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Dr KK Aggarwal

From the Desk of Editor in Chief
Dr B C Roy National Awardee,

Dr KK Aggarwal
President, Heart Care Foundation of India; Sr Consultant and Dean Medical Education, Moolchand Medcity; Member, Delhi Medical Council; Past President, Delhi Medical Association; Past President, IMA New Delhi Branch; Past Hony Director. IMA AKN Sinha Institute, Chairman IMA Academy of Medical Specialities & Hony Finance Secretary National IMA; Editor in Chief IJCP Group of Publications & Hony Visiting Professor (Clinical Research) DIPSAR

Dear Colleague,

20th January, Wednesday, 2010

Bromocriptine for diabetes
In early 2009, bromocriptine mesylate was approved by the US FDA for treatment of type 2 diabetes. On 22-10-09, it was also approved by Drug Controller of India (0.8mg as additional Indication), as an adjunct to diet and exercise to improve glycemic control in adults with type 2 diabetes mellitus. Bromocriptine is otherwise approved for the treatment of hyperprolactinemia-associated dysfunctions, acromegaly and Parkinson disease.

For patients newly diagnosed with type 2 diabetes or those who cannot adequately control their blood sugar with currently available medications, bromocriptine provides a completely new approach to treating diabetes. Clinical data reveal that bromocriptine mesylate was not associated with an increase in adverse cardiovascular outcomes, a composite of myocardial infarction, stroke, hospitalization for unstable angina, congestive heart failure and revascularization surgery, compared with placebo.

Patients with type 2 diabetes should take bromocriptine mesylate within two hours of waking in the morning. An initial daily dose of 0.8 mg should be titrated weekly until a maximum tolerated dose of 1.6 mg to 4.8 mg is achieved. The daily dose provides a single, brief pulse of dopamine activity shortly after administration. In the morning, the drug improves postprandial glucose without increasing plasma insulin concentrations; improvements in postmeal glycemic control continue several hours after administration.

Bromocriptine mesylate is the first drug that has been approved by the FDA after initiation of new guidelines that require studies to demonstrate that diabetes drugs do not increase CV risk.

The specific mechanism by which bromocriptine mesylate improves glycemic control is not known. Development of this drug for the treatment of type 2 diabetes was based upon preclinical studies that have shown brain dopamine activity to be low in metabolic disease states, which contributes to multiple metabolic dysfunctions such as insulin resistance.

The idea of using bromocriptine for the treatment of type-2 diabetes came while studying the metabolism of migrating birds; that they develop seasonal insulin resistance and dopamine plays a role in it.

The normal circadian cycle that results in a leaner body in the summer and heavier body in winter is disrupted in humans because of abundant caloric intake year-round resulting in the absence of a lean phase. Stimulation of the hypothalamus promotes the release of several hormones that respond to the traditional shift in caloric intake and storage. Quick-release bromocriptine (dopamine 2 receptor agonist), given once in the morning, stimulates the hypothalamus to release cortisol, growth hormone, and prolactin, allowing a reset of the circadian clock permanently stuck in a winter rhythm. This means that there occurs resetting of the abnormally elevated hypothalamic drive for increased plasma glucose, triglyceride and free fatty acid levels in fasting and postprandial states in insulin-resistant patients.

Dr KK Aggarwal
Chief Editor

Breaking News
The US FDA has approved pitavastatin, a new cholesterol-lowering drug for the primary treatment of hypercholesterolemia and combined dyslipidemia. FDA approved the drug on the basis of results from five clinical trials showing that pitavastatin was as safe and effective as other statins on the market.

Pitavastatin is the newest addition to the statins, joining atorvastatin, rosuvastatin, simvastatin, pravastatin, lovastatin, and fluvastatin. The drug is available in three low dosages: 1 mg, 2 mg, and 4 mg. It is has been available in Japan since 2003, and is also available in South Korea, Thailand, and China. It was introduced by Zydus Cadila in the Indian market a few years back but was not pushed.

Studies have shown pitavastatin to be particularly effective in special populations, including the elderly, patients with diabetes, and those at higher cardiovascular risk.

1. Pregnant women tempted to induce labor for convenience rather than medical necessity may want to wait for nature to take its course. Inducing labor introduces a risk of 1 to 2 cesareans per 25 inductions that might have been avoided by waiting for spontaneous labor to begin. (Dr. J. Christopher Glantz, University of Rochester School of Medicine)

2. The radiation risk from full body scanners used to improve airport security is low and unlikely to raise an individual's risk of cancer. Airports in Britain, the Netherlands and Canada have said they plan to use full-body scanners to foil future terror attempts like the Christmas Day attempt to blow up a Detroit-bound flight. There are two types of machines, millimeter wavelength imaging and backscatter X-ray scanners. Backscatter X-ray machines, expose individuals to ionizing radiation such as that used in common medical X-rays. But the radiation levels are well below the threshold that could be considered a risk to an individual's health. (Dr. James Thrall, American College of Radiology and chief of radiology, Massachusetts General Hospital, Boston)

3. US adults being treated for mental illness are more likely to be prescribed two or more drugs today than a decade ago. Psychiatric drug combinations are increasingly being used to treat a wide range of mental illness including anxiety, depression, panic disorder, posttraumatic stress disorder, bipolar disorder and schizophrenia. (Dr. Ramin Mojtabai, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland)

Opioid painkillers potential addict and overdose threat
Dr Nora Volkow, director of the National Institute on Drug Abuse at the National Institutes of Health, says that between five and 10% of people who take opioids regularly become addicted.

Deficiencies in depression treatment
According to a study published Jan. 6 in the Archives of General Psychiatry, only about half of all Americans with depression receive treatment of any kind, with only one in five getting care, talk therapy, medication or both that conforms to American Psychiatric Association guidelines.

Antibiotics overdose blamed for mutating infectious diseases
All the leading killer infectious diseases TB, malaria and HIV are mutating at an alarming rate. Overuse of those antibiotics is largely to blame. [Dr. Thomas Frieden, director of the US Centers for Disease Control and Prevention]

Diarrhea linked to influenza infection
Diarrhea in flu infected children may harbor the virus as per a study published in the journal BioMed Central. Flu may invade the GI tract, potentially acting as a mode of transmission.

Depo Provera can cause bone loss
45% of women, who use medroxyprogesterone acetate, lose a significant amount of bone mass within two years. [Jan. issue of Obstetrics & Gynecology]

FDA approves new RA treatment.
FDA has approved tocilizumab to treat rheumatoid arthritis.
Vaccine effective against dengue
Sanofi-Aventis experimental vaccine against dengue protected healthy volunteers against all four strains of the virus in a study. [Jan 9 on the Journal of Infectious Diseases]

Our HIP's

Question of the day
How do you differentiate between large and small bowel diarrhea?
Diarrhea usually results from malabsorption, secretory states and inflammation. Steatorrhea is suggested by pale, smelly stools which would indicate either a small bowel problem or pancreatic insufficiency. In lactose intolerance, the diarrhea tends to be watery. These two are examples of small bowel diarrhea, and for differentiating between them, it is important to known the cause as the diarrheal patterns are different. It is very important to take a good history as watery diarrhea also occurs in colonic diseases like collagenous colitis, which should be typically thought of in an older patient who is using nonsteroidal anti-inflammatory drugs (NSAIDs) and presents with watery, nonbloody diarrhea. Patient history, examination findings and investigations all play a major part in diagnosing diarrhea. A bloody diarrhea points to colitis and cramping abdominal pain with diarrhea and vomiting points to a small bowel pathology such as Crohn’s disease.

Dr Good Dr Bad
Situation: A patient came with chest pain of 3 hours duration and negative trop I.
Dr Bad: You do not have cardiac disease.
Dr Good: Repeat Trop I at 12 hours.
Lesson: A single set of negative cardiac biomarkers is NOT sufficient to rule out myocardial infarction. In acute myocardial infarction, cardiac troponin I rises after approximately 6 hours, peaks at 12 hours, and remains elevated for 7 to 10 days.

Make Sure
Situation: A patient on ampicillin developed persistent diarrhea.
Reaction: Oh my God! You should have suspected Clostridium difficile-colitis
Make sure: No antibiotic is safe. All antibiotics can predispose to Clostridium difficile- colitis, and ampicillin is a commonly implicated beta-lactam. (
N Engl J Med 1994;330:257.)

Formulae in Imaging
A pleural effusion of 500 mL will obscure the diaphragmatic contour on an upright chest radiograph.

Mistakes in clinical practice
Clinicians may be better at avoiding over-prescribing of inappropriate drug therapies than at prescribing indicated drug therapies.

ENT Facts
Chronic suppurative otitis media (CSOM) occurs with a perforated tympanic membrane in the setting of chronic ear infections.

SMS Anemia
A hemoglobin (Hb) value <12.0 g/dL or Hematocrit (HCT) <36.0 percent, represents anemia in women.

Emedinews Try this : It Works
A different approach to percussion
The traditional method is to strike the terminal phalanx of the middle finger of the nondominant hand with the tip of the middle finger of the dominant hand.
But, try striking the non dominant middle finger with a reflex hammer. It is easier to perform, is more easily reproduced, producing more audible notes, and is less painful to the struck phalanx (no injury by the nails).

Milestones in Neurology
Paul Pierre Broca was a French physician, anatomist and anthropologist. Broca is most famous for his discovery of the speech production center of the brain located in the frontal lobes, now known as the Broca’s area.

Laughter the Best Medicine
Bachelor - a fellow that can take women or leave them, and prefers to do both.

Prayer is not merely an occasional impulse to which we respond when we are in trouble: prayer is a life attitude. (Walter A. Mueller)

To what extent is children education allowance exempt?
Children education allowance incurred on the education of children is exempt up to amount received per child or Rs. 100 p.m. per child up to a maximum of two children, whichever is less.

How is a 'Consent' defined?
Consent is defined under Section 13 of Indian Contract Act, 1872 as "two or more persons are said to consent when they agree to the same thing in the same sense."

DocConnect Milestone (www.docconnect.com)
Docconnect: Doctors can create a webpage which is customizable and also facilitates interaction with your patients.

Presswatch: (Dr Vivek Chabbra)
Daily Telegraph: Gene linked to aggressive cancer: Scientists have discovered the first gene linked to the aggressive form of prostate cancer, raising the prospect of doctors predicting how the disease will progress. The cancer is often either slow-growing or aggressive. At the moment, there is no way to predict which type a patient will suffer. Although carrying the newly-identified gene does not in itself guarantee that a patients' cancer will be aggressive, the breakthrough raises hopes that doctors could one day discover a number of genes that would allow them to make a diagnosis when the disease is still curable. Dr Jianfeng Xu, from Wake Forest University in North Carolina, who led the study, said men who carried the genes would be encouraged to attend screening at a young age.

Useful tips: (Dr G M Singh)
1. The use of some cardiovascular drugs is associated with reduced grip strength in older people, UK researchers have found. Furosemide was associated with average decreases in grip strength of 3.15 kg among men and 2.35 kg among women after adjustment for age and height, both of which were statistically significant. Nitrates also reduced grip strength by 1.84 kg among men and 3.66 kg among women. Calcium channel blockers and fibrates were associated with reduced grip among women. The results - published online in Age and Ageing journal - were all drawn from 1,572 men and 1,415 women aged 59 to 73, 45% of whom were taking a cardiovascular drug. The researchers speculated that cardiovascular drugs might adversely affect muscle strength. Professor Avan Aihie Sayer, Professor of Geriatric Medicine at the University of Southampton, concluded: These findings have potential implications for the functional ability of older people treated with these drugs.

2. When a Pap test shows atypical squamous cells of unknown significance (ASCUS) and human papillomavirus (HPV) test results are negative, in most cases cytologic regression will occur within two years, a study from China shows. Regression may take somewhat longer in women with antecedent cervical lesions, according to Dr. Jing He Lang and colleagues from the Peking Union Medical College Hospital, Beijing, People's Republic of China.

Their paper, published in the December issue of the American Journal of Obstetrics and Gynecology notes that HPV-negative women with ASCUS account for more than 50% of all women with the condition.

Letter to the Editor
I'm thankful to Dr. K. K. Arora for his kind observation on my 'Eye Care Snippets' column. It's readers like him who encourage writers to keep on contributing. I'm also thankful to Dr. K K Aggarwal who gave me this wonderful platform. Dr. Narendra Kumar


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