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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; Chairman Ethical Committee 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

29th July, 2010, Thursday

For regular emedinews updates follow at www.twitter.com/DrKKAggarwal

Measuring blood pressure (Part 2)

  1. Even under optimal conditions, many patients are apprehensive when seeing a doctor. This causes an acute rise in BP. About 20–30% of patients with hypertension in the clinic are normotensive outside the clinic. This is called "white coat" or isolated office hypertension and should be suspected in any patient with marked high BP in the absence of end–organ damage or with normal ambulatory BP taken at work or at home.
  2. The presence of white coat hypertension can be diagnosed by 24–hour ambulatory BP monitoring or self–recorded readings or by having a nurse measure the BP.
  3. The white–coat effect can persist for years.
  4. Cuff placement: The BP cuff should be placed with the bladder mid line over the brachial artery pulsation, with the arm without restrictive clothing. The sleeve should not be rolled up as this may act as a tourniquet. Lower end of the BP cuff should be 2–3 cm above the antecubital fossa to minimize artifactual noise related to the stethoscope touching the cuff.
  5. The cuff should be inflated to a pressure 30 mm Hg greater than upper systolic, as estimated from the disappearance of the pulse in the brachial artery by palpation. In some patients, the Korotkoff sounds transiently disappear as the cuff is deflated. As an example, the Korotkoff sounds in a patient with a systolic pressure of 180 mm Hg may be first heard at 180 mm Hg, disappear at 165 mm Hg, and then be reheard at 140 mm Hg. This auscultatory gap is associated with increased arterial stiffness and carotid atherosclerosis.
  6. Neither the patient nor the doctor should talk during the measurement
  7. The BP should be taken with the patient’s arm supported at the level of the heart; allowing the arm to hang down when the patient is sitting or standing will result in the brachial artery being 15 cm below the heart. As a result, the measured BP will be elevated by 10 to 12 mm Hg due to the added hydrostatic pressure induced by gravity.
  8. The stethoscope should be placed lightly over the brachial artery. The use of excessive pressure can increase turbulence and delay the disappearance of sound. The lower diastolic pressure reading may be artifactually reduced by up to 10 to 15 mmHg.
  9. The cuff should be deflated slowly at a rate of 2 to 3 mm Hg per heartbeat. The systolic pressure is equal to the pressure at which the brachial pulse can first be palpated or at which the pulse is first heard by auscultation (Korotkoff phase I).
  10. As the cuff is deflated below the systolic pressure, the pulse continues to be heard until there is abrupt muffling (phase IV) and, approximately 8 to 10 mm Hg later, disappearance of sound (phase V).
  11. The diastolic pressure is generally equal to phase V. The point of muffling should be used in those patients in whom there is more than a 10 mm Hg difference between phases IV and V. This can occur in children, and in high-output states such as thyrotoxicosis (hyperfunction of the thyroid), anemia (low Hb), and aortic regurgitation (leaking valve).
  12. The BP should be measured initially in both arms.
  13. If there is a disparity between the two arm readings, the arm with higher pressure should be used. Normal difference between two arms can be 3–5 mm Hg.
  14. The BP should be taken twice on each visit, with the readings separated by 1 to 2 minutes to allow the release of trapped blood. If the second value is > 5 mm Hg different from the first, continued measurements should be made until a stable value is attained. The correct value is average of the last two measurements.
  15. There are occasional patients in whom the BP needs to be measured in the legs. The classic example is in cases of suspected coarctation of the aorta in which there is an arm–to–leg gradient.
  16. BP should be taken in the leg among women with breast cancer with bilateral axillary lymph node dissection. In unilateral axillary node dissection, BP should be taken in the opposite arm. The tourniquet effect may damage the lymphatics and exacerbate the arm edema. No precaution is needed if there has not been axillary node dissection.
  17. The systolic upper pressure in the leg is 10 to 20 % higher than that in the brachial (elbow) artery. Values > 10 % lower than brachial measurements are used to screen for significant peripheral vascular disease.
  18. Measurement of BP at the wrist may be more practical in obese people, since wrist diameter is not significantly affected.
  19. Systolic upper BP rises, and diastolic lower BP falls, in more distal arteries. In the wrist, the hydrostatic pressure related to the lower position of the wrist relative to the heart can result in a further false elevation of BP. This can be minimized by taking the BP with the wrist kept at the level of the heart.
  20. Errors can occur when the BP is taken at home or work by the patient or spouse, even when the instrument is accurate. The BP varies throughout the day. For monitoring therapy, the BP should be measured at roughly the same time each day and the relation to meals and medications noted. The patient should be instructed to wait to measure the BP if they have recently eaten a meal or exercised.
  21. Cuff inflation hypertension: A problem with self–measurement of BP is that the muscular activity used to inflate the cuff can acutely raise the BP by as much as 12/9 mm Hg. This dissipates within 5 to 20 seconds. Inflating the cuff to at least 30 mm Hg above supper BP and then allowing the mercury column to fall no more than 2 to 3 mm Hg per heartbeat is indicated both for accurate measurement and to permit this effect to disappear.
  22. One should take multiple BP measurements.
  23. In the absence of end–organ damage, the diagnosis of mild hypertension should not be made until the blood pressure has been measured on at least two additional visits, spaced over a period of one week or more. BP drops by an average of 10 to 15 mm Hg between the first and third visits in newly diagnosed patients, with a stable value not being achieved until more than six visits in some cases. Thus, many patients considered to be having high BP at the first visit may in fact be normal.
  24. If the BP is taken at home to diagnose or monitor treatment at least 12 to 14 measurements should be obtained, with both morning and evening measurements taken over seven workdays.

Dr KK Aggarwal
Editor in Chief
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Photo Feature (From HCFI file)

 Chaturmas is the time to strengthen inner healing

This was the message given by Acharya Sadhvi Dr Sadhna Ji Maharaj, Chairperson, World Fellowship of Religions and Maha Mandeleshwar Swami Anubhutanandji. The "Chaturmas" begins on the Ekadashi in the month of 'Ashadha' and ends with the Ekadashi in the month of 'Kartik.' It has both spiritual and health implications.

 In the photo: Padma Shri and Dr B C Roy National Awardee Dr KK Aggarwal, President Heart Care Foundation of India.BSNL Dil Ka Darbar  & MTNL Perfect Health Mela.

Dr k k Aggarwal


News and views


Your phone has more germs than flush handle!

Mobiles have 18 times more bacteria than toilet handle. The average mobile phone carries 18 times more potentially harmful germs than a flush handle in a men's toilet. One of the phones in the test had such high levels of bacteria that it could have given its owner a serious stomach upset.

Hygiene expert Jim Francis, who carried out the tests, said, "The levels of potentially harmful bacteria on one mobile were off the scale. That phone needs sterilising."  (TOI)


Simple screening test reduces invasive examinations for suspected bowel disease

A simple screening test identifies patients who are most likely to have inflammatory bowel disease and reduces the need for expensive, invasive and time consuming endoscopies. Measuring levels of calprotectin (a protein found in inflammatory cells) in stools could be a good screening test, but its accuracy is largely unknown. The researchers evaluated results of six adult (670 patients) and seven child studies (371 patients) that compared fecal calprotectin with endoscopy in patients with suspected inflammatory bowel disease. Inflammatory bowel disease was confirmed in 32% of the adults and 61% of the children. Screening with faecal calprotectin reduced the number of endoscopies by 67% in adults and 35% in children, but it also delayed diagnosis in 6% (2 in 32) of the affected adults and 8% (5 in 61) of the affected children. Based on their results, the authors of the study conclude that fecal calprotectin is a useful screening tool for identifying patients who are most likely to need endoscopic evaluation for suspected inflammatory bowel disease. The study findings are published online in the British Medical Journal.

Obesity epidemic putting more people at risk for heart disease

According to Vincent Bufalino, MD, a spokesman for the American Heart Association, the obesity epidemic is increasing the number of people at risk of heart diseases by acting on its own and/or exaggerating other risk factors: obesity can boost your levels of bad cholesterol, raise your blood pressure, and increase your chances of acquiring diabetes.

Bypassing EDs for "Cath Labs" could reduce time needed to treat the most dangerous heart attacks

If you’re having a heart attack, you may not need an emergency department at all. A study published in the journal Circulation: Cardiovascular Quality and Outcomes,observes that patients receive faster care, and are more likely to survive, if an ambulance crew takes them straight to a specialized hospital ‘cath lab,’ where doctors can act quickly to open their blocked arteries. Doing so, will cut down on the the time to treat the most dangerous heart attacks from an average of 81 minutes to 36 minutes, and vastly improve the chances of recovery.

(Contributed by Dr. Monica and Brahm Vasudev)

What to do when migraine symptoms begin

Migraines are severe headaches that may be accompanied by nausea, vomiting and sensitivity to light and sound. When symptoms of migraine begin:

• Promptly take migraine medication that your doctor has prescribed.
• Drink plenty of fluids, as long as you don’t feel nauseated.
Lie down and relax in a room that’s quiet and dark.
Drape a cool cloth across your forehead.
Gently massage the area of your head that’s painful
(Contributed by Dr. G.M. Singh)


Legal Column

Forensic Column (Dr Sudhir Gupta, Associate Professor, Forensic Medicine & Toxicology, AIIMS)

What is conduct money for doctors?

In criminal cases, no fee is paid to any witness, including the doctor, at the time of serving the summons. The summoned doctor must attend the Court and give evidence because of the interest of the State in securing truth/justice, otherwise the doctor will be charged with contempt of Court. However, in criminal cases, conveyance charges and daily allowance can be claimed by the doctor according to Government rules.


Experts’ Views

Interesting Tips in Hepatology & Gastroenterology

(Dr. Neelam Mohan – Director Pediatric Gastroenterology, Hepatology and Liver Transplantation Medanta Medicity)

Gastroesophageal Reflux Disease in Children (cont…)

Management of GERD

Lifestyle changes

Thickened Feedings and other dietary modifications: Thickening the child’s food (e.g., rice cereal in formula) to reduce the clinical symptoms of children with GER has long been an accepted practice. This assumption has been tested with pH probe data, and thickened feedings (e.g., apple juice thickened with rice cereal) were found to have no effect on reflux time unless the child was in a head-elevated prone position after the feeding. However, although infants with GER who are given thickened feedings might not have significantly reduced reflux time as measured by a pH probe, other criteria, such as episodes of emesis, time spent crying, and time spent awake, may be reduced. In addition, their effects may often result in the therapeutic success of thickened feedings.

Question of the Day

How frequently and at what times should blood sugar be monitored? (Dr G M Singh)

The American Association of Diabetes Educators recommends that all patients should be encouraged to self–monitor blood glucose (BG), regardless of whether they are being treated with insulin or oral agents.The American Diabetes Association (ADA) recommends that patients with type 2 diabetes who are taking multiple insulin injections should monitor BG at least 3 times per day, but they also note that the optimum frequency for self–monitoring is not clear for patients taking oral drugs or less frequent insulin injections.

Others have suggested that patients taking insulin should self–monitor BG at least 4 times a day, before meals and bedtime; and that patients with type 2 diabetes should check their BG at least 4 times per week (twice fasting and twice after meals).


Public Forum (Press Release for use by the newspapers)

High risk groups for H1N1flu

Swine flu is normally mild and requires no attention but if the following groups of people develop flu–like symptoms, they should contact their doctor said Padma Shri and Dr B C Roy National Awardee Dr KK Aggarwal, President Heart Care Foundation of India & MTNL Perfect Health Mela.

They include

  • Children younger than 5 years of age (particularly those less than 2 years of age)
  • Individuals 65 years of age or older
  • Individuals younger than 19 years of age who are receiving long–term aspirin therapy and who therefore might be at risk for Reye syndrome after influenza virus infection
  • Pregnant women
  • Individuals with chronic medical conditions requiring ongoing medical care, including:

    • Chronic pulmonary disease, including asthma particularly if systemic glucocorticoids have been required during the past year)
    • Cardiovascular disease, except isolated hypertension
    • Active malignancy
    • Chronic renal insufficiency
    • Chronic liver disease
    • Diabetes mellitus
    • Hemoglobinopathies such as sickle cell disease
    • Immunosuppression, including HIV infection (particularly if CD4 <200 cells/microL), organ or hematopoietic stem cell transplantation, inflammatory disorders treated with immunosuppressants
    • Individuals who have any condition that can compromise handling of respiratory secretions (eg, cognitive dysfunction, spinal cord injuries, seizure disorders, neuromuscular disorders, cerebral palsy, metabolic conditions)
    • Children with an underlying metabolic disorder, such as medium–chain acyl–CoA dehydrogenase deficiency, who are unable to tolerate prolonged fasting
    • Children with poor nutritional and fluid intake because of prolonged vomiting and diarrhea
    • Residents of nursing homes and other chronic care facilities
    • People without spleen
    • Obesity

Commonwealth Medical Association 

(Dr. S. Arulrhaj, MD., FRCP (Glasg), President) 

Commonwealth Foundation

Commonwealth Medical Association (CMA) is a conglomeration of National Medical Associations of Commonwealth countries. As on date, CMA has 48 member countries. Associate Membership is open to other countries. CMA was established in 1962. The CMA constitution was later changed in 1989. CMA is a Registered Company in UK with its office at London.

The President
The Commonwealth Medical Association (CMA)
British Medical Association Building
International Department
Tavistock Square,
London, WC1H 9JP
London Officer – Ms. Janet Adrah
(on behalf of President)
Telephone number: 0207 383 6069
Email : cmaliaison@cma.bma.org.uk
Website: http://www.commonwealthmedics.org


An Inspirational Story

Boy and the Soccer Game

Once there lived a boy who was very interested in football. Along with his father he would go everyday go to the playing field. Both of them would sit in different places. Days passed by and the day of tournament was coming near, but the boy suddenly stopped coming to the grounds. Then after 15 days he unexpectedly reappeared and asked his coach to let him play.

Although the coach was in a dilemma whether the boy could play, he decided to let him play. In fact, the team won as a result of the boy’s significant contributions. Later, the coach asked the boy how he could perform so well in spite of not practicing a single day. The boy said, "Coach, my father was watching me."

The coach was very clearly annoyed. The boy then continued, "Sir I used to daily come with my father but he was blind. I stopped playing because I knew he couldn’t see me play. Recently my father died, and now I know that he can see me from the abode of God."


IJCP Special

Dr Good Dr Bad

Situation: A diabetic patient with stroke came for evaluation.
Dr Bad: Get routine test done.
Dr Good: Get blood sugar and A1C also done.
Lesson: Increased rate of heart failure can contribute to higher mortality in stroke patients with hyperglycemia. On multivariate analysis, fasting glucose was significantly associated with risk of in–hospital heart failure. (Eur J Neurol 2009;16(2):251–6.)

Make Sure

Situation: A patient with suspected meningitis developed brain damage.
Reaction: Oh My God! Why was antibiotic not started when the diagnosis was suspected?
Lesson: Make sure that first dose of antibiotic is given at the time meningitis is suspected

Quote of the Day

"Burn brightly without burning out." Richard Biggs

Are you fit to fly?


  1. Invasive procedures introduce air into isolated body cavities that could expand at altitude in a pressurized cabin and cause barotrauma.

  2. Patients should postpone air travel until at least 10 to 14 days after most surgical procedures. This delay should provide enough time for air in the intrathoracic, intraabdominal, or other cavities to be resorbed, and reduces the risk for barotrauma.

International Medical Science Academy Update (IMSA)

Autism and MMR

The Lancet has fully retracted the 1998 paper, which suggested an association between the measles–mumps–rubella vaccine (MMR), enterocolitis, and autism.


  1. Wakefield AJ, Murch SH, Anthony A, et al. Ileallymphoidnodular hyperplasia, nonspecific colitis, and pervasive developmental disorder in children. Lancet 1998; 351:637.

  2. RetractionIleallymphoid-nodular hyperplasia, nonspecific colitis, and pervasive developmental disorder in children. Lancet 2010.

Drug Update

List of Approved drugs from 01.01.2010 TO 30.4.2010

Drug Name


DCI Approval Date

Sphaeranthus Indicus Extract Tablets 700mg.

For the management of psoriasis



Medi Finance

Q. What is the treatment of building, furniture, and plant and machinery used for doctor’s profession in the books of accounts?

Ans. Building, furniture, and plant and machinery are shown on the assets side of the balance sheet. A doctor can claim depreciation on these assets according to income tax rules.


Lab Medicine (Dr Arpan Gandhi and Dr Navin Dang)

Blood Ceruloplasmin

  • Decreased ceruloplasmin levels: Lower-than-normal ceruloplasmin levels may indicate Menke's disease, Wilson's disease (a rare copper storage disease), overdose of Vitamin C and aceruloplasminemia.

  • Elevated ceruloplasmin levels: May indicate or be noticed in pregnancy, oral contraceptive pill use, lymphoma, acute and chronic inflammation (it is an acute-phase reactant), rheumatoid arthritis, angina and Alzheimer's disease.

Lateral thinking

Read this……………


Send in your answer to emedinews@gmail.com

The answer for yesterday puzzle  “I understand”

Correct answer received from:

Dr Geeta Yadav,  Dr. Shakuntala Dawesar, Dr. Prashant Bharadwaj, Dr Theogaraj Samraj, Dr Gitanjali Arora, Dr Gagan Shrivastava, Chief Cardiac Anesthesiologist Gokuldas Heart Hospital, Indore, Dr Aanchal Jain, DMA, Dr.Prita Trehan, Dr Rajiv Kohli, Dr. Noopur Gupta


Humor Section


Doctor: Did you know that there are more than 1,000 bones in the human body?
Tom: Shhh, doctor! My dog’s outside in the waiting room!

Medical bloopers on medical charts!

The patient was in his usual state of good health until his airplane ran out of gas and crashed.


Readers Responses

  1. My dear Dr. K.K. Aggarwal, I must congratulate you for your tremendous efforts in publishing emedinews daily on net covering wide range of topics and other common medical issue. Please keep it up: Dr. A .K. Srivastava MD Past President IMA UP State and IMA Kanpur Branch.

  2. Dear Dr K K; Dr Manocha case well taken - there is always a double edged sward on the head of every doctor; either you treat or don’t treat/ take up the case in the interest of patient. Honourable Supreme court of India had rightly  said in its judgment. CA No. 3541 of 2002 that “113. While this Court has no sympathy for doctors who are negligent, it must also be said that frivolous complaints against doctors have increased by leaps and bounds in our country particularly after the medical profession was placed within the purview of the Consumer Protection Act. To give an example, earlier when a patient who had a symptom of having a heart attack would come to a doctor, the doctor would immediately inject him with Morphia or Pethidine injection before sending him to the Cardiac Care Unit (CCU) because in cases of heart attack time is the essence of the matter. However, in some cases the patient died before he reached the hospital. After the medical profession was brought under the Consumer Protection Act vide Indian Medical Association vs. V.P. Shantha 1995 (6) SCC 651 doctors who administer the Morphia or Pethidine injection are often blamed and cases of medical negligence are filed against them. The result is that many doctors have stopped giving (even as family physicians) Morphia or Pethidine injection even in emergencies despite the fact that from the symptoms the doctor honestly thought that the patient was having a heart attack. This was out of fear that if the patient died the doctor would have to face legal proceedings. 114. Similarly in cases of head injuries (which are very common in road side accidents in Delhi and other cities) earlier the doctor who was first approached would started giving first aid and apply stitches to stop the bleeding. However, now what is often seen is that doctors out of fear of facing legal proceedings do not give first aid to the patient, and instead tell him to proceed to the hospital by which time the patient may develop other complications.” [Dr V K Goyal - MD Peds; IMA - EDB – 949]

  3. The column “Dr Good Dr Bad” on very high triglycerides needs some elaboration. General perception is that high triglycerides occur because of over-consumption of fat. But the “lesson” in this column says—high triglycerides are due to excess of refined carbohydrates in diet. Is sugar also included in “refined carbohydrates” or only things like “very refined wheat flour (Maida)? 
    Confusion is also caused on a daily basis by so many news on medical research. The latest is published today (July 27, 2010) in TOI, based on a Canadian research. It suggests—if you drink 800 ml of milk daily, your risk of prostate cancer doubles. I think 800 ml is not a big quantity—calculate number of cups of tea, curd and milk—many people might be taking this much quantity daily. eMedinewS articles on osteoporosis keep on harping on Vit-D (1000 IU) and calcium and more intake of milk. One in this situation is not sure how much milk one should take daily: Vinod Varshney
    eMedinewS Responds: Fat increases bad LDL cholesterol while TGs are linked to refined cabs. Sugar is a refined carb. Milk and cancer link has not been substantiated by the research. It might be an individual observation.

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

26th September: BSNL Dil ka Darbar A day–long 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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