not satisfied with a doctor, go back to him and ask him to review you again as a fresh case.

Also in judicial system, if you are not satisfied with the judgment, you do not go to single judge bench but a double judge bench. Same thing should happen in medical science. If you are not happy with one doctor, never go to another single doctor but ask for a joint opinion with two specialists.

Inspirational Story

Planting a Memory

Memories are alive and well here at our schoolhouse home! It has become such a special place to live! As I gather the many thrilling and joyful treasures we have found here, I begin to realize how important memories are to all of us. They are the glue that holds our thoughts of love and caring together. They are cherished dreams we shared -- occasions far too precious to be forgotten. Memories are the people who helped form us into what we are today.

As I gather the "bits and pieces" of the old, my mind looks into the future. Have I formed memories worth holding dear for my children? Will they hold close the memories of the things I have taught them? Have I shown them the importance of remembering?

Last September, my Father turned 90 years old. As usual, I planned a birthday celebration for him. But, this was the biggie! The big 9-0! This was going to be the biggest and the best!

As the invitations were made, sent out and plans set in place, my thoughts turned to Dad. What could I do that would make this his most memorable birthday... both for him and for me?

I thought of Dad's life. What was important to him over the years? What was he the most proud of? What was the one most important thing that he would want me to remember about him? I thought and thought for many days, asking the Lord to turn my mind inward to the many years of having this special man as my Father. As the warm memories of good times filled my heart, my mind turned back to work filled days, when every spring we would plant Christmas trees on his tree plantations. This had become my Father's hobby, but quickly became a family project. How I loved to work with my Dad on those tree farms! It was there that I really learned about the man I loved so dearly. He was fun, hard working, vital and alive! He passed these feelings on to his children.

His special day arrived, with many people present to wish him happiness. As he sat in my big yard swing, I came around the schoolhouse with a shovel and gloves. "Dad, put these on -- you are going to plant a Christmas tree!" As I said these words, my husband came around the house with a four foot tree, the roots bundled in burlap, proudly perched in our antique wheelbarrow. Dad's eyes sparkled as he put on the gloves. Philip and I had selected the perfect spot for this tree to take root and grow.

This wonderful ninety year old antique tree farmer began to dig! Soon everyone at the party was digging. From the oldest to the youngest, everyone had a chance to "help." Philip gently lowered the tree into its new resting place. Dad slowly threw a few shovels full of soil over the roots. Then the small children, scurrying around him like mice, all knelt down and began pushing soil into the opening.

The cheers went up! Pictures were taken! The tree was planted!

Six weeks after this magnificent day, my Dad passed away from a stroke. The tree stands, its small branches reaching heavenward -- a living sentinel on my lawn. As I sit in my swing and quietly gaze at the tree, I think of Dad. He's here with me.

We planted a memory that day. A memory for me, for my children and my grandchildren.

Rabies News (Dr A K Gupta)

What are the signs of rabies in dogs/cats?

  • Any change in normal behavior suggesting either undue aggression or depression.
  • Running aimlessly and attacking others without provocation.
  • Becomes too drowsy and withdraws to a corner.
  • Change in voice/bark.
  • Excessive salivation.
  • Refusal to feed or eating objects like stone, paper, wood, metal pieces etc.

Cardiology eMedinewS

  • Atrial fibrillation (AF) is associated with a more than two-fold increase in the odds for silent cerebral infarction (SCI), or a stroke that has no outward signs or symptoms, suggests a review published online in Annals of Internal Medicine. Having AF was associated with SCIs in patients with no history of symptomatic stroke (odds ratio 2.62, 95% CI 1.81-3.80), and this association was independent of AF type (paroxysmal versus persistent).
  • Patients with nonobstructive coronary artery disease (CAD) have an increased risk of MI at 1 year compared with individuals without any coronary disease, suggests a large analysis of patients in the Veterans Affairs healthcare system. The findings are published in the November 5 issue of the Journal of the American Medical Association.

Pediatrics eMedinewS

  • Dietary patterns of children vary according to the racial, ethnic and educational backgrounds of their mothers, suggests new research at the University at Buffalo School of Medicine and Biomedical Sciences. Researchers found that babies whose diet included more breastfeeding and solid foods that adhere to guidelines from international and pediatric organizations were associated with higher household income and mothers with higher educational levels.
  • Obesity in a pregnant woman may increase the risk that her children will be born with congenital abnormalities of the kidney and urinary tract, suggests a study scheduled to be presented at ASN Kidney Week 2014.

Quote of the Day

  • Winners compare their achievements with their goals, while losers compare their achievements with those of other people. Nido Qubein

Wellness Blog

Diet and Aging: Gaining a Nutritional Edge

Choose fruits and vegetables wisely

  • Get at least five servings of fruits and vegetables a day.
  • When filling your plate with fruits and vegetables, choose from a full color palette.
  • For even more health benefits, aim for nine servings a day. To get there, choose vegetable soups and vegetable or fruit salads. Sprinkle fruit on breakfast cereal, and select it for snacks or as a sweet end note after meals.

Choose fats wisely

  • Whenever possible, use monounsaturated and polyunsaturated oils. Avoid trans fats entirely. Limit saturated fats to less than 7% of daily calories and total fat to 20% to 30% of daily calories.
  • If you don’t have coronary artery disease, the American Heart Association recommends eating foods rich in omega–3 fatty acids, such as salmon, trout, or mackerel, twice weekly. If you have documented coronary artery disease, consume roughly 1 gram a day of EPA or DHA from oily fish and supplements if your doctor advises this.

Choose carbohydrates wisely

  • Choose whole–grain foods over those made with refined grains, such as white bread. Look beyond popular choices like whole oats and brown rice to lesser–known whole grains like barley, bulgur, kasha, and quinoa. Limit your intake of white potatoes.

Choosing proteins wisely

  • Emphasize plant sources of protein, such as beans, nuts, and grains, to help you bypass unhealthy fats predominant in animal sources. Enjoying a wide variety of vegetables and eating beans and grains helps you get a full complement of amino acids over the course of a week. Shy away from protein sources high in saturated fat. Favor fish and well–trimmed poultry. If you do eat beef, pick lean cuts.
  • Don’t char or overcook meat, poultry, or fish — it causes a buildup of carcinogens. Cutting off fat, which causes flames to flare on the grill, can help avoid charring; try gently sautéing, steaming, or braising these foods in liquid instead. Grilling vegetables is safe, however.

ePress Release

Strengthen your Heart

Padma Shri, Dr. B C Roy National Awardee & DST National Science Communication Awardee, Dr. K K Aggarwal, President Heart Care Foundation of India and Sr National Vice President Indian Medical Association advised the people to take care of their heart. He gave few tips to do so.

  • Follow Dr. KK Aggarwal’s ‘Formula of 80’ i.e. keep your pulse rate, lower blood pressure, fasting sugar, abdominal circumference and bad cholesterol levels all below 80. To achieve these, walk 80 minutes a day with a speed of 80 steps per minute; eat less – not more than 80 gm or 80 ml of caloric food; do 80 cycles of pranayams in a day, avoid alcohol and if one does so, do not consume more than 80 ml in a day.
  • After the age of 30, get an annual medical checkup done with exercise treadmill test every three years.
  • Eat in moderation and take a variety of food consisting of seven colours and six tastes.
  • Avoid using trans fats. Trans fats increase bad cholesterol and reduce good cholesterol. Hydrogenated oil is an example of trans fat.
  • Avoid three ‘whites’ in your diet - white maida, white sugar and white rice - or consume them only in minimum amounts. They are known to cause abdominal obesity, which is a risk factor for heart diseases.
  • Do not smoke or consume tobacco in any form as it increases the chances of heart attack, paralysis and erectile dysfunction.
  • Do not ignore any symptom, which is unusual, unexplained and is detected for the very first time.
  • Do not ignore any chest pain, burning or discomfort in the centre of the chest, which is diffuse in nature and lasts for more than 30 seconds.
  • If a heart attack is suspected, then one should chew 300 mg of water-soluble aspirin and immediately rush to the nearest heart hospital.
  • All heart patients should remember that sudden cardiac death is reversible in the first 10 minutes. For this, remember Dr. KK Aggarwal’s Formula of 10 i.e. within 10 minutes of death, for the next 10 minutes, compress the chest with a speed of 10 x 10 = 100 per minute. This can revive more than 75% of the patients.
  • Heart patients too can lead a normal physical, mental and sexual life.
  • Presence of heart blockages in the heart does not mean that a person requires angioplasty or surgery. These are indicated in case of failure of adequate medical treatment to provide the desired risk-free quality of life.
  • Following the traditional Indian customs and rituals can help reduce chances of heart attack. The weekly fast of not consuming cereals can be adopted by all of us to reduce risk of metabolic syndrome, which develops due to insulin resistance because of eating a carbohydrate-rich diet, especially one that contains refined carbohydrates, on a daily basis.
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21st Perfect Health Mela 15th October 2014



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Treating Vitamin D deficiency in the country

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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

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Hands–only CPR 10 English
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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 patient with mediclaim policy required hospitalization for dental treatment.
Dr. Bad: It will not be covered.
Dr. Good: It will be covered.
Lesson: Clause 4.7 excludes dental treatment/surgery unless requiring hospitalization.

Make Sure

Situation: A foreigner with a single loose stool developed sepsis.
Reaction: Oh my God! Why were antibiotics not started in time?
Lesson: Make sure that all foreigners are diagnosed to be suffering from Traveler’s diarrhea even if there is one single loose motion.

eMedinewS Humor

Blonde Stop

A Police car pulled alongside a speeding car on the motorway.

Glancing at the car he was astonished to see that the blond behind the wheel was knitting!

Realizing that she was oblivious to his flashing lights and siren, the cop rolled down his window and shouted "Pullover!"

The blonde rolled down her window and yelled back "No, it's a scarf!"

Twitter of the Day

Dr KK Aggarwal: Keep your fasting sugar lower than 80%
Dr Deepak Chopra: The same thing that roots life in suffering also leads to the way out of suffering: self-awareness

eMedi Quiz

A 30-year-old man came to the outpatient department because he had suddenly developed double vision. On examination it was found that his right eye, when at rest, was turned medially. The most likely anatomical structures involved are:

1.Medial rectus and superior division of oculomotor nerve.
2.Inferior oblique and inferior division of oculomotor nerve.
3.Lateral rectus and abducent nerve.
4.Superior rectus and trochlear nerve.

Yesterday’s Mind Teaser: A lesion of ventrolateral part of spinal cord will lead to loss (below the level of lesion) of:

1.Pain sensation on the ipsilateral side.
2.Proprioception on the contralateral side.
3.Pain sensation on the contralateral side.
4.Propriception on the ipsilateral side.

Answer for yesterday’s Mind Teaser: 3.Pain sensation on the contralateral side.

Correct answers received from: Dr KV Sarma, Dr Jainendra Upadhyay, Dr Avtar Krishan.

Answer for 4th November Mind Teaser: 2.Hypovolemia.

Correct answers received from: Dr Jainendra Upadhyay, Dr Avtar Krishan, Najib Khatee.

Send your answer to email

medicolegal update

(Dr. K K Aggarwal, Padma Shri and Dr. B C Roy National Awardee; Editor eMedinewS and President Heart Care Foundation of India)

Giving wrong advice on email is liable for negligence

If the doctor has charged his/her full fees for the email consultation from the patient or a referring physician regarding a patient, he/she will be liable as if he or she has seen the patient. When giving a written opinion through email one can take the following precautions and write:

  • “Expert opinion provided as a professional courtesy only”
  • “Nominal fee charged is only to cover the secretarial / incidental expenses involved and does not count towards a consideration or contract”
  • “This is only an opinion based on the information provided to me. It is not a final opinion which cannot be given without seeing the patient physically.
  • “This is not a final opinion and you may use this opinion at your own responsibility and discretion”
  • “As it is an opinion given without seeing the patient I take no legal responsibility for the opinion given”.
medicolegal update
  1. Dear Sir, Thanks for providing the useful information. Regards: Dr Shravan

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