eMedinewS1st September 2014, Monday

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

Neck Artery Wall Thickness and Plaque Area – a new test to diagnose early heart diseases

Treadmill, stress echocardiography, Thallium and Angiography do not detect early blockages. Treadmill can miss blockages up to 70%; stress echocardiography up to 60% and angiography up to 40%.

Most heart attacks occur because of a plaque rupture in patients with blockages of less than 50%. If the blockage is more than 70% the patient usually presents with heart pain and not massive heart attack.

The only way to detect heart blockages before they cause symptoms or are detected in conventional tests is to measure the wall thickness of the neck artery or the leg artery. Normally, the wall thickness is less than 0.5mm. If the wall thickness is more than 0.75mm, it is suggestive of underlying heart blockages and if it is more than 1mm, it is suggestive of blockages in all three arteries of the heart.

Any thickness of more than 1mm is called as a plaque and a plaque area calculated by high resolution ultrasound is a new marker for heart blockages, progression as well as regression.

If the artery wall is thick in both the neck artery and the leg artery, it is very likely that the patient will also have blockages in the arteries of the heart.

All high risk individuals, therefore, should have their neck and leg artery wall thickness checkup done. Only 2% of patients with blockages in all three arteries of the heart have a neck artery wall thickness of less than 1mm and 94% of patients with a neck artery wall thickness of more than 1.15mm will have multiple blockages in the heart.

Innovations in Cardiology (IIC) Summit 2014

Dr Rajneesh Kapoor

Intraprocedural coronary artery stent thrombosis

In the CHAMPION PHOENIX trial (Clinical trial comparing cangrelor to clopidogrel standard of care therapy in subjects who require percutaneous coronary intervention), occurrence of intraprocedural stent thrombosis (IPST) was strongly predictive of subsequent adverse cardiovascular events. Patients with IPST had a marked increase in composite ischemia (death, myocardial infarction, ischemia-driven revascularization, or new–onset out–of–laboratory stent thrombosis [Academic Research Consortium]) at 48 h and at 30 days. Cangrelor, a potent intravenous adenosine diphosphate antagonist significantly reduced IPST, contributing to its beneficial effects at 48 h and 30 days. J Am Coll Cardiol 2014 Feb 25;63(7):619–29.

News Around The Globe

  • A case series published online August 25 in JAMA Neurology has pointed that an intensive approach to autologous stem cells transplantation has facilitated a return to normal function for patients with stiff person syndrome (SPS).
  • Although elective splenectomy is a minor procedure, it may be risky for certain patients, including those with advanced age, poor performance and nutritional status, and malignant disease. Such patients may be at high risk for complications and death from elective splenectomy. The findings are published online in JAMA Surgery.
  • The use of a bundled approach to prevent surgical site infections (SSIs) after colorectal surgery (CRS) appears effective and might lower healthcare costs, suggests a retrospective study published online August 27 in JAMA Surgery.
  • A new integrated approach for treating depression in cancer patients is reported to be "strikingly more effective" at both reducing depressive symptoms and improving quality of life than the current standard of care. The new approach, known as Depression Care for People with Cancer (DCPC), was tested in 2 clinical trials: the SMaRT–2 study, reported in the Lancet, and the SMaRT–3 study, reported in the Lancet Oncology.
  • New research published in the Journal of Neurology, Neurosurgery & Psychiatry has reported that there may be a link between salt consumption and multiple sclerosis (MS) disease activity.

Rabies News (Dr A K Gupta)

If RIG is inadequate to infiltrate extensive wounds, what should be done?

If RIG is inadequate to infiltrate extensive wounds, the RIG should be diluted with normal saline. This is a particular issue in children, whose body weight may be small in relation to the size and number of wounds.

Cardiology eMedinewS

  • Although drinking alcohol has been linked in the past to a higher risk of hypertension, a new meta–analysis published recently in Mayo Clinic Proceedings reported that a drink or two a day seemed to protect even those with hypertension from heart disease and death.
  • Eagerly awaited results from a heart failure drug trial, potentially the first to prove a real benefit in the condition, top the agenda at the European Society of Cardiology meeting. The drug, know as LCZ696, has been in talks since last March when the data safety monitoring board for PARADIGM–HF shut down the trial when an interim analysis revealed that patients treated with LCZ696 were less likely to die or be hospitalized than those randomized to enalapril.

Pediatrics eMedinewS

  • Children and teens constantly plugged into personal listening devices, such as phones, computers or music players, could be harming their ears without realizing it, suggests a new report by an audiologist at the Purdue University.
  • Children with cleft lip or palate (CLP) have no worse complications from ventilation tube (VT) insertion in their ears to treat otitis media with effusion or acute otitis media. The findings are published online August 28 in JAMA Otolaryngology – Head and Neck Surgery.

Dr K K Spiritual Blog

Importance of silence

True silence is the silence between thoughts and represents the true self, consciousness or the soul. It is a web of energized information ready to take all provided there is a right intent. Meditation is the process of achieving this silence.

Observing silence is another way of getting benefits of meditation. Many yogis in the past have recommended and observed silence now and then. Mahatma Gandhi used to spend one day of each week in silence. He believed that abstaining from speech brought him inner peace and happiness. On these days, he communicated with others only by writing on paper.

Hindu principles also talks about a correlation between mauna (silence) and shanti (harmony). Mauna Ekadashi is a ritual followed traditionally in our country. On this day the person is not supposed to speak at all and keep complete silence throughout day and night. It gives immense peace to the mind and strength to the body. In Jainism this ritual has a lot of importance. Nimith was a great saint in Jainism who long ago asked all Jains to observe this vrata. Some people recommend that on every ekadashi one should observe silence for few hours in a day if not the whole day.

Deepak Chopra in his book 7 Laws of Spiritual Success talks in great detail about the importance of observing silence in day to day life. He recommends that everyone should observe silence for 20 minutes every day. Silence helps redirecting our imagination towards self from the outer atmosphere. Even Swami Sivananda in his teachings has recommended daily observation of mauna for 2 hours for ekadashi, take milk and fruits every day, study daily one chapter of Bhagwad Gita, do regular charity and donate one–tenth of the income in the welfare of the society. Ekadashi is the 11th day of Hindu lunar fortnight. Ekadashi is the day of celebration occurring twice a month, meant for meditation and increasing soul consciousness.

Vinoba Bhave was a great sage of our country who is known for this bhoodaan movement. He was a great advocator and practical preacher of mauna vrata.

Mauna means silence and vrata means vow; hence, mauna vrata means vow of silence. Mauna was practiced by saints to end enmity. Prolonged silence as a form of silence is observed by rishi munis.

Silence is a source of all that exists. Silence is where conscious dwells. There is no religious tradition which does not talk about silence. It breaks outward communication and forces a dialogue towards inner communication. This is one reason why all prayers, meditation and worship or any other practice whether we attune our mind to the spiritual consciousness within are done in silence. After the death of a person it is a practice to observe silence for two minutes. The immediate benefit is that it saves a tremendous amount of energy.

Silence is cessation of both sensory and mental activity. It is like having a still mind and listening to the inner mind. Behind this screen of our internal dialogue is the silence of spirit. Meditation is the combination of observing silence and the art of observation.

Wellness Blog

Top 5 Pain Interventions to Avoid

In response to a call from the American Board of Internal Medicine (ABIM) Foundation for recommendations on the most overused interventions, the American Society of Anesthesiologists (ASA) issued its list of top 5 tests and therapies that are of questionable usefulness in the field of pain medicine.

The new list includes the following recommendations for doctors:

  • Don’t prescribe opioid analgesics as first–line therapy to treat chronic non–cancer pain. Consider multimodal therapy, including nondrug treatments, such as behavioral and physical therapies, before pharmacologic intervention. If drug therapy appears indicated, try nonopioid medication, such as nonsteroidal anti–inflammatory drugs, or anticonvulsants, before starting opioids.
  • Don’t prescribe opioid analgesics as long–term therapy to treat chronic non–cancer pain until the risks are considered and discussed with the patient. Inform patients of the risks of such treatments, including the potential for addiction. Review and sign a written agreement identifying both your and the patient’s responsibilities (e.g., urine drug testing) and the consequences of noncompliance with the agreement. Be cautious in coprescribing opioids and benzodiazepines. Proactively evaluate and treat, if indicated, the nearly universal adverse effects of constipation and low testosterone or estrogen.
  • Avoid imaging tests, such as MRI, CT, or radiography, for acute low back pain without specific indications. Avoid these interventions for low back pain in the first 6 weeks after pain begins if there are no specific clinical indications (e.g., history of cancer with potential metastases, known aortic aneurysm, progressive neurologic deficit). Most low back pain doesn’t require imaging, and performing such tests may reveal incidental findings that divert attention and increase the risk of having unhelpful surgery.
  • Don’t use intravenous sedation, such as propofol, midazolam, or ultra–short–acting opioid infusions for diagnostic and therapeutic nerve blocks, or joint injections, as a default practice. (This recommendation does not apply to pediatric patients.) Ideally, diagnostic procedures should be performed with local anesthetic alone. Intravenous sedation can be used after evaluation and discussion of risks, including interference with assessing the acute pain–relieving effects of the procedure and the potential for false–positive responses. Follow ASA Standards for Basic Anesthetic Monitoring in cases where moderate or deep sedation is provided or anticipated.
  • Avoid irreversible interventions for non–cancer pain, such as peripheral chemical neurolytic blocks or peripheral radiofrequency ablation. Such interventions may be costly and carry significant long–term risks of weakness, numbness, or increased pain.

Inspirational Story

Benefits of Struggling

A man found a cocoon of a butterfly. One day a small opening appeared, he sat and watched the butterfly for several hours as it struggled to force its body through that little hole.

Then it seemed to stop making any progress. It appeared as if it had gotten as far as it could and it could go no farther. Then the man decided to help the butterfly, so he took a pair of scissors and snipped off the remaining bit of the cocoon. The butterfly then emerged easily.

But it had a swollen body and small, shriveled wings. The man continued to watch the butterfly because he expected that, at any moment, the wings would enlarge and expand to be able to support the body, which would contract in time.

Neither happened!

In fact, the butterfly spent the rest of its life crawling around with a swollen body and shriveled wings.

It was never able to fly.

What the man in his kindness and haste did not understand was that the restricting cocoon and the struggle required for the butterfly to get through the tiny opening were God’s way of forcing fluid from the body of the butterfly into its wings so that it would be ready for flight once it achieved its freedom from the cocoon.

Sometimes struggles are exactly what we need in our life. If God allowed us to go through our life without any obstacles, it would cripple us. We would not be as strong as what we could have been.

And we could never fly.

ePress Release

5% high risk patients get heart attacks during perioperative period

Patients with underlying heart blockages or those with risk factors are at increased risk for perioperative heart attacks. Perioperative period is the time period extending from when the patient goes into the hospital for surgery until the time he/she is discharged home, 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.

The largest data on the subject come from over 8000 patients in the randomized POISE trial of perioperative beta–blocker therapy, which has shown that at 30 days after the surgery the incidence of heart attack is 5 percent and 71 percent of these occur within 48 hours of surgery. Approximately 65 percent of patients with heart attack are without symptoms.

Therefore, perioperative heart attack is not uncommon and occurs with increasing frequency as the number of identified risk factors increases. Both short– and long–term survival are decreased in patients who have sustained a perioperative heart attack.

Treatment for perioperative heart attack is the same as for any heart attack in the general population. However, anticlotting drugs should be started carefully.

Perioperative heart attack is detected by presence of an elevated heart muscle injury blood test (troponin) and one or more of the following: ischemic (heart pain) symptoms, ECG changes in two contiguous leads, coronary artery intervention (balloon dilatation or stenting), or evidence of heart attack on cardiac echocardiography or autopsy.

All high–risk patients with cardiac troponin both before and after non cardiac surgery should be screened in order to detect a perioperative heart attack. Cardiac troponin levels should be measured for the following patients:

  • Patients with symptoms or ECG changes suggestive of ischemia or heart attack (2 or 3 serial biomarkers).
  • Patients at high cardiac risk (at 6 to 12 hours, and days 1, 2, and 3 after surgery)

A 12–lead ECG in the perioperative period should be done for the following patients:

  • All patients with symptoms of myocardial ischemia
  • All patients with risk factors for perioperative heart attack (baseline and daily for two, and possibly, three days)

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 ispilateral side.

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

Correct answers received from: Dr Rajesh, Dr KN Tripathy, Dr Jayshree, Dr Chandresh, Dr Rama, Dr Srikant, Dr Apurva, Dr Apurva, Dr Shagun, Dr KM Triphulli

Answer for 30th August Mind Teaser: 1.Glyceraldehyde–3–phosphate dehydrogenase.

Correct answers received from: Dr Jayshree, Dr Shreyesh

Send your answer to ijcp12@gmail.com

Self-Assessment-Quiz

 

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Total CPR since 1st November 2012 – 96458 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."

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Health Check Up Camp at Sarvodya Kanya Vidyalaya, 8th May 2014

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 with acid peptic disease was denied any painkiller for his distressing illness.
Reaction: Oh, my God! Why did you not give him nimesulide?
Lesson: Make sure to prescribe nimesulide as it is safe in acid peptic disease.

eMedinewS Humor

Military Medical Clinic

During a visit to a military medical clinic, I was sent to the lab to have blood drawn. The technician there was friendly and mentioned that his mood improved every day because he was due to leave the service in two months. As he applied the tourniquet on my arm, he told me that taking the blood wouldn’t hurt much. Then, noticing my Air Force T–shirt, he asked me what my husband did.

When I replied that he was a recruiter, the technician smiled slyly and said, "This might hurt a little more than I thought."

Quote of the Day

Be rich to yourself… and poor to your friends. Juvenal

Twitter of the Day

Dr KK Aggarwal: Diabetes is a progressive disease http://bit.ly/HTZaj4 #Health
Dr Deepak Chopra: We exist in each others mind where there is no separation in space or time. Physical separation is projected illusion http://bit.ly/DC_Ananda

   
medicolegal update

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  1. Dear Sir, Thanks for the useful information: Regards Dr Kanika

Forthcoming Events

Dear Colleague

Kindly attend ‘Innovations in Cardiology (IIC) Summit 2014’ on 6th September, 11 am – 6 pm at Hotel Oberoi, Gurgaon.

The Organizing Secretary is Dr Rajneesh Kapoor

Highlights of the conference

  • Separate hall for Clinical Cardiology
  • One session on Medicolegal aspects will be taken by me.
  • No registration fee, limited seats

Kindly send your confirmation to rawat.vandana89@gmail.com or sms 9891673085

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