September 14   2015, Monday
Updates in Hypertension and Kidney disease
Dr KK Aggarwal
  • Remote ischemic preconditioning protects against ischemic acute kidney injury: A multicenter trial of 240 patients at high risk for acute kidney injury concluded that among high-risk patients undergoing cardiac surgery, remote ischemic preconditioning compared with noischemic preconditioning significantly reduced the rate of acute kidney injury and use of renal replacement therapy. Fewer patients receiving remote ischemic preconditioning received renal replacement therapy, and remote ischemic preconditioning reduced intensive care unit stay. There was no significant effect of remote ischemic preconditioning on myocardial infarction, stroke, or mortality. (1)
  • Cinacalcet may reduce risk of calcific uremic arteriolopathy in hemodialysis patients: Uncontrolled secondary hyperparathyroidism (sHPT) in patients with ESRD is a risk factor for calcific uremicarteriolopathy (CUA; calciphylaxis). The EVOLVE trial concluded that cinacalcet reduces the incidence of CUA in hemodialysis recipients who have moderate to severe sHPT. Median plasma parathyroid hormone concentrations proximal to the report of CUA were 796 pg/ml and 410 pg/ml in patients randomly assigned to placebo and cinacalcet, respectively. Active use of vitamin K antagonists was recorded in 11 of 24 patients with CUA, nine randomly assigned to placebo, and two to cinacalcet, in contrast to 5%-7% at any one time point in patients in whom CUA was not reported.(2)
  • Patiromer in patients with hyperkalemia and diabetic kidney disease: Among patients with hyperkalemia and diabetic kidney disease, patiromer starting doses of 4.2 to 16.8 g twice daily resulted in statistically significant decreases in serum potassium level after 4 weeks of treatment, lasting through 52 weeks. In those with moderate hyperkalemia, the reduction was 0.87 mEq/L for the 8.4 g twice daily starting-dose group, 0.97 mEq/L for the 12.6 g twice daily starting-dose group, and 0.92 mEq/L for the 16.8 g twice daily starting-dose group (P < .001 for all changes vs baseline by hyperkalemia starting-dose groups within strata).. Over the 52 weeks, hypomagnesemia (7.2%) was the most common treatment-related adverse event; other adverse events included mild to moderate constipation, hypokalemia (<3.5 mEq/L). (3)
  • Chlorthalidone and indapamide for hypertension: A systematic review of 14 randomized trials with 883 patients comparing hydrochlorothiazide with indapamide and chlorthalidone on antihypertensive potency or metabolic effects, INDAP and chlorthalidone lowered systolic blood pressure more than hydrochlorothiazide: -5.1 mmHg (95% confidence interval, -8.7 to -1.6); P=0.004 and -3.6 mmHg (95% confidence interval, -7.3 to 0.0); P=0.052, respectively. The review concluded that these head-to-head comparisons demonstrate that, like chlorthalidone, indapamide is more potent than hydrochlorothiazide at commonly prescribed doses without evidence for greater adverse metabolic effects.(4)
  1. Zarbock A, Schmidt C, Van Aken H, et al; Renal RIPC Investigators. Effect of remote ischemic preconditioning on kidney injury among high-risk patients undergoing cardiac surgery: a randomized clinical trial. JAMA. 2015 Jun 2;313(21):2133-41
  2. Floege J, Kubo Y, Floege A, et al. The Effect of Cinacalcet on Calcific Uremic Arteriolopathy Events in Patients Receiving Hemodialysis: The EVOLVE Trial. Clin J Am Soc Nephrol. 2015 May 7;10(5):800-7.
  3. Bakris GL, Pitt B, Weir MR, et al; AMETHYST-DN Investigators. Effect of Patiromer on Serum Potassium Level in Patients With Hyperkalemia and Diabetic Kidney Disease: The AMETHYST-DN Randomized Clinical Trial. JAMA. 2015 Jul 14;314(2):151-61.
  4. Roush GC, Ernst ME, Kostis JB, et al. Head-to-head comparisons of hydrochlorothiazide with indapamide and chlorthalidone: antihypertensive and metabolic effects. Hypertension. 2015 May;65(5):1041-6.
(Source: Uptodate, Pubmed)
Heart Care Foundation of India (HCFI) trains school children on the importance of healthy eating, hygiene and sanitation
Anesthesiology/Pain Medicine

Injection of botulinum toxin type A through 32-gauge needles is slightly less painful than injection through 30-gauge needles, suggested a randomized trial published online in JAMA Dermatology.


All colorectal cancer patients should undergo tumor testing to see if they carry Lynch syndrome, the most common inherited cause of colorectal cancer, suggests a new guideline published in Gastroenterology.


New research, published in Ophthalmology, suggests that in patients with diabetic retinopathy, peripheral lesions in the retina, which are not detected by traditional eye imaging, correlate very closely with the loss of retinal blood flow called retinal "non-perfusion" caused by loss of small blood vessels or capillaries.

Obstetrics and Gynecology
A new University of New South Wales (UNSW) report suggests that IVF cycles using embryos that have been frozen and thawed are just as successful as fresh embryos.

Physical Fitness

Resistance exercise can increase the number of Vitamin D receptors (VDRs) in the muscle and improve Vitamin D metabolism, suggested a study published in Experimental Physiology.
Cardiology eMedinewS
  • Low heart rate variability may contribute to the risk of post-traumatic stress disorder in military personnel returning from combat deployment, suggests a new study published in JAMA Psychiatry.
  • Among patients scheduled for coronary CT angiography, those with uncomplicated hypertension had higher levels of pericardial-fat volume, coronary artery calcium (CAC) scores, extracoronary calcification, and Gensini scores (an indication of severity of coronary artery disease) than patients with no hypertension, reported an observational study presented at the European Society of Cardiology (ESC) 2015 Congress.
Pediatrics eMedinewS

The Physical Activity and Nutrition in Children Study (PANIC) revealed that low levels of physical activity, weaker physical fitness and higher body fat content are linked to arterial stiffness already in 6-8 year-old children. The findings were published in Scandinavian Journal of Medicine and Science in Sports.

Sleep Disorders

New research sheds light on teenagers' use of social media, suggesting the pressure to be online 24 hours a day disrupts their sleep patterns and may lead to mental health problems, such as anxiety and depression. The findings were presented at The British Psychological Society (BPS) Developmental and Social Psychology Section Annual Conference.
Pulmonary Embolism
Pulmonary embolism (PE) is more common in males than females. The overall incidence of PE is approximately 112 cases per 100,000 and rises with age. Deaths from PE account for approximately 100,000 deaths per year in the United States
Dr KK Spiritual Blog
Science behind regrets

In a US–based study, dying people were asked about their regrets, if any. The top five regrets were:
  1. I wish I had the courage to live a life I wanted to live and not what others expected me to live.
  2. I wish I had worked harder.
  3. I wish I had the courage to express my feelings.
  4. I wish I had stayed in touch with my friends.
  5. I wish I had let myself to be happier.
Regrets are always based on suppression of emotions or non–fulfillment of desires and needs. These need-based desires can be at the level of physical body, mind, intellect, ego or the soul. Therefore, regrets can be at any of these levels.
I did a survey of 15 of my patients and asked them a simple question that if they come to know that they are going to die in next 24 hours, what would be their biggest regret.
Only one of them, a doctor said that she would have no regrets.
Only one person expressed a physical regret and that was from a Yoga expert who said that her regret was not getting married till that day.

Mental regrets were two.
  1. A state trading businessman said, "I wish I could have taken care of my parents."
  2. A homeopathic doctor said, "I wish I could have given more time to my family."
Intellectual regrets were three.
  1. A lawyer said, "I wish I could have become something in life."
  2. A businessman said, "I wish I could have helped more people."
  3. A retired revenue inspector said, "I wish I had married off my younger child."
Egoistic regrets were two.
  1. One fashion designer said, "I wish I could have become a singer."
  2. A housewife said, "I wish I could have become a dietician."
Spiritual regrets were six.
  1. A Consultant Government Liaison officer said, "I wish I could have made my family members happy."
  2. A businessman said, "I wish I could have meditated more."
  3. A Homeopathic doctor said, "I wish I could have spent more time with my family."
  4. A reception executive said, "I wish I could have spent more time with my parents."
  5. An entertainment CEO said, "I wish I could have taken my parents for a pilgrimage."
  6. A fashion designer said, "I wish I could have worked more for the animals."
In a very popular and successful movie, Kal Ho Na Ho, the hero was to die in the next 40 days. When asked to remember the days of his life, he could not remember 20 ecstatic instances in life.
This is what happens with each one of us where we waste all our days and cannot remember more than 50 or even 20 of such instances. If we are given 40 days to live and if we live every day ecstatically, we can get inner happiness. Therefore, we should learn to live in the present instead of having a habit of postponing everything we do.
We should learn to prioritize our work and do difficult work first or else we would be in a state of constant worry till that work is over.
I teach my patients that they should practice confession exercise and one confession is to talk about your regrets and take them as challenge and finish before the next Tuesday. When working, there are three things which are to be remembered – passion, profession and fashion. Profession is at the level of mind, ego and spirit.
We should convert our profession in such a manner that it is fashionable and passionate. Passion means working from the heart and profession means working from mind and intellect and fashion means working the same at the level of ego which is based on show–off.
Scientific awareness on personal hygiene and prevention from obesity among school going children, N P Girls Sr. Sec. School, Gol Market
Make Sure
Situation: A patient with dengue fever developed shock.
Reaction: Oh my God! Why was the blood pressure of 90/80 ignored?
Lesson: Make sure that a pulse pressure of less than 20 is not ignored, it is an impending sign that the patient is going into shock.
Dr Good Dr Bad
Situation: A patient with hypertension had non–responding cough.
Dr. Bad: Take an X–ray.
Dr. Good: Stop ACE inhibitors.
Lesson: The commonest cause of cough in a patient with high blood pressure is the intake of angiotensin-converting enzyme (ACE) inhibitors.

(Copyright IJCP)
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CPR 10
Successfully trained 113241 people since 1st November 2012 in Hands-only CPR 10
Video of the Day
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 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
eIMA News
  • Bariatric surgery is more effective than medical treatment alone for the long-term control of type 2 diabetes in obese patients, finds the first 5-year follow-up study (Francesco Rubino, MD, senior author of the study and chair of bariatric and metabolic surgery at King's College London, United Kingdom.)
  • The proportion of diabetics who underwent coronary artery bypass grafting jumped fivefold over the past 40 years [ August issue of the Journal of Thoracic and Cardiovascular Surgery )
  • More stringent blood pressure targets could save lives and reduce cardiovascular events, according to preliminary results from a large NIH clinical trial, SPRINT, the Systolic Blood Pressure Intervention Trial, the trial randomized 9,361 hypertensive patients 50 years of age or older to what was the standard systolic blood pressure target when the trial began — less than 140 mm Hg — or the more intensive target of less than 120 mm Hg. The lower target reduced rates of a first occurrence of myocardial infarction, acute coronary syndrome, stroke, heart failure, or cardiovascular death by 30% and the risk of death by almost 25%, as compared to the target systolic pressure of less than 140 mm Hg.([Medpage today)
  • A US Food and Drug Administration (FDA) advisory committee has recommended approval of a new extended-release, abuse-deterrent oxycodone for management of pain severe enough to require daily, around-the-clock, long-term opioid treatment and for which alternatives are inadequate.
  • Four clinical and four endoscopic features can predict eosinophilic esophagitis (EoE) with a high degree of accuracy without the need for biopsy, according to gastroenterologists from University of North Carolina, Chapel Hill. The clinical features are younger age, male sex, and presence of dysphagia and food allergies. The endoscopic features are esophageal rings, furrows, and plaques, and lack of a hiatal hernia.
  • In a small, preliminary study reported online September 3 in the Journal of Allergy and Clinical Immunology, infants in households with furry pets were found to share some of the animals' gut bacteria - possibly explaining why early animal exposure may protect against some allergies. The infants' mothers had a history of allergy, so the babies were at increased risk.
  • Coating on endovascular devices is associated with embolization and microvascular occlusion leading to purpura or livedo racemosa. According to Dr. Alina Bridges, of the Department of Dermatology at Mayo Clinic in Rochester, Minnesota, this study was done to make clinicians and pathologists aware of this underrecognized phenomenon of iatrogenic hydrophilic polymer gel embolization that can involve the skin and present with purpura.
  • Vestibular disorders are common and often severe in children congenitally infected with cytomegalovirus (CMV). The study authors recommend that screening and monitoring vestibular disorders should be included in standard assessment and follow-up" of these children.
  • Steroid injections are commonly and increasingly used to treat radiculopathy and spinal stenosis, despite conflicting evidence of efficacy. A systematic review and meta-analysis of published studies published online August 24 in Annals of Internal Medicine however suggests that epidural corticosteroid injections offer limited short-term relief for radiculopathy and no clear benefit for spinal stenosis.
Bioethical issues in medical practice
Privacy and confidentiality

Dr Smita N Deshpande
Head, Dept. of Psychiatry, De-addiction Services
PGIMER-Dr. Ram Manohar Lohia Hospital
New Delhi

A 17-year-old student of a premier school, studying in Class 12, came to see his family doctor alone and in confidence. The doctor had seen this boy grow up and knew him as shy and studious. Although the doctor did not know his family very well he was aware that it was a large joint family where both parents were busy.

The boy told the doctor his story. After his girlfriend broke up with him the boy was disconsolate and considered suicide. His family had no idea about his relationship or breakup. He is unable to study and tells the doctor that his parents are extremely worried about his condition, but forbids the doctor from informing about his condition to his parents.

What should the doctor do?
  • Do nothing and treat the boy as per his usual practice
  • Inform the parents behind the boy’s back
  • Insist that the boy bring his parents when he visits next
  • Inform the police or child protection services?
Do write in with views and your solutions!
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Inspirational Story
Cure for Sorrow

There is an old Chinese tale about a woman whose only son died. In her grief, she went to the holy man and said, "What prayers, what magical incantations do you have to bring my son back to life?"

Instead of sending her away or reasoning with her, he said to her, "Fetch me a mustard seed from a home that has never known sorrow. We will use it to drive the sorrow out of your life." The woman went off at once in search of that magical mustard seed. She came first to a splendid mansion, knocked at the door, and said, "I am looking for a home that has never known sorrow. Is this a place? It is very important to me."

They told her, "You’ve certainly come to the wrong place," and began to describe all the tragic things that recently had befallen them.

The woman said to herself, "Who is better able to help these poor, unfortunate people that I, who have had misfortune of my own?" She stayed to comfort them, and then went in search of a home that had never known sorrow. But wherever she turned, in hovels and in other places, she found one tale after another of sadness and misfortune. She became so involved in ministering to other people’s grief that ultimately she forgot about her quest for the magical mustard seed, never realizing that it had, in fact, driven the sorrow out of her life.
eIMA Quiz
Hoigene's phenomenon is seen due to which of the following components?

a. Benzylpenicilloyl
b. Procaine penicillin
c. Crystalline penicillin
d. Benzathine penicillin

Yesterday’s Mind Teaser: A hybrid teledermatology is

a. Combination of store and forward and mobile teledermatology
b. Combination of store and forward and video conference
c. Combination of online discussion group and author based second opinion teledermatology
d. Combination of online discussion group and video conference

Answer for Yesterday’s Mind Teaser: b. Combination of store and forward and video conference

Correct answers received from: Dr Poonam Chablani, Raghavendra Chakurkar, Raju Kuppusamy, Dr Avtar Krishan

Answer for 12th September Mind Teaser: c. Store-and-forward teledermatology

Correct Answers received from: Dr BR Bhatnagar, Dr Poonam Chablani, Raju Kuppusamy, Dr Shangarpawar, Dr Ridu Kumar Sharma, Dr Avtar Krishan, Daivadheenam Jella.
Quote of the Day
A good book should leave you... slightly exhausted at the end. You live several lives while reading it. William Styron
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Reader Response
Dear Sir, Congratulations for the Vishva Hindi Samman at the 10th Vishva Hindi Samelan in Bhopal. Regards: Dr Neeraj
IMA Videos
News on Maps
eMedinewS Humor
A Following Person

A teacher was sitting at her desk grading papers when her first–grade class came back from lunch. Alice informed the teacher, "Paul has to go to the principal’s office."

"I wonder why," the teacher mused.

"Because he’s a following person," Alice replied.

"A what?" the teacher asked.

"It came over the loudspeaker: ‘The following persons are to go to the office.’"
Rabies News (Dr A K Gupta)
Should modern rabies vaccines meant for use in man be given to animals?

It is advisable to use human vaccines for human use and use the veterinary vaccines for animals.
Wellness Blog
Don’t start if you do not drink; if you cannot stop, limit your intake
  • The definition of a standard drink differs in countries: US = 14–15 gm alcohol equivalent to 12 oz beer, 5 oz wine and 1.5 oz 80 proof liquor; UK 8 gm alcohol, Japan 19.75 gm alcohol and India 10 gm alcohol
  • A standard drink usually means a US drink.
  • Alcohol contents: Beer 5%; Malt liquor 7%; Table wine 12%; Fortified wine (sherry, port) 17%; Cordial liquor (aperitif) 24%; Brandy (single jigger) 40% and 80 proof gin, Vodka, whisky 40%
  • 10 ml of alcohol (hard liquor) = 0.8 gm of alcohol; 1 oz = 30 ml; 12 oz of beer = 360 ml of beer (360×5% = 18 ml of alcohol = 14.4 gm of alcohol); 18 oz of beer = 8 to 9 oz of malt liquor = 5 oz of table wine = 3–4 oz of 45 wine = 2–3 oz of cordial liquor=1.5 oz of brandy=1.5 oz hard liquor
  • Binge drinking means 4 or more drinks at one time (women) or 5 or more at one time (men)
  • Heavy drinking means more than 7 drinks per week or 3 drinks per occasion (women) or more than 14 drinks per week or 4 drinks per occasion (men).
  • Moderate drinking means less than 2 drinks per day (women) and less than 3 drinks per day (men) and for people aged more than 65, less than two drinks per day
  • Safe limits: No level of alcohol compensation can be 100% safe for some people.
  • Contraindications: Pregnancy, present or strong family history of alcoholism, previous paralysis because of brain hemorrhage, liver disease, pancreas disease, running potentially dangerous equipment or machinery
  • Limit alcohol in acute gastritis, esophagitis, strong family history of breast cancer and pre cancerous GI lesions.
  • Ideal dose of alcohol = 6 gm per day
  • 10–15gm of ethanol is found in one glass of wine, one can or bottle of beer or one mixed drink.
  • One should not take more than two drinks (men) and one drink daily (women).
  • Men under the age of 45 may experience more harm than benefit from alcohol consumption.
  • Alcohol benefits for the heart are only in 45+ people.
Press Release
From Law-makers to lifesavers

Heart Care Foundation of India (HCFI) trains 300 people in the Delhi High Court in the life-saving technique of Hands only CPR 10 for revival after sudden cardiac arrest

Sudden cardiac arrest is the number one killer in India taking an estimated 25 lakh lives annually. It can happen to anyone at anytime with no evident warning signs. However what most people remain unaware of is that a sudden cardiac arrest victim can be brought back to life within 10 minutes of their death through the life-saving technique of hands only CPR 10. Keeping this in mind, HCFI took up the task of safe-guarding the lives of our indispensible law makers who with the stress of their daily lives are at high risk of a sudden cardiac arrest. In a one of its kind initiative, over 300 personnel including, lawyers and administration staff of the Delhi High Court were trained in Hands Only CPR 10.

According to the data revealed by the Delhi Economical Survey, 150 to 250 deaths happen in the city every single day. Out of these 25 – 45 deaths occur suddenly. With 60% of the people dying before they reach the hospital and the large number of sudden cardiac arrest victims; it is essential that each one of us must know the essential life-saving technique of hands only CPR – 10. A simple and easy to learn technique, Hands only CPR 10 does not require any mouth-to-mouth resuscitation and can be performed by anyone.

Speaking about the initiative, Padma Shri Awardee, Dr KK Aggarwal, President HCFI& Hony. Sec General IMA said, “With the increasing lifestyle pressures in today’s day and age the incidence of sudden cardiac arrest is on the rise. An increasing number of people living in urban households and the younger generation are becoming victims of sudden cardiac death. While prevention is key and awareness needs to be generated about how lifestyle modifications are a must for healthy heart health, what most people are not aware of is that death is reversible within the first ten mintues of a sudden cardiac arrest. Given this fact, knowing the easy to learn and extremely effective technique of hands only CPR 10 is a must for all. We are extremely thankful to the High Court Bar Association for letting us conduct this training program today.”

“The Heart Care Foundation of India Hands- Only CPR 10 mantra is: Within 10 minutes of death (earlier the better), for a minimum of 10 minutes (adults 25 minutes and children 35 minutes), compress the center of the chest of the deceased person continuously and effectively with a speed of 10×10 = 100 per minute”he added

Heart Care Foundation of India, a non-profit organization working towards raising health awareness in the country has been training people in this life-saving technique for over two years now. It has successfully trained over 1,20,000 people till now in Delhi NCR itself and holds three Limca Book of World Records for the maximum number of people trained at a time, at the same place and in an hour. The NGO is in the process of training 100% of the Delhi Police PCR van staff in association the Indian Medical Association, Delhi Red Cross Society and Delhi Police by the end of this month.

A sudden cardiac arrest occurs when the electrical conducting system of the heart fails and the heartbeats irregularly and very fast (more than 1000 times, technically called as ventricular fibrillation). Soon after the heart suddenly stops beating and the blood flow to the brain stops. As a result, the person becomes unconscious and stops normal breathing. A cardiac arrest is not the same as a heart attack, but it may be caused by a heart attack. In most cases, sudden cardiac arrest may be reversible in the first 10 minutes. This is possible because the brain remains alive during this period when the heart and respiration have stopped, a situation called clinical death.

Continuous compression only CPR compresses the heart between the sternum and the backbone and builds up the pressure that keeps the oxygenated blood flowing to the brain and keeps the person alive until a defibrillator becomes available or expert medical help arrives. It is important to act quickly for every minute lost reduces the chances of revival by 10%. So, if you wait 5 minutes, the chances of surviving are 50% less. To know more or to organize a training camp in your locality, please call the NGO’s helpline number 9958771177.