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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; Member 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

4th July, Sunday, 2010

Cold Urticaria

Cold urticaria is characterized by itchy wheals and/or angioedema due to skin mast cell activation and release of proinflammatory mediators after cold exposure. More than 90% of cold urticaria is idiopathic, the rest are mostly secondary to cryoglobulinemia.1

Cold urticaria is rare in children. Children with cold urticaria have an increased risk of anaphylaxis.2 The symptoms are usually limited to cold–exposed skin areas and develop within minutes of cold exposure. A cold stimulation test (CST) confirms the diagnosis in most and avoidance of cold exposure is the best prophylaxis.

A CST is considered positive when the patient develops urticarial skin lesions at the site of the cold challenge. CSTs are performed using ice cubes, cold packs, cold water baths.

The ice cube test has a sensitivity of 83–90% and a specificity of 100%.3,4 The ice cube should be melting and contained in a thin plastic bag to avoid cold damage of the skin.5 Cold stimulation time thresholds can also be noted.6 This method is readily performed in most clinics. Use of cold packs/cold water baths is not recommended as first–line screening tests, as it may induce systemic reactions.6 But, it may help in confirming the diagnosis in patients who have a negative ice cube test.

Cold stimulation tests are performed for five minutes and test responses are assessed 10 minutes after the end of provocation testing.

  • The test is considered positive if there is a palpable and clearly visible wheal–and–flare skin reaction. This reaction is itchy and/or associated with a burning sensation in most cases.

  • The test is considered negative if there is no reaction, or erythema or pruritus/burning only. Suspected patients who show a negative test should be re–evaluated.

Further testing is performed using larger areas for provocation (e.g. cold pack or cold water bath) or using triggers that induced urticarial reactions earlier (e.g. cold wind, cold water). Atypical cold urticarias should be considered if the additional stimulation tests are also negative.

Treatment involves the use of nonsedating H1 antihistamines for those who are unable to sufficiently avoid cold exposure and have frequent symptoms. Start with secondgeneration H1 antihistamine at the standard dose and increase upto four times the standard dose as needed. Treat coldinduced anaphylaxis with epinephrine.


  1. Alangari AA, et al. Clinical features and anaphylaxis in children with cold urticaria. Pediatrics 2004;113(4):e313–7.

  2. Anaphylaxis common in children with cold urticaria. Respiratory Reviews 2004;9(6).

  3. Neittaanmoki H. Cold urticaria. Clinical findings in 220 patients. J Am Acad Dermatol 1985;13(4):636–44.

  4. Mathelier–Fusade P, et al. Clinical predictive factors of severity in cold urticaria. Arch Dermatol 1998;134(1):106–7.

  5. Siebenhaar F, et al. Peltier effect-based temperature challenge: an improved method for diagnosing cold urticaria. J Allergy Clin Immunol 2004;114(5):1224–5.

  6. Wanderer AA, et al. Clinical characteristics of cold-induced systemic reactions in acquired cold urticaria syndromes: recommendations for prevention of this complication and a proposal for a diagnostic classification of cold urticaria. J Allergy Clin Immunol 1986;78(3 pt 1):417–23.

Dr KK Aggarwal
Padma Shri Awardee and Chief Editor


Photo Feature (From HCFI file)


17th MTNL Perfect Health Mela (23-30th Oct 2010)

The Logo and Theme of 17th MTNL Perfect Health Mela were released by Former Cricketer Chetan Chauhan at a press conference on 30.6.2010. The theme for this year is "Rising Problems of Lifestyle Disorders"


Dr k k Aggarwal
Padma Shri and Dr BC Roy Awardee Dr KK Aggarwal, President HCFI demonstrating the correct method of taking BP by measuring BP of Former Cricketer Chetan Chauhan


News and views

Dr Monica and Brahm Vasudeva

Boosting consumption of omega3 fatty acids may not lower heart disease risk in women with type 1 diabetes Increasing consumption of omega–3 fatty acids does not seem to lower the risk of heart disease in women with type 1 diabetes, according to research presented at the American Diabetes Association’s Scientific Sessions.

FDA Okays First Rapid HCV Test

The FDA Has approved the first rapid blood hepatitis C virus test for patients 15 and older. The OraQuick HCV Rapid Antibody Test can read oral and blood samples for hepatitis C in 20 to 40 minutes with 99% accuracy, according to statements made on manufacturer OraSure Technologies’ website. The device uses a test strip for sampling and does not need an instrument to provide results.

New studies say no to statins for healthy people

Re–analysis of a landmark cholesterol–lowering trial of people typically considered at low risk for heart attacks indicated that the results are flawed –– and do not support the primary–prevention benefits that made headlines. The re–analysis of the JUPITER trial involving almost 18,000 people with low or normal cholesterol but elevated inflammatory biomarker C–reactive protein (CRP) levels showed no evidence of the striking decrease in coronary heart disease complications reported by the trial investigators. Instead, the re–analysis has called into question the involvement of drug companies in such clinical trials, according to an article in the June 28 issue of the Archives of Internal Medicine.

Adults with newly diagnosed diabetes at risk of liver disease (Dr G M Singh)

Adults with newly diagnosed diabetes are at higher long–term risk of serious liver disease, including cirrhosis and liver failure, according to a research article published in CMAJ, the Journal of the Canadian Medical Association Journal.


Legal Column

Forensic Column

Dr Sudhir Gupta, MBBS (Gold Medal), MD (BHU), DNB, MNAMS, Associate Professor, Forensic Medicine & Toxicology, AIIMS

How do drugs influence driving?

If you think drugtaking has little, or even a positive impact on your driving, you are sadly mistaken. It’s also important to bear in mind that it can be hard to determine exactly how a drug will affect your driving ability. Impairment caused by drugs can vary according to the individual, drug type, dosage, the length of time the drug stays in the body, or if the drug has been taken with other drugs or alcohol.

According to road traffic rules in Delhi, driving with blood alcohol levels more than 30 mg is an offence.

But, blood alcohol level is not the only thing that can determine a person’s sobriety. A driver whose blood alcohol content reading is somewhat less than 0.03%, but shows signs of impairment can be charged with an intoxicated driving. The "legal limit" is simply the number above which a driver is automatically guilty of driving under the influence without any other evidence.

On merely a suspicion of alcohol in the individual’s body, the police may demand the driver to give a sample of his or her breath into an approved screening device, which will determine the driver’s bloodalcohol concentration on a preliminary basis. In many countries there are provisions of penalty for refusing to provide a specimen of breath, blood or urine for analysis is a up to six months’ imprisonment, and a driving ban of at least 12 months.

Causing death by careless driving when under the influence of drink or drugs carries a maximum penalty of 14 years in prison, a minimum twoyear driving ban and a requirement to pass an extended driving test before the offender is able to drive legally again.


Experts’ Views

Interesting tips in Hepatology & Gastroenterology

Dr Neelam Mohan, Consultant Pediatric, Gastroenterologist, Hepatologist, Therapeutic Endoscopist & Liver Transplant Physician Sir Ganga Ram Hospital, Delhi

Treatment of Celiac Disease

Gluten-free Diet (GFD) for life is the mainstay of treatment in CD. In addition, iron, folic acid, calcium, zinc, vitamin D and other vitamin supplements for the initial few months after diagnosis is recommended.

The patient should be re-assessed after 812 weeks of starting GFD to look for response to treatment. The patient should be on a regular followup (preferably once in six months to a year), to assess growth, compliance and development of any complications.

The only treatment for celiac disease is a glutenfree diet. For most people, following this diet will stop symptoms, heal existing intestinal damage, and prevent further damage. Improvement begins within days of starting the diet. The small intestine usually heals in 3 to 6 months in children but may take several years in adults. A healed intestine means a person now has villi that can absorb nutrients from food into the bloodstream.

To stay well, people with celiac disease must avoid gluten for the rest of their lives. Eating even a small amount of gluten can damage the small intestine. The damage will occur in anyone with the disease, including people without noticeable symptoms. Depending on a person’s age at diagnosis, some problems will not improve, such as short stature and dental enamel defects.

Some people with celiac disease show no improvement on the glutenfree diet. The most common reason for poor response to the diet is that small amounts of gluten are still being consumed. Hidden sources of gluten include additives such as modified food starch, preservatives, and stabilizers made with wheat.


Public Forum (Press Release for use by the newspapers)

Blood Pressure: A silent killer

Hypertension or high blood pressure is the present ongoing epidemic of the society. Blood pressure is a silent killer said Padma Shri and Dr B C Roy National Awardee Dr KK Aggarwal, President Heart Care Foundation of India.

Antihypertensive treatment is associated with reductions in stroke incidence averaging 35–40%, myocardial infarction, by 20-25 %; and heart failure, by more than 50%. A 5 mm reduction in diastolic lower blood pressure can reduce heart disease by 21%.

Dr Aggarwal said that if we were to eliminate pre hypertension from the society (or in other words keep the community blood pressure lower than 120/80 mm Hg) we can potentially prevent about 47 percent of all heart attacks.

The Framingham Study found that a pre hypertensive person is more than three times more likely to have a heart attack and 1.7 times more likely to have heart disease than a person with normal blood pressure.

Lifestyle modifications reduce BP, enhance anti-hypertensive drug efficacy, and decrease cardiovascular risk. If there is no target organ damage diabetes or multi cardiac risk factors one can try lifestyle management for up to 6 months. Presence of target organ damage necessitates drug treatment to lower the BP.

A 1,600 mg sodium DASH eating plan has effects similar to single drug therapy. Combinations of two (or more) lifestyle modifications can achieve even better results.

One should maintain normal body weight. A reduction of 520 mmHg of BP can be achieved for every 10 kg weight loss.

One should consume a diet rich in fruits, vegetables, and low fat dairy products with a reduced content of saturated and total fat. It can reduce blood pressure by 814 mm Hg.

One should reduce dietary sodium intake to no more than 100 mmol per day (2.4 g sodium or 6 g sodium chloride). It can alone reduce blood pressure by
28 mm Hg.

One should engage in regular aerobic physical activity such as brisk walking (at least 30 min per day, most days of the week). It can alone reduce blood pressure by 49 mm Hg.

For those who drink should limit consumption to no more than 2 drinks (1 oz or 30 mL ethanol; e.g., 24 oz beer, 10 oz wine, or 3 oz 80-proof whiskey) per day in most men and to no more than 1 drink per day in women and lighter weight persons. It can alone reduce blood pressure by 24 mm Hg.


An Inspirational Story (Anuj Goyal)

When Albert Einstein was working in Princeton University, one day while he was returning home he forgot his home address. The driver of the cab did not recognize him.

Einstein asked the driver if he knew where Einstein lived. The driver said "Who does not know Einstein’s address? Everyone in Princeton knows. Do you want to meet him?"

Einstein replied "I am Einstein. I forgot my home address, can you take me there? " The driver took Einstein to his home and did not even collect his fare from him.


IJCP Special

Question of the Day

What is the link between soft drinks and milk intake?

Dr. Swati Bhave & Dr. Alok Gupta

As soft drink consumption increases, milk consumption decreases, and milk is the principal source of calcium. Children should be given nutritious alternatives such as water, real fruit juices and lowfat milks. Eating fresh fruits is far better than fresh fruit juice even it no sugar is added. This is because juice will have concentrated fructose as compared to eating a fresh fruit which gives good exercise to the teeth and gums and also provides necessary fibre needed for good bowel movements.

Dr Good Dr Bad

Situation: A patient with severe LV systolic dysfunction came with severe MR.
Dr Bad: Go for mitral valve repair.
Dr Good: Go for medical treatment.
Lesson: As per the 2006 Heart Failure Society of America practice guidelines, isolated mitral valve repair or replacement for severe mitral regurgitation secondary to ventricular dilatation in the presence of severe LV systolic dysfunction is not generally recommended. (J Card Fail 2006:12:e1)

Make Sure

Situation: A known patient of NIDDM taking oral hypoglycemic presented with hyperglycemic crisis.
Reaction: Oh, my God! I did not manage the patient aggressively.
Lesson: Make sure that patients with impaired glucose tolerance or NIDDM are fully evaluated for complications at the first visit. Present approach to therapy of NIDDM is characterized by proactive shifts to agents that may be combined or prescribed in maximal doses to achieve normal or near normal glycemia from the time of diagnoses of NIDDM or impaired glucose tolerance, in order to prevent complications.

Mistakes in Clinical practice

Do not write trailing zero after 1 mg: it can be mistaken as 10 mg if the decimal points is not seen

Mnemonic of the Day (Dr. Maj Prachi Garg)

 The ‘A to Z’ of ICU management

A: Asepsis/ Airway
B: Bed sore/ encourage Breathing/ Blood pressure
C: Circulation/ encourage Coughing/ Consciousness
D: Drains
F: Fluid status
G: GI losses/ Gag reflex
H: Head positioning/ Height
I: Insensible losses
J: Jugular venous pulse
K: Kindness
L: Limb care/ Label
M: Mouth care
N: Nociception/ Nutrition
O: Oxygenation/ Orient the patient
P: Pulse/ Peristalsis/ Physiotherapy
Q: Quiet surroundings
R: Respiratory rate/ Restraint
S: Stress ulcer/ Suctioning
T: Temperature
U: Urine
V: Ventilator
W: Wounds/ Weight
X: Xerosis
Y: whY
Z: Zestful care of the patient

Quote of the Day (Dr. Santosh Sahi)

"What you get by achieving your goals is not as important as what you become by achieving your goals." Zig Ziglar

Milestones in Medicine

1796 A.D. The smallpox vaccine was developed by Edward Jenner, initiating the science of immunology.


Puzzle of the day

Your age by eMedinewS Math: How many timesyou read emedinews in a week

  1. First of all, pick the number of times a week that you read eMedinewS in a week (more than once but less than 7)

  2. Multiply this number by 2

  3. Add 5

  4. Multiply it by 50

  5. If you have already had your birthday this year add 1760.If you haven’t, add 1759.

  6. Now subtract the four digit year that you were born.

You should have a three digit number.

The first digit of this was your original number i.e., how many times you read emedinews in a week.

The next two numbers are……… YOUR AGE!

This is the only year (2010) it will ever work.


International Medical Science Academy Update (IMSA)

 Digoxin may be harmful in hemodialysis patients

Digoxin may increase mortality rates in patients with end-stage renal disease undergoing hemodialysis. Doctors performed an observational cohort study in 120,864 incident dialysis patients to determine the relationship between digoxin and mortality rates. The study results were published early online June 24 by the Journal of the American Society of Nephrology. Of the 120,864 patients, 4,549 used digoxin. Digoxin use was associated with a 28% higher risk for death.

Drug Update

List of Approved drugs from 1.01.2009 to 31.10.2009

Drug Name


DCI Approval Date

Voglibose 0.2 mg + Metformin 500mg Tablets

As second line treatment of type 2 Diabetes mellitus when diet, exercise and the single agent do not result in adequate glycemic control.


Medi Finance

Individual–Mediclaim Policy
General Conditions
Annual policy only, no short period polices is permitted. All claims for compensation have to be legally established in a court of law. Jurisdiction applicable will be Indian courts. Premium rating varies for practitioner depending upon the class of work he performs as a medical practitioner.

Lab Medicine

Lab Test (Dr Arpan Gandhi and Dr Navin Dang)

Tests for Sjögren’s syndrome

Antinuclear antibodies (ANA) (positive in most cases); Rheumatoid factor (RF) (may be positive). Antibodies specific to Sjögren’s syndrome: Anti–SS–A (also called Ro) and Anti–SS–B (also called La)– (frequently positive) and HLA–DR positive glandular cells


Humor Section

Doctor, doctor, I keep thinking I’m a dog." "Sit down and tell me all about it."

"I can’t, I’m not allowed on the furniture."


 Readers Responses

  1. Dear Dr. Aggarwal: I am reproducing below an e–mail received today from my daughter, Dr.Divya Parashar from USA. Because of a very wide circulation of E–Medinews, I thought it would be a nice platform to disseminate this information on " New Serious Hazard of Laptop" Dr.S K Parashar.

    " You may have heard that a good friend of ours in Mequon lost their 25–year–old son (Arun Gopal Ratnam) in a fire at home June 4th. This is what happened. He graduated with MBA from University of Wisconsin-Madison two weeks earlier and came home. Had lunch with his dad at home and decided to go back to clean up his room at school. Father told him to wait and see his mother before he went back for a few days. He decided to take a snooze while waiting for his mom to come home from work. Neighbors called 911 when they saw black smoke coming out of the house. Their 25 year old son Arun died in the three year old house. It took several days of investigation to find out the cause of the fire. It was determined that the fire was caused by laptop in the bed. When the laptop is on the bed cooling fan does not get air to cool the computer and that is what caused the fire. He did not even wake up to get out of the bed as he died of carbon monoxide poisoning.

    The reason I am writing this to all of you is that I have seen all of us using our laptop in bed. Let us all decide and make it a practice not to do that. Risk is real. Let us make it a rule not to use laptop in bed or put computer on bed with blankets and pillows around. What a way to learn a lesson? Divya

  2. After reading e- MediNews on Doctors Day, my suggestion is: There should be a "Healthy People’s Day" also. The suggestion of Dr. Arulrhaj for IMA to start a website "Healthy India" and invite views of public and consumer associations, is immediately actionable. The issue of doctors’ illegible prescriptions is perennial. Can doctors not computerize this part of their job? Can they not write their prescriptions only by their laptops, and gave patients the printouts, so that they are readable? What is the problem? Now laptop costs only Rs 30,000.00 and printer only Rs 3,000.00. Ink cartridge can be re-filled for about Rs 75.00. A print–out costs only Re 1.00. Computer will help them retain past medical record of the patients as well: Vinod Varshney

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

12th September: BSNL Dil ka Darbar A daylong 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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