eMedinewS3rd April 2014, Thursday

Dr K K AggarwalPadma Shri, Dr B C Roy National Awardee and DST National Science Communication Awardee

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

Replacing IV Nitroglycerin in the Shortage

IV nitroglycerin is needed in myocardial infarction, hypertensive crisis, and acute decompensated heart failure. Following are the alternatives, if there is shortage in its supply.

  1. NTG Paste: In acute coronary syndrome, use nitro paste or sublingual tablets.
  2. NTG spray: One can use 400 mcg of nitro spray and titrates one spray every 4 minutes, which results in a 100–mcg per minute dose.
  3. S/L NTG: Give multiple sublingual tablets of nitroglycerin instead of using nitro paste. With one 100–mcg tablet, absorption is roughly 70–80 mcg/min. If blood pressure holds after about 5 minutes one can double the dose. Because some patients’ blood pressure drops with nitroglycerin, start with one sublingual nitroglycerin tablet. Then up from there and then escalate to bilevel positive air pressure (BiPAP) or continuous airway pressure (CPAP) with nitroglycerin in the most severely ill patients. Do X–rays the chest to confirm fluid overload before starting furosemide because symptoms are sometimes confused with COPD exacerbation, pneumonia, or lung cancer, and giving furosemide can make them much worse or increase mortality. If the patient is wheezing, use a bronchodilator.
  4. Drip ACE Inhibitors: In acute heart failure one can start with enalaprilat for preload reduction and nicardipine for afterload reduction. One can start with low dose enalaprilat 1.25 mg IV. The exception would be hypotensive patients.
  5. Try Nitroprusside: It reduces both preload and afterload.
  6. Try Nicardipine: For acute decompensated heart failure, 1 mcg/kg/min of nicardipine is the optimal dose for patients.
  7. Do Not use: Nesiritide; loop diuretics as first line as furosemide makes patients worse in the first 10 to 20 minutes of management, which is the critical time in APE resuscitation.

Suggested protocol

  1. Sublingual nitroglycerin, 1 to 2 tabs every 5 mins × 3 –– reassess BP
  2. If well–controlled, then transition to NTP or Isordil p.o. (Nitro paste or longer acting NTG)
  3. If not well–controlled (>160/100) then consider IV enalapril –– 0.625–1.25 mg IV bolus or IV hydralazine 5–10 mg IV bolus or IV nitroprusside.

News Around The Globe

  • The Anti–Infective Drugs Advisory Committee of the US Food and Drug Administration (FDA) has voted in favor of recommending the approval of 2 new antibacterial agents for the treatment of skin and skin structure infections caused by Gram–positive pathogens, including methicillin–resistant Staphylococcus aureus (MRSA). The drugs are tedizolid phosphate and dalbavancin. Both the drugs have completed phase III noninferiority clinical trials and have been considered for approval under the Generating Antibiotic Incentives Now (GAIN) initiative.
  • Restricting red blood cell (RBC) transfusions to hospital patients with hemoglobin levels below 7 g/dL could significantly reduce the risk for healthcare-acquired infections (HAIs), reports an article published in the April 2 issue of JAMA. In a systematic review and meta–analysis of published clinical trials to compare restrictive and liberal transfusion strategies and the risk for HAI, the summary risk for all serious infections came out to be 11.8% for restrictive transfusion strategies as compared to 16.9% for liberal strategies.
  • A study presented at the American Institute of Ultrasound in Medicine (AIUM) 2014 Annual Convention states that hypofractionated radiation therapy that encompasses a higher daily dose of radiation delivered over a shorter period than standard radiotherapy, is associated with significantly lesser skin toxicity in women receiving radiation for invasive breast cancer. Skin thickness, a good surrogate of skin toxicity, was measured in patients subjected to either of the treatments. Skin thickening was noted to be greater in women treated with the standard regimen than in those treated with the hypofractionated regimen.
  • A novel study published online in the Annals of the Rheumatic Diseases has reported that methotrexate (MTX) reduces pain, improves function, and produces a clinically relevant and radiologically verifiable reduction in synovitis in patients with symptomatic knee osteoarthritis.
  • High–resolution ultrasound conducted at a physician’s office is a fast, convenient, and friendly alternative to MRI for determining the status of breast implants, suggests a pilot study presented at the American Institute of Ultrasound in Medicine (AIUM) 2014 Annual Convention. Study authors noted that ultrasound examination, conducted 6 months to 7 years after implantation, revealed 25% of the Mentor CPG implants and 21% of the Allergan 410 implants to have rotated from their original position.

Medicine news

Obesity primes the colon for cancer, according to NIH study

Obesity, rather than diet, causes changes in the colon that may lead to colorectal cancer, according to a study in mice by the National Institutes of Health. The finding bolsters the recommendation that calorie control and frequent exercise are not only key to a healthy lifestyle, but a strategy to lower the risk for colon cancer, the second leading cause of cancer–related death in the United State

Rabies News (Dr A K Gupta)

What does humanizing your dog means?

  • Talking to your dog like he/she is a person.
  • Treating your dog like he/she is a person.
  • Allowing dogs to do what they want because it will hurt their "feelings."
  • Dressing them up in little doggie clothes.

Remember, humanizing your dog is fulfilling your own human needs, not your dogs. Humanizing dogs does more harm than good.

Cardiology eMedinewS

  • New UK CV prevention recommendations take the longer view: Cardiovascular–disease prevention efforts should extend to people with low short–term risk but high lifetime risk of cardiovascular events, according to new CV prevention recommendations by the Joint British Societies. The Joint British Societies’ Consensus Recommendations for the Prevention of Cardiovascular Disease (JBS3) is particularly important in young people and in women whose 10–year CVD risk is very low but whose lifetime risk is much higher. JBS3 is published in the journal Heart. The ACC/AHA cholesterol guidelines include recommendations to initiate statin therapy in individuals who have LDL–cholesterol levels between 70 and 189 mg/dL and a 10–year risk of atherosclerotic cardiovascular disease of >7.5%. The JBS3 recommendations, by contrast, use a higher 10-year risk of CVD—"threshold to be defined by NICE guidance." which uses a cut point of 10%, down from 20% in the last NICE document, but higher than the 7.5% in the ACC/AHA guidelines). "Heart age" can be estimated using an online JBS3 calculator that draws on individual age and risk factors.
  • SYMPLICITY: Is this the end of renal denervation? Renal denervation with Medtronic’s Symplicity catheter was safe, but it was no better than a sham procedure for reducing office blood pressure in the SYMPLICITY HTN–3 trial. Through 6 months, office systolic blood pressure dropped by 14.13 mm Hg in the denervation group and by 11.74 mm Hg in the sham–control group, which received renal angiography alone (P<0.001 for both from baseline), yielding a between–group difference of only 2.39 mm Hg (P=0.26 with a superiority margin of 5 mm Hg), according to Deepak Bhatt, MD, MPH, of Brigham and Women’s Hospital in Boston. The findings were published online in the New England Journal of Medicine and simultaneously presented as a late–breaking clinical trial at the American College of Cardiology meeting.

Pediatrics eMedinewS

  • Drug or alcohol addiction in a parent may be associated with arthritis risk in his/her offspring in adulthood, reports a novel study published online in the International Journal of Population Research. This was an observational study including >13,000 adults showing that those with a history of parental addiction were about 30% more prone to have arthritis than their peers without such history after adjusting for relevant confounding factors.
  • A double–blind, placebo–controlled, randomized trial published online April 1 in BMJ has stated that treatment of infants with Lactobacillus reuteri DSM 17938 did not improve symptoms of colic. These findings are in contrast with the findings of previous smaller studies. It was noted that at 1 month into treatment, the infants in the probiotic group fussed or cried for 49 minutes more than those in the placebo group.

Dr K K Spiritual Blog

On 4th Navratri Be Happy in All Situations

Kushmanda is worshipped on the fourth day of Navratri. SHE shines brightly with a laughing face.

Out of eight hands (Ashtabhuja), she carries weapons like bow, arrow, discus and mace in four arms.

In other three hands, she holds a lotus, a beaded rosary and a Kamandalu. In the remaining hand, she carries a jar of nectar.

SHE rides on Lion. Rosary represents her power to bless her devotees with Ashtasiddhi (eight types of studies or wisdom sources) and Navanidhi (nine types of wealth). In Ayurveda SHE represents the control over the air element.

In Yoga Shastra SHE represents the heart or Anhata Chakra with the Bija sound YAM.

Spiritual mantra on the 4th Navratri

One should continuously (beaded rosary) control the air (anahata plexus) within us by using our sharp intelligence (sword) and balancing the mind (Trishul) by focusing on one point (arrow and bow), practicing detached attachment (lotus), accepting things as they are (Kamandalu), keep smiling in both acceptable and difficult situations (smiling face) and killing the negative energies by using discus (power) when needed.

Wellness Blog

All diabetics must have an eye check up done

The vast majority of diabetic patients who develop diabetic retinopathy (eye involvement) have no symptoms until the very late stages (by which time it may be too late for effective treatment). Because the rate of progression may be rapid, therapy can be beneficial for both symptom amelioration as well as reduction in the rate of disease progression, it is important to screen patients with diabetes regularly for the development of retinal disease.

The eyes carry important early clues to heart disease, signaling damage to tiny blood vessels long before symptoms start to show elsewhere. Diabetic people with retinopathy are more likely to die of heart disease over the next 12 years than those without it.

As per a study from the University of Sydney and the University of Melbourne in Australia and the National University of Singapore, people with retinopathy are nearly twice as likely to die of heart disease as people without it.

People with these changes in the eyes may be getting a first warning that damage is occurring in their arteries, and work to lower cholesterol and blood pressure.

Patients with retinopathy have a greater risk of incident cardiovascular disease (CVD) events, including heart attack, stroke, revascularization, and CVD death, compared with those without retinopathy.

Inspirational Story

Be Content about Your Life

Wonder if any of you ever had the feeling that life is bad, real bad…and you wish you were in another situation. Do you find that life seems to make things difficult for you, work sucks, life sucks, and everything seems to go wrong…

It was not until yesterday that I totally changed my views about life; after a conversation with one of my friends.

He told me despite taking 2 jobs, and bringing back barely above 1K per month, he is happy as he is. I wonder how he can be as happy as he is now, considering that he has to skimp his life with the low pay to support a pair of old-age parents, in-laws, wife, 2 daughters and the many bills of a household.

He explained that it was through one incident that he saw in India……

That happened a few years ago when he was really feeling low and was touring India after a major setback. He said that right in front of his very eyes, he saw an Indian mother chopped off her child’s right hand with a chopper. The helplessness in the mother’s eyes, the scream of the pain from the innocent 4 years old child haunted him until today. You may ask why did the mother do so, has the child been naughty, was the child’s hand infected??

No, it was done for two simple words — to beg. The desperate mother deliberately caused the child to be handicapped so that the child can go out to the streets to beg. I cannot accept how this could happen, but it really did, just in another part of the world which I don’t see.

Taken aback by the scene, he dropped a small piece of bread he was eating half–way. And almost instantly, flock of 5 or 6 children swamp towards this small piece of bread which was then covered with sand, robbing of bits from one another. The natural reaction of hunger. Stricken by the happenings, he instructed his guide to drive him to the nearest bakery. He arrived at two bakeries and bought every single loaf of bread he found in the bakeries.

The owner is dumb folded, but willing sold everything. He spent less than $100 to obtain about 400 loaf of bread (this is less than $0.25/per loaf) and spend another $100 to get daily necessities. Off he went in the truck full of bread into the streets. As he distributed the bread and necessities to the children (mostly handicapped) and a few adults, he received cheers and bows from these unfortunate. For the first time in life he wonders how people can give up their dignity for a loaf of bread which cost less than $0.25. He began to ask himself how fortunate he is as a Singaporean. How fortunate he to be able to have a complete body, have a job, have a family, have the chance to complain what food is nice what isn’t, have the chance to be clothed, have the many things that these people in front of him are deprived of……

Now I begin to think and feel it, too. Was my life really that bad? Perhaps…no,… it should not be bad at all…

What about you? Maybe the next time you think you are, think about the child who lost one hand to beg on the streets.

ePress Release

Diabetes and heart patients beware during Navratri fasts

Fast during Navratri for diabetic patients carries a risk of complications said 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.

Dr. Aggarwal released following facts about Navratri diet for patients with diabetes.

  • Type 1 diabetes should not observe fast.
  • Diabetic patients should not fast if their blood sugar level is below 60.
  • Fast should also be broken if blood sugar is less than 70 in the first few hours after starting the fast.
  • In type 2 diabetes, well–controlled with diet alone, the risk associated with fasting is low. However, there is a potential risk of post food high blood sugar if the patients overindulge in eating.
  • Type 2 diabetic patients on diet control who also regularly exercise daily should modify their exercise program and not do it when they are fasting. They should do exercise only after 2 to 3 hours following the sunset meal.
  • In diabetics with uncontrolled high blood sugar and high cholesterol, restriction of fluids intake during the day, can precipitate dehydration leading to paralysis and heart attack.
  • Patients on metformin alone can fast as the possibility of low blood sugar is minimal. Two–thirds of the normal dose of metformin should be given immediately before post sunset meal and rest one–third can be given in the morning if they take a fruit-based breakfast. Similarly patients on pioglitazone can do fast without change in the dosage pattern.
  • Diabetic patients who are on sulfonylurea drugs should talk to their doctors before fasting. Only glimepiride and gliclazide, which have also lower risk of low blood sugar can be given during fast but under medical supervision. Sometimes these drugs may be shifted to short acting drugs like repaglinide during the period of the past again under medical supervision.
  • Patients who are taking insulin and taking only one meal a day may have to adjust the dose of their insulin and the requirement of insulin may reduce upto 40%.
  • Most diabetic patients during fast will get control on a single dose of plain insulin before the major meal or longer acting at insulin at bed time.
  • Patients on plain insulin should talk to their doctor whether they need to shift to lispro insulin instead of regular insulin to reduce chances of low blood sugar.
  • Fasting diabetic patients who take heavy dinner may have to accordingly modify the dose of their insulin.
  • The dose of high blood pressure drugs may need to be reduced up to 40% during Navratri fasts.

About HCFI : The only National Not for profit NGO, on whose mega community health education events, Govt. of India has released two National commemorative stamps and one cancellation stamp, and who has conducted one to one training on" Hands only CPR" of 88972 people since 1stNovember 2012.

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 10x10 i.e. 100 per minute."

Zee News – Health Wealth Shows

Cancer Prevention
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Total CPR since 1st November 2012 – 88972 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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VIP’s on CPR 10 Mantra Video

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

emedipicstoday emedipics

A free heart checkup camp was organised by Heart Care Foundation of India at Mandi House, Doordarshan Kendra where over 500 people were examined.

press release

Monitoring LFT in a patient on statins

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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 :


Make Sure

Situation: A patient developed fainting attack after sublingual nitrate.
Reaction: Oh my God! Why was the systolic murmur missed on auscultation?
Lesson: Make sure that patient with LVOT obstruction are not given sublingual nitrates.

eMedinewS Humor

Law of Bag/Box Occupancy

All bags and boxes in a given room must contain a cat within the earliest possible nanosecond.

Quote of the Day

The only good luck many great men ever had was being born with the ability and determination to overcome bad luck. Channing Pollock


Twitter of the Day

Dr KK Aggarwal: Diabetes and heart patients beware during Navratri fasts http://youtu.be/NMIK16PyBrY?a via @YouTube
Dr Deepak Chopra: Recurrent anxiety can have a devastating toll on all aspects of our life. How to deal with anxiety? http://bit.ly/DC_Ananda #ananda


Forthcoming events

Date: Saturday 2PM–Sunday 3PM, 26–27 April 2014
Venue: Om Shanti Retreat Centre, Bhora Kalan, Pataudi Road, Manesar
Course Directors: Padma Shri and Dr B C Roy National Awardee Dr K K Aggarwal and BK Sapna
Organisers: Heart Care Foundation of India. Prajapati Brahma Kumari Ishwariye Vidyalaya and eMedinews
Facilities: Lodging and boarding provided (one room per family or one room for two persons). Limited rooms for first three hundred registrants.
Course: Meditation, Lectures, Practical workshops
Atmosphere: Silence, Nature, Pyramid Meditation, Night Walk
Registration: SMS– Vandana Rawat – reg mno, rawat.vandana89@gmail.com
SMS – BK Sapna reg mno1, bksapna@hotmail.com

Note: Donation in Favor of Om Shanti Retreat Centre will be welcomed


Our Contributors

Dr Veena Aggarwal, Dr Chanchal Pal, Dr A K Gupta, Dr Brahm Vasudev, Dr GM Singh, Dr Monica Vasudev, Dr Navin Dang, Dr Pawan Gupta, Dr Parveen Bhatia, Dr Prachi Garg, Rajat Bhatnagar, Dr Sudhir Gupta, Prof.(Dr).C V Raghuveer

eMedi Quiz

The cells belonging to the following type of epithelium are provided with extra reserve of cell membrane:

1. Transitional
2. Stratified squamous
3. Stratified cuboidal
4. Stratified columnar

Yesterday’s Mind Teaser: 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.

Answer for yesterday’s Mind Teaser: 3.Lateral rectus and abducent nerve.

Correct answers received from: Dr KV Sarma, Arvind Gajjar, Dr Pankaj Gupta, Dr P C Das, Dr Ratnesh Prakash,
Dr Poonam Chablani, Dr Jainendra Upadhyay, Dr Pankaj Agarwal, Dr Chandresh Jardosh, Dr Avtar Krishan, Daivadheenam Jella, Dr BK Agarwal, Dr Abbas Vakil, Dr Bitaan Sen & Dr Jayashree Sen.

Answer for 1st April Mind Teaser: 3.Pain sensation on the contralateral side.

Correct answers received from: Arvind Gajjar, Dr Chandresh Jardosh.

Send your answer to ijcp12@gmail.com

medicolegal update

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  1. Dear Editor, "Babloo goes for an eye test" for students, parents and teachers is equally suitable and must–read book for everyone including doctors…and the added bonus is that the little book is available "free" for collection for libraries of hospitals and medical teaching institutions (from Ophthacare Eye Centre, C2C/236A Janakpuri, New Delhi 110058, 6.00 pm to 8.00 pm) with prior intimation at Phone 25599839. Dr. Narendra Kumar Chairman, Eye Care India
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