13th November 2014, Thursday

Dr K K AggarwalPadma Shri, Dr B C Roy National Awardee and National Science Communication Awardee. Limca Book of Record Holder (CPR). Gold Medalist

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

Non obstructive heart blockages not benign

In a retrospective study of patients undergoing elective coronary angiography, non-obstructive coronary artery disease (heart blockages), compared with no apparent coronary artery disease (no blockages), was associated with a significantly greater 1-year risk of heart attack and all-cause mortality.

After risk adjustment, there was no significant association between 1- or 2-vessel non-obstructive coronary artery disease (blockages in one or two arteries) and mortality, but there were significant associations with mortality for 3-vessel non-obstructive coronary artery disease (blockages in all three arteries).

Veterans with evidence of non-obstructive CAD on elective coronary angiography had a 2- to 4.5-fold greater risk for heart attack compared with those with no evidence of blockages and 1-year heart attack risk was found to increase progressively by the extent of blockages, rather than increasing abruptly when blockages became obstructive. The results of this study are published in Nov. 5 issue of JAMA.

Never tell your patients “that your coronaries are fine and they have nothing to worry about." Instead, one should say “There is evidence of atherosclerosis and while there is no need to panic, we need to address it.”

Remember there is nothing like “mild coronary artery disease." Up to 1 in 4 angiograms show minimal plaque or blockages.

Non-obstructive blockages mean presence of atherosclerotic plaque revealed during coronary angioplasty or angiography that does not appear to obstruct blood flow or result in angina symptoms.

These non-obstructive lesions occur in between 10% and 25% of patients undergoing elective angiography, and their presence has historically been characterized as "insignificant" or "no significant blockages in the medical literature even though multiple studies have shown plaque ruptures leading to heart attack commonly come from non-obstructive plaques.

News Around The Globe

  • Aspirin, already touted for its cardiovascular and anti-inflammatory prowess, seems to be flexing its muscles against liver fibrosis, particularly in people at risk for chronic liver disease. "Clinical equipoise is emerging that may justify prospective randomized trials of aspirin and, potentially, other antiplatelet drugs such as antifibrotic agents," Gordon Jiang, MD, a gastroenterology fellow at the Beth Israel Deaconess Medical Center in Boston, and colleagues state in a scientific poster here at The Liver Meeting 2014.
  • Nurses and physicians in at least one hospital owned by Intermountain Healthcare, a healthcare system based in Salt Lake City, Utah, are wearing specially designed smart watches that show whether they have washed their hands before they walk into patient rooms. The watch detects motion and it knows when a wearer goes from room to room.
  • The introduction of pneumococcal conjugate vaccine (PCV) was linked to a decrease in hospitalizations for sinusitis among children younger than 2 years and pneumonia among children younger than 5 years in a retrospective population-based study in Sweden. The work was published online November 10 in the journal Pediatrics.
  • Physicians have been slow to stop using tight glycemic control in intensive care units (ICUs), despite a 5-year-old randomized controlled trial showing it is a risky practice. The approach first gained momentum after the Leuven 1 study suggested an improvement in tightly controlled surgical patients (N Engl J Med. 2001;345:1359-1367). But further investigation in the NICE-SUGAR study demonstrated increased mortality (N Engl J Med. 2009;360:1283-1297).
  • A study conducted in Taiwan, China, Chung and colleagues identified 48 patients with severe allopurinol-related skin reactions and compared their clinical and genetic features with those of 138 patients who tolerated allopurinol. Of the patients with skin reactions, 26 had Stevens-Johnson syndrome (SJS), and 22 had drug rash with eosinophilia and systemic symptoms (DRESS). Ten of these patients died, all of whom had SJS. The study showed that women were more likely than men to have severe skin reactions. Moreover, the presence of the HLA B*58:01 genotype was strongly associated with severe skin reactions. Renal insufficiency (defined as a glomerular filtration rate of <30 mL/minute) was also associated with an increased risk for severe skin reactions. Furthermore, patients with severe skin reactions were found to have elevated levels of the allopurinol metabolite oxypurinol as well as elevated granulysin levels. (Medscape)
  • Green tea extract may modestly lower SUA level and decreases uric acid clearance. Green tea extract also significantly elevated serum antioxidant capacity with a positive dosage effect. The effect of GTE on SUA in healthy individuals was short term (J Clin Rheumatol. 2014;20(6):310-313).
  • A US Food and Drug Administration (FDA) advisory committee voted 8 to 3 to recommend marketing approval of soluble ferric pyrophosphate (SFP; Triferic, Rockland Medical) as a parenteral iron agent to treat iron loss or iron deficiency and to maintain hemoglobin in adults with hemodialysis-dependent chronic kidney disease.
  • Coffee intake is inversely associated with advanced fibrosis among NAFLD patients with lower HOMA-IR (Liver International. 2014;34(8):1250-1258).

IMA News

NDTV: The Supreme Court has declined to declare strikes by doctors illegal but said it hoped that doctors, being life savers, would not resort to strike. The court was hearing a petition by an NGO, People for Better Treatment (PBT), opposing a doctors' strike back in 2012, and seeking that it be declared illegal.

The NGO's lawyer, MN Krishnamani, argued that the strike violates provisions in the Medical Council India and MCI should take action against striking doctors. Chief Justice of India HL Dattu, who was heading the bench, said, "Lawyers also go on strike. There is no point in issuing directions. We should not pass any order which can't be implemented."

Dismissing the PIL, the court, in its order, said, "The relief sought in this PIL is commendable but difficult to grant. Therefore we express our desire that doctors, being saviours of life, should not resort to illegal strikes."

The PIL was filed in 2012, when a nationwide strike was called by the Indian Medical Association, which was protesting against certain reforms initiated by the Central government in the field of medicine. At the time too, the Supreme Court had declined to interfere in the matter.

(Free Press Journal: The Supreme Court on Tuesday refused to pass an order restraining doctors to go on strike, but hoped that they do not resort to such action which can jeopardise life of patients. “Being God’s agent, they should not go on strike. We can express our desire. Beyond that, positive directions cannot be issued particularly when we know it would be difficult to implement our order,” a bench headed by Chief Justice H L Dattu said. The court was hearing a PIL filed by NGO People for Better Treatment pleading that doctors have no ethical, moral or legal right to deny treatment to the ailing citizens by going on strike. Agreeing with the petitioner, the bench, however, said that it cannot pass direction to restrain doctors from going on strike. See more at: http://freepressjournal.in/sc-refuses-to-declare-doctors-strike-illegal/#sthash.5yI1ZlZY.dpuf)

Dr KK Spiritual Blog

The Buddha Description of a Disease: Desire, Hatred and Ignorance

According to the Buddhism, three negative emotions cause a disease and they are “ignorance, hatred and desire”. According to the Buddhism philosophy, physical sicknesses are classified into three main types.

  • Disorders of the desire (Ayurvedic equivalent Vata Imbalance): These are disharmony of the wind or energy. The seed of these disorders are located in the lower part of the body. It has cold preferences and affected by mental desires. A person suffers from the disorders of movement functions.
  • Disorders of the hatred (Ayurveda equivalent Pitta imbalance): It is due to disharmony of the bile. The seed of these disorders is centered in the middle and upper part of the body and is caused by the mental emotion hatred. In Ayurveda text, it is equivalent to “Pitta” disorder. The person suffers from metabolic and digestive abnormalities.
  • Disorders of the ignorance (Ayurveda equivalent Kapha imbalance): It is due to the disharmony of phlegm, which is generally centered in the chest or in the head and is cold in nature. It is caused by the mental emotion ignorance.

Desire, hatred and ignorance are the main negativities mentioned in Buddha philosophy. They are all produced in the mind. Once produced, they behave like a slow poison. The Udanavarga once said, “From iron appears rust, and rust eats the iron”, “Likewise, the careless actions (karma) that we perform, lead us to hellish lives.

According to the other scriptures six afflictions are most troublesome, ignorance, hatred, desire, miserliness, jealousy and arrogance. Patience is the most potent virtue a person can acquire. According to the Shanti Deva, “There is no evil like hatred, and there is no marriage like patience. Therefore, dedicate your life to the practice of patience.”

Bhagvad Gita mentions the enemies as Kama, Krodha, Lobh, Moh and Ahankar and out of the Kama Lobh and Ahankar as the three gate ways to hell.

Inspirational Story

My Mom Only Had One Eye

My mom only had one eye. I hated her… She was such an embarrassment. She cooked for students and teachers to support the family. There was this one day during elementary school where my mom came to say hello to me. I was so embarrassed.

How could she do this to me? I ignored her, threw her a hateful look and ran out. The next day at school one of my classmates said, ‘EEEE, your mom only has one eye!’ I wanted to bury myself. I also wanted my mom to just disappear. I confronted her that day and said, ‘If you’re only going to make me a laughing stock, why don’t you just die?’

My mom did not respond… I didn’t even stop to think for a second about what I had said, because I was full of anger. I was oblivious to her feelings. I wanted out of that house, and have nothing to do with her. So I studied real hard, got a chance to go abroad to study.

Then, I got married. I bought a house of my own. I had kids of my own. I was happy with my life, my kids and the comforts. Then one day, my Mother came to visit me. She hadn’t seen me in years and she didn’t even meet her grandchildren.

When she stood by the door, my children laughed at her, and I yelled at her for coming over uninvited. I screamed at her, ‘How dare you come to my house and scare my children!’ GET OUT OF HERE! NOW!!!’

And to this, my mother quietly answered, ‘Oh, I’m so sorry. I may have gotten the wrong address,’ and she disappeared out of sight. One day, a letter regarding a school reunion came to my house. So I lied to my wife that I was going on a business trip. After the reunion, I went to the old shack just out of curiosity.

My neighbors said that she died. I did not shed a single tear. They handed me a letter that she had wanted me to have.

‘My dearest son,

I think of you all the time. I’m sorry that I came to your house and scared your children. I was so glad when I heard you were coming for the reunion. But I may not be able to even get out of bed to see you. I’m sorry that I was a constant embarrassment to you when you were growing up.

You see……..when you were very little, you got into an accident, and lost your eye. As a mother, I couldn’t stand watching you having to grow up with one eye. So I gave you mine. I was so proud of my son who was seeing a whole new world for me, in my place, with that eye.

With all my love to you,

Your mother’

Rabies News (Dr A K Gupta)

What precautions should be taken while vaccinating by the ID route?

  • The ID injections must be administered by staff trained in this technique.
  • The Vaccine vials must be stored at +2°C to + 8°C after reconstitution.
  • The total content should be used as soon as possible, but at least within 8 hours.
  • The 0.1 ml. ID administration of cell–culture vaccine should create a wheal of at least 5 mm diameter with "peau de orange" appearance.
  • If ID dose is given subcutaneously then there is a possibility of poor immune response due to low antigen load. This may be life–threatening.

Cardiology eMedinewS

  • In a single-center study, only 17% of hospitalized nonsmokers with coronary heart disease (CHD) were asked about exposure to tobacco smoke, and only 1.4% remembered receiving any advice about this modifiable risk factor, reported researchers. The study thus suggests that clinicians are missing an important teachable moment. The report is published online in JAMA Internal Medicine.
  • Elevated blood glucose in patients presenting to the emergency department (ED) with chest pain is independently associated with an increased risk of cardiac events in the next 30 days, suggests new research from Australia and New Zealand. The findings are published online in the Emergency Medicine Journal.

Pediatrics eMedinewS

  • According to a study presented at the American College of Allergy, Asthma and Immunology (ACAAI) Annual Scientific Meeting, increased levels of asthma and allergic rhinitis (hay fever) were found in children in India who were exposed to more indoor pollutants.
  • Overweight or obese asthmatic children may mistakenly be attributing exertional dyspnea and esophageal reflux symptoms to their asthma, leading to overuse of rescue medication, suggests a new study published online in the Journal of Allergy and Clinical Immunology.

Quote of the Day

  • We are accountable only to ourselves for what happens to us in our lives. ~ Mildred Newman

Wellness Blog

How to answer and call on mobiles

  • Say Hello and not “yes” when calling or answering calls. It’s hard and rude.
  • Always put the phone gently if you need to put the telephone down during the conversation. Also hang up gently. Never slam the phone. The person at the other end may still be on the phone and sudden bang can be hurtful as well as rude.
  • Make sure the number is correct so as not to risk disturbing strangers.
  • Make your call as brief as possible, especially with busy people.
  • When calling people who do not recognize your voice, introduce yourself.
  • Time your calls. Do not interfere with the work schedule of others
  • Make business calls well before the close of the office hours.
  • After dialing a wrong number, apologize.
  • When the number you are calling is not answered quickly, wait long enough for someone to put aside what he or she is doing. It is very annoying to have been disturbed just to pick up the telephone and find the caller has hung up.
  • Never take a personal mobile call during a business meeting.
  • Never talk in public places
  • Don't talk emotional in public. 13. Don't use loud and annoying ring tones
  • Never make calls while shopping, banking or waiting in line.
  • Keep all talks brief and to the point.
  • Use an earpiece in high-traffic or noisy locations.
  • Demand "quiet zones" and "phone-free areas" at work and in public venues.
  • Never call people at odd hours. If you sleep at 2am does not mean, others also follow the same.
  • When calling on mobile always ask if the other person is free to talk.
  • Learn to text when not in emergency.
emedipicstoday emedipics

21st Perfect Health Mela 17th October 2014



press release

Obesity reduces life expectancy

video of day

Other Blogs

Video Library

Sameer Malik Heart Care Foundation Fund

The Sameer Malik Heart Care Foundation Fund is a one of its kind initiative by the Heart Care Foundation of India instituted in memory of Sameer Malik to ensure that no person dies of a heart disease because they cannot afford treatment. Any person can apply for the financial and technical assistance provided by the fund by calling on its helpline number +91 9958771177 or by filling the online form.

Madan Singh, SM Heart Care Foundation Fund, Post CAG

Kishan, SM Heart Care Foundation Fund, Post CHD Repair

Deepak, SM Heart Care Foundation Fund, CHD TOF

Total CPR since 1st November 2012 – 101090 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

cpr 10 mantra
VIP’s on CPR 10 Mantra Video

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


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 :


Dr Good and Dr Bad

Situation: A patient came with classical benign postural vertigo.
Dr Bad: Take these drugs
Dr Good: Do Epley maneuver.
Lesson: Epley maneuver in most situations can cure benign postural vertigo.

Make Sure

Situation: A patient with acute heart attack died on the way to the hospital.
Reaction: Oh my God! Why was the patient not accompanied by the doctor?
Lesson: Make sure that all heart attack patients are accompanied by the doctor to the hospital so that chest compression (CPR) can be given if the heart stops on the way.

eMedinewS Humor


Imagine there is a bank that credits your account with morning with Rs 86400. It carries over no balance from day to day. Every evening deletes whatever part of the balance you failed to use during the day. What would you do?

Draw out every rupee, of course!

Each of us has such a bank, its name is TIME.

Every morning, it credits you with 86400 seconds. Every night it writes off, as lost, whatever of this you have failed to invest to good purpose. It carries over no balance. It allows no over draft. Each day it opens a new account for you. Each night it burns the remains of the day. If you fail to use the day's deposits, the loss is yours. There is no going back. There is no drawing against "tomorrow".

You must live in the present on today's deposits. Invest it so as to get from it the utmost in health, happiness, and success!

The clock is ticking, make the most of today.

Twitter of the Day

Dr KK Aggarwal: Stress can increase your Blood sugar
Dr Deepak Chopra: How do you know that a dream is your true calling and not an indulgence of the ego mind?

ePress Release

Beware of cardiovascular diseases this winter

Indians run a 35% higher risk of suffering from heart disease in the winters than the summers -

Research indicates a major disparity in the demand and supply of pacemaker implants in the country

Winter often brings along with it common ailments like the flu, coughs, depression and colds. Add to these ailments a more deadly one: heart attacks. Research proves that more fatal heart attacks, heart rhythm disorders and strokes occur during the winter than at other times of the year. The reason for this is the increase of alpha activity in our body’s receptors leading to a 5mm Hg higher blood pressure level than in the summer months. In addition to this reduction in the daily activity and exercise level is also directly linked to increased chances of heart disease.

It is estimated that the incidence of heart disease goes up by about 35% in cold weather with the maximum number of heart attacks occurring early in the morning. Worsening of heart failure and occurrence of heart electrical blockages are also more in this time of the year. All this leads to an increase in the number of stents, bypasses and pacemaker implants. Such an increase is not seen in diabetics or those who are on aspirin prophylaxis.

Pacemakers are medical devices that use electrical impulses, delivered by electrodes contracting the heart muscles, to regulate the beating of the heart. They are the most common line of treatment for most heart rhythm disorders linked to low heart rate, one of the growing epidemics of the Indian society. However, there exists a great disparity in the requirement for pacemakers and the number implanted each year.

According a white book recently released by the Asia Pacific Heart Rhythm Society, in India in the year 2013 only 2 pacemakers were implanted per week per center (India has a total of 888 centers which are equipped to implant pacemakers). In Japan on the other hand over 9 pacemakers were implanted per week per center in the same year. This indicates the gap in the demand and supply.

Speaking on the topic, Padma Shri Awardee, President of the Heart Care Foundation of India and Sr. National VP and Secretary General Elect of the IMA, Dr. K K Aggarwal said,” The primary purpose of a pacemaker is to maintain an adequate heart rate, either because the heart's natural pacemaker is not fast enough, or there is a block in the heart's electrical conduction system. The number of patients in need of a pacemaker is growing by the year. It is estimated that over 1.5 lakh pacemakers are needed in India in a year however only 36,322 are actually implanted. Heart blockages may be asymptomatic or reversible. In such cases permanent pacemaker implantation is not required”.

“Recently our Prime Minister Mr. Narendra Modi started a campaign called Make in India. At the moment there are only a few local companies, which make pacemakers however, their market share is negligible. Indian companies must come forward and manufacture low cost, life-saving technology in the country”, he added.

Discussing the technological developments in the management of Heart Rhythm disorders, Director Cardiology at Saket City Hospital and Chairman, Organizing Committee 7th APHRS Scientific Session 2014, Dr Mohan Nair said, “Leadless pacemakers are the latest innovations in the field and are awaiting launch in the country. Unlike conventional pacemakers, leadless pacemakers are placed directly in the heart without the need for a surgical pocket and placing leads. The device is much smaller and consists of a battery and steroid eluting electrodes as sensors”.

“A pacemaker may need to be changed after 5 to 10 years depending on the usage and make. Once a pacemaker is implanted usually an MRI could not be done. However MRI compatible pacemakers are now available. All patients undergoing a pacemaker surgery should ask their doctors to talk about this issue,” he added.

The APHRS White Book further discloses that in India:

  • The implantation of permanent pacemakers increased from 27,518 in 2012 to 36,322 in 2013 (32% increase)
  • The most common indication for pacemaker implantation all over the world is sinus node dysfunction followed by AV Block. But in India AV block forms 65% of the indications as against sinus node dysfunctions which is an indication in only 25% cases.
  • Globally single chamber pacemakers are used only in chronic Atrial Fibrillation with low heart rate or in very elderly patients. In all other situations, dual chamber pacemakers are used. However in India out of 36322, 14477 patients still get single chamber pacemakers. With single chamber pacemakers, one may not get a good quality of life in the long run.
  • Out of 100 pacemakers implanted, 86% are new implants and 14% are replacement implants (old pacemaker being replaced).
  • There are only 0.7 centers which implant pacemakers per million population in the country.
  • In India 70% people pay for their own treatment including the cost of pacemakers. The government and the insurance sector both public and private, reimburse only 10% and 20% respectively One essential point to keep in mind in India is that after the death of a person, a pacemaker needs to be removed before a patient is put on fire as otherwise it runs the risk of exploding. Many centers globally believe in re-implanting extracted pacemakers however there are no consensus guidelines on this issue in India.

eMedi Quiz

In a patient with a tumor in superior mediastinum compressing the superior vena cava, all the following veins would serve as alternate pathways for the blood to return to the right atrium, except:

1.Lateral thoracic vein.
2.Internal thoracic vein.
3.Hemiazygos vein.
4.Vertebral venous plexus.

Yesterday’s Mind Teaser: Brocq's phenomenon is analogous to which clinical sign in psoriasis?

a. Olfleck's phenomenon
b. Auspitz sign
c. Salmon patch
d. Candle wax scales

Answer for yesterday’s Mind Teaser: b. Auspitz sigh

Correct answers received from: Dr Jainendra Upadhyay, Dr Avtar Krishan, Daivadheenam Jella.

Answer for 11th November Mind Teaser: c.5

Correct answers received from: Dr Jainendra Upadhyay, Dr Avtar Krishan.

Send your answer to email

medicolegal update

(Dr. K K Aggarwal, Padma Shri and Dr. B C Roy National Awardee; Editor eMedinewS and President Heart Care Foundation of India)

(Contributed by Dr MC Gupta, Advocate)

Q: I had a query and then I saw you who knows about the law. Would you mind telling me few rules about govt jobs? I have applied for job in medical college. But I am confused if I can resign from it easily if I don’t feel like continuing with it. Few of my colleagues have told me that it’s tough to get into govt job and even tougher to get out of it as the Govt does not let you go even if you want to resign. Can you tell me how far this is true?


Rules about government jobs are as follows:

  • Just as "God helps those who help themselves", government tends to give jobs to those who can write good English.
  • Getting in is difficult. Many people would gain by preventing the entry. Getting out is easy. Many people would gain by facilitating the exit.
  • Bonded labour is unconstitutional. Nobody can be made to work forcibly. I have resigned five jobs, including that of an army officer.
  • It is better (and more sensible) to get a job and then resign rather than not get a job because it would be difficult to resign. Of course, the more sensible thing would be to seek a job that one likes and to not think of resigning even before getting the job.
medicolegal update
  1. I will like to express my views that mixing allopathy with homeopathy or Ayurvedic is totally wrong.Even fundamentals of all these three are different. About 70 years back Govt. Had done the experiment when they started a course of B.M.B.S but soon they realised their mistake and withdrew the scheme. Allopaths now oppose it with stiffness. Dr.B.R.Bhatnagar Andheri East Mumbai

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