20th December 2014, Saturday

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

Jail for doctor

Six infants were charred to death in incubators while four were critically injured when a fire broke out due to an electric short-circuit at the photo-therapy unit of Rajindra Hospital, Patiala, in January 2009.

Additional District and Sessions Judge Rajinder Aggarwal in Patiala recently awarded two-year imprisonment to Dr K K Locham, head of the Pediatrics Department at Government Rajindra Hospital, nurse Reeta and Class IV employee Satya in connection with the death of six infants at the hospital in 2009. A fine of Rs 5,000 each was also imposed on the accused.

Ten newborns lay unattended in the incubators when the fire broke out. Within hours, the incubators and the photo-therapy unit were reduced to ashes. Attendants of some patients somehow managed to save four children.

Dr Locham was accused of overlooking the facts that the infants had been kept in “poor-quality” incubators and room heaters were being used instead of the central heating system.

The court had charged them under Section 304-A (culpable homicide not amounting to murder) of the IPC. "Causing death by negligence.—Whoever causes the death of any person by doing any rash or negligent act not amounting to culpable homicide, shall be punished with imprisonment of either description for a term which may extend to two years, or with fine, or with both".

In another case in US two pharmacists were charged with second degree murder in fungal meningitis outbreak. The pharmacists at the notorious New England Compounding Center were charged for the deaths of 25 individuals who received non-sterile steroid pain injections in 2012 and 2013 by the federal district court in Boston. The pain medicine preservative-free methyl-prednisolone acetate harbored fungal meningitis. Both the pharmacists, knew they were producing their medications in an unsafe manner and in unsanitary conditions.

The second-degree murder charges are framed as racketeering acts. Prosecutors generally do not need to prove that someone charged with second-degree murder specifically intended to kill someone, only that he or she acted with extreme indifference to human life. If convicted they could be sentenced to life in prison.

The charge framed were

  • using expired and expiring ingredients to compound the steroid injections and falsifying expiration dates on documents,
  • autoclaving drugs for less than the 20 minutes needed for sterilization,
  • failing to properly test drugs for sterility,
  • failing to recall tainted drugs when microbial growth was later detected,
  • falsifying drug labels to conceal how expired or untested drug solution lots were mixed with other lots, and
  • failing to properly clean and disinfect the "clean rooms" where the steroid injections were manufactured. Cleaning logs were falsified to state otherwise, said prosecutors.

IMA Comments: A similar charges should be framed amongst all in India who end up with substandard spurious drugs or provide poor infrastructure for health care.

  1. MCI ethics regulations 1.7 Exposure of Unethical Conduct: A Physician should expose, without fear or favour, incompetent or corrupt, dishonest or unethical conduct on the part of members of the profession. This clause also covers that it is our duty to inform the MS of our hospital about any sub standard care or equipments being supplied.
  2. If one works in an atmosphere where he knows that providing treatment can end up with complications one can be tried under 304A if death is the result. For example if one knows before the surgery that the OT is infected or the said investigations, life saving equipments or drugs are not available. Another example is admitting a patient who you know may end up with a ventilator and the facility for the same is not available in the said health care setting.
  3. Recently MCI ethic committee in one of the cases observed and gave warning to the cardiologist when he said the complications occurred because the hospital resident care was not up to the mark. The committee observed that if he knew that the services were not upto the mark than why did he admitted anon emergency case in that facility.
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45th Indian Society of Nephrology Conference, Kolkata, 18th to 21st December 2014

Dr Tiny Nair

An Interview with: Dr DS Rana, Awarded Padma Shri by the Hon'ble President of India New Delhi

Q. 1: Why it is important to address iron deficiency early in patients with CKD?
Ans. 1: Anemia in CKD is known to cause fatigue, cognitive impairment, sleep disturbance, pain, anxiety, depression. Iron is a key functional component of hemoglobin, myoglobin and a large number of enzymes involved in cellular receptors, immune mechanism.
Q. 2: It has been observed that clinical trials on the outcome of anemia correction with new or different endpoints are gaining attention. What could be the rationale behind such trial designs?
Ans. 2: The rationale behind recent trials is to assess the outcome of anemia correction based on targeting higher ferritin levels with IV iron without use of erythropoietin.
Q. 3: In brief, could you highlight the background and rationale of the FIND-CKD study?
Ans. 3: FIND-CKD trial was a 56-week open-label, multicentric, prospective and randomized study of 626 patients with nondialysis-dependent CKD, anemia and iron deficiency not receiving erythropoietin-stimulating agent (ESA). Patients were randomized (1:1:2) to IV ferric carboxymaltose (FCM), targeting a higher (400-600 µg/L) or lower (100-200 µg/L) ferritin or oral iron therapy.
Q. 4: There seems to be an uniqueness in the design of the FIND-CKD study. What’s your opinion on the same?
Ans. 4: FIND-CKD trial is unique since it compares both high- and low-ferritin target groups using IV iron and oral iron, irrespective of use of ESA.
Q. 5: What was the primary endpoint of FIND-CKD?
Ans. 5: Primary endpoint of the study was the time to initiation of other methods of anemia management or hemoglobin triggers of two consecutive values <10 g/dL during Weeks 8-52, after using IV FCM or oral iron.
Q. 6: What was the outcome of the study?
Ans. 6: Primary endpoint was achieved in 23.5% of patients in high-ferritin FCM group; 32.5% of low-ferritin FCM group and 31.8% of oral iron group. The increase in hemoglobin was greater in high-ferritin FCM group versus oral iron group. Rates of adverse events and serious adverse events were similar in all groups.
Q. 7: What is the conclusion of the study?
Ans. 7: Conclusion of the study: Compared with oral iron, IV FCM targeting a high-ferritin of 400-600 mg/L reached Hb level quickly and maintained it. This also delayed and/or reduced the need for other methods of anemia management including ESA. Also, no difference in cardiovascular infections events or renal toxicity was observed.
Q. 8: What was the IV iron vs oral iron tolerability profile observed in FIND-CKD study?
Ans. 8: The tolerability profile between and IV iron was comparable. Iron was well-tolerated in each group. However, patients who were intolerant to oral iron were excluded from this study.
Q. 9: Do you think the findings of FIND-CKD should be considered by the writing committee of various guidelines to amend their existing recommendation in view of providing better treatment option?
Ans. 9: This trial has to be further evaluated with skepticism. The major limitations in this trial were that there was no placebo in this study. Thus comparison of efficacy and safety between the intervention and no treatment could not be done. The design of this trial was open label. Double blinding design would have been more desirable, if ethically acceptable, since it would be unethical to give placebo IV iron injections. Also, the patients in oral iron group were higher in number, better preserved and those intolerant to oral iron were excluded. This is averse to patient profile in clinical practice. Hence, this trial needs further modification before it could be considered by writing committees of guidelines.
Q. 10: From Trial prospective what should be the next new endpoint you would personally look forward?
Ans. 10: Next new endpoint should be assessing hard endpoints such as cardiovascular morbidity/mortality outcomes, quality-of-life outcomes after correcting anemia with IV iron/ oral iron versus ESA alone for different ferritin target levels.

Dr Tiny Nair

An Interview with: Dr. K. C. Gurudev, Bangalore

Q.1. Why did the KDIGO guidelines not recommend initiation of statin treatment in dialysis patients?
Three large trials1-3 have failed to show a conclusive benefit of statin treatment (alone or in combination) among prevalent dialysis patients—raising the hypothesis that inadequate statistical power was responsible for the apparent lack of benefit. Nonetheless, it is clear that even if statins do prevent cardiovascular events in prevalent dialysis patients, the magnitude of any relative reduction in risk is substantially smaller than in earlier stages of CKD. Therefore, in the judgment of the Work Group, initiation of statin treatment is not recommended for most prevalent hemodialysis patients. However, patients might decide to receive statin treatment if they are interested in a relatively uncertain and small reduction in cardiovascular events.

  1. Baigent C, Landray MJ, Reith C, et al. The effects of lowering LDL cholesterol with simvastatin plus ezetimibe in patients with chronic kidney disease (Study of Heart and Renal Protection): a randomised placebo-controlled trial. Lancet 2011;377:2181-92.
  2. Wanner C, Krane V, Marz W, et al. Atorvastatin in patients with type 2 diabetes mellitus undergoing hemodialysis. N Engl J Med 2005;353:238-48.
  3. Fellstrom BC, Jardine AG, Schmieder RE, et al. Rosuvastatin and cardiovascular events in patients undergoing hemodialysis. N Engl J Med 2009;360:1395-407.

Q.2. Why should statin treatment not be stopped when the patient, new on dialysis, has received treatment in earlier stages of CKD?
Available evidence does not directly address whether statins should be discontinued in incident dialysis patients, who may be systematically different from those who are already prevalent on dialysis (such as those included in the major trials of lipid-lowering treatment in dialysis patients). However, 2141 (34%) of SHARP patients without kidney failure at baseline commenced dialysis during the trial and were considered as 'nondialysis' patients; overall benefit was observed in this latter group. The Work Group judged that it is reasonable to continue statins in patients who are already receiving them at the time of dialysis initiation, recognizing that they may lead to less clinical benefit than in patients without kidney failure. Physicians should consider periodically reviewing the clinical status of dialysis patients and revisiting the decision to prescribe statins as required.
As there is no direct evidence that statin treatment improves cardiovascular outcomes in patients who require dialysis treatment, this is a weak recommendation.
Q. 3. Should we treat patients with a statin after kidney transplantation?
The risk of future cardiovascular events in kidney transplant recipients is substantially elevated compared with people without CKD: The rate of cardiovascular death or nonfatal MI is approximately 21.5 per 1,000 patient-years. The Assessment of LEscol in Renal Transplantation (ALERT) trial showed that fluvastatin (40-80 mg/day) nonsignificantly reduced the risk of coronary death or nonfatal MI, compared with placebo (RR: 0.83; 95% CI: 0.64-1.06). However, fluvastatin led to a significant 35% relative reduction in the risk of cardiac death or definite nonfatal MI (HR: 0.65; 95% CI: 0.48-0.88) in an unblinded extension study. A significant reduction in the original primary outcome was found after 6.7 years of follow-up. The Work Group judged that the apparent benefits observed in ALERT are consistent with the effects of statins in the general population, suggesting that statins will improve cardiovascular outcomes in kidney transplant recipients. However, the lack of statistical significance in the primary analysis and the fact that only one randomized trial was available, both favor a weak recommendation.
Q.4. Lack of evidence for benefit and safety precludes statin treatment in children or adolescents. Your opinion on the same?
Clinical trials of dyslipidemias in children are limited given the rapid transitions from CKD to dialysis and/or transplant, which complicates trial design, recruitment and analyses. Four randomized trials have examined drug treatment of dyslipidemia primarily in children with nephrotic syndrome, but no trials have studied clinically relevant outcomes. These trials demonstrate that statins lower LDL-C over 7 months to 5 years, but no dose escalation has been carried out. There have been 13 placebo-controlled trials of statins in 1,683 children with dyslipidemias and normal kidney function.
This recommendation does not apply to children with severely elevated LDL-C, and therapeutic lifestyle changes should be adopted among all children with CKD. As for all weak recommendations, practitioners should consider the clinical circumstances, patient's age, and preferences when considering an individual patient and his lifetime risk for atherosclerotic cardiovascular disease events with potential exposure to high LCL-C.
Q. 5. No recommendation for pharmacological treatment of high TGs in adults could be made. Your clinical opinion on the same.
A meta-analysis of data from 18 randomized trials involving 45,058 participants drawn from the general population (i.e., not specific to CKD) demonstrated a modest 10% relative risk reduction in major cardiovascular events and a 13% relative risk reduction in coronary events for fibrate therapy.
Few participants with eGFR <60 mL/min/1.73 m2 were included in either FIELD (The Fenofibrate Intervention and Event Lowering in Diabetes) or ACCORD-Lipid (Action to Control CardiOvascular Risk in Diabetes-Lipid) to provide reliable information on either the safety or efficacy of fenofibrate in this group.
Allocation to fenofibrate in the FIELD study was associated with an increased risk of doubling of plasma creatinine, which cannot simply be explained by the small step-rise in creatinine due to fenofibrate.
A recent large observational study in patients aged >66 years demonstrated a clear association between new prescriptions for fibric acid derivatives and increased serum creatinine levels, as well as a small increase in the risk of hospitalization and nephrologist consultation.
These findings contribute to the uncertainty that fibric acid derivatives would yield net clinical benefit in people with CKD. For these reasons, the use of fibric acid derivatives to reduce cardiovascular risk is not recommended in patients with CKD.
Fibric acid derivatives could be considered for the rare patients with CKD and markedly elevated fasting levels of serum TGs (>11.3 mmol/L (>1,000 mg/dL)). If such therapy is prescribed, fibric acid derivatives must be dose-adjusted for kidney function. Concomitant therapy with both a fibric acid derivative and a statin is not recommended in patients with CKD owing to the potential for toxicity.
Nonpharmacological treatment of high TGs (>500 mg/dL; 5.65 mmol/L) includes therapeutic lifestyle changes such as dietary modification, weight reduction, increased physical activity, reducing alcohol intake and treatment of hyperglycemia (if present). Evidence that lifestyle changes will reduce serum TGs in patients with CKD is weak, but the elements of lifestyle changes are unlikely to lead to harm, and may improve general health.

News Around The Globe

  • Patients with migraine have almost twice the risk of developing Bell's palsy compared with those without migraine, suggests a new study published online in Neurology.
  • The US Food and Drug Administration has approved the injectable long-acting somatostatin analog pasireotide for the treatment of acromegaly in patients who have had an inadequate response to surgery or for those in whom surgery is not an option.
  • Whole-body diffusion-weighted imaging (WB-DWI) is a reliable alternative to positron emission tomography/computed tomography (PET/CT) for detecting gastrointestinal cancers without the ionizing radiation, suggests new research published online in Gastroenterology Report.

Dr KK Spiritual Blog

How to Improve Your Soul Profile

1. What is my purpose of life?
2. What is my contribution going to be for my friends and family?
3. Three instances in my life when I had my peak experiences.
4. Names of three people who inspire me the most.
5. Three qualities which I admire the most in others.
6. Three of my unique talents.
7. Three qualities I best express in my relationship.

These twenty one answers will characterize one’s soul profile and can be used as a passport for every action performed in life and to be used as a reference in any difficulty. The principle is that in everyday life, one should act from the Soul Profile and not from the Ego Profile. While the Soul profile cannot be manipulated, the Ego Profile can be.

emedipicstoday emedipics

Health Check Up and CPR 10 Camp at GB S School, Khan Pur, New Delhi, on 27th November 2014

nova nova video of day
press release

Strain echo imaging for cancer chemotherapy toxicity

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 on Mediclaim developed a recurrence of illness after three months.
Dr. Bad: It will not be covered under Mediclaim.
Dr. Good: Yes, it will be covered as it is a fresh illness.
Lesson: Occurrence of the same illness after lapse of 105 days is considered as fresh illness for the purpose of Mediclaim policy.

Make Sure

Situation: During evening round in a renal unit, a doctor comes across a patient complaining of headache.
Reaction: Give him a tablet of Nimesulide.
Lesson: Make sure to remember that nimesulide, a selective COX–2 antagonist has minimal potential for renal toxicity.

eMedinewS Humor


"So, how did you do?" the boss asked his new salesman after his first day on the road. "All I got were two orders."

"What were they? Anything good?" "Nope," the salesman replied. "They were ‘Get out!’ and ‘Stay out!"

Twitter of the Day

Dr KK Aggarwal: Relieve Stress by Changing the Interpretation
Dr Deepak Chopra: In every moment, we have the power to choose our attitude & reaction to every person & every situation we encounter

Inspirational Story

The Choice - II

A woman came out of her house and saw three old men with long white beards sitting in her front yard. She did not recognize them.

She said, "I don't think I know you, but you must be hungry. Please come in and have something to eat." "Is the man of the house home?" they asked. "No," she said, "he's out." "Then we cannot come in," they replied.

In the evening when her husband came home, she told him what had happened. "Go tell them I am home and invite them in!" The woman went out and invited the men in.

"We do not go into a house together," they replied. "Why is that?" she wanted to know. One of the old men explained, "His name is Wealth," said pointing to one of his friends, and said, pointing to another one, "He is Success, and I am Love." Then he added, "Now go in and discuss with your husband which one of us you want in your home."

The woman went in and told her husband what was said. Her husband was overjoyed. "How nice!" he said. "Since that is the case, let us invite Wealth. Let him come in and fill our home with wealth!" His wife disagreed.

"My dear, why don't we invite Success?" Their daughter-in-law was listening from another corner of the house. She jumped in with her own suggestion: "Would it not be better to invite Love? Our home will then be filled with love!"

"Let us heed our daughter-in-law's advice," said the husband to his wife. "Go out and invite Love to be our guest." The woman went out and asked the three old men, "Which one of you is Love? Please come in and be our guest."

Love got up and started walking toward the house. The other two also got up and followed him. Surprised, the woman asked Wealth and Success: "I only invited Love, why are you coming in?" The old men replied together:

“If you had invited Wealth or Success, the other two of us would have stayed out, but since you invited Love, wherever he goes, we go with him. Wherever there is Love, there is Wealth and Success!!!"

"Where there is pain, we wish you peace and mercy. Where there is self-doubting, we wish you a renewed confidence in your ability to work through it. Where there is tiredness, or exhaustion, we wish you understanding, patience, and renewed strength. Where there is fear, we wish you love, and courage."

Rabies News (Dr A K Gupta)

What are the precautions to be taken while administering RIGs?

  • Patient should not be on an empty stomach.
  • The RIGs vial taken out from the refrigerator should be kept outside for a few minutes to warm it to room/body temperature.
  • While infiltrating RIGs into the bite wound, care must be taken to avoid injecting into blood vessels and nerves.
  • While injecting into finger tips, care must be taken to avoid compartment syndrome.
  • All emergency drugs and facilities for managing any adverse reactions must be available.
  • For ERIG, keep the patient under observation for at least one hour after ERIG administration and then send home.
  • RIGs can be infiltrated even to already sutured wounds without disturbing the sutures.

Cardiology eMedinewS

  • The UK's National Institute for Health and Clinical Excellence (NICE) has published final draft guidance giving the green light on using dabigatran for the treatment of deep vein thrombosis (DVT) and pulmonary embolism (PE).
  • Nearly 6% of patients undergoing transcatheter aortic-valve replacement (TAVR) will experience a late major bleeding complication, and the bleeding events are associated with a significantly increased risk of death, suggested a new analysis of the PARTNER study, published in December 23 issue of the Journal of the American College of Cardiology.

Pediatrics eMedinewS

  • Presepsin (P-SEP) appears to be an accurate biomarker of late-onset sepsis in premature infants and might help in monitoring response to treatment, suggests new research published online in Pediatrics.
  • Children with osteomyelitis who were discharged from the hospital to complete several weeks of outpatient antibiotic therapy with an oral medication did not have a higher rate of treatment failure than children who received their antibiotic therapy intravenously, suggested a study published online in JAMA Pediatrics.

Quote of the Day

A successful man is one who can lay a firm foundation with the bricks others have thrown at him. ~ David Brinkley

Wellness Blog

Ten ways to ease neck pain

  • Don’t stay in one position for too long
  • Position your computer monitor at eye level.
  • Use the hands-free function on your phone or wear a headset.
  • Prop your touch-screen tablet on a pillow so that it sits at a 45° angle, instead of lying flat on your lap.
  • Keep your glass prescription up to date otherwise you tend to lean your head back to see better.
  • Don’t use too many pillows as it can stifle your neck’s range of motion.
  • Before you move a big armoire across the room, consider what it might do to your neck and back, and ask for help.
  • Get a good night’s sleep.
  • See your doctors if neck pain is associated with radiating pain, weakness, or numbness of an arm or leg.
  • Also see the doctors if you have fever or weight loss associated with your neck pain, or severe pain.

ePress Release

The holiday season is also the season for heart attack

A look at a U.S. database of 53 million deaths occurring between 1973 and 2001 reveals that deaths from heart disease peak in December/January, with spikes on Christmas and New Year's Day.

Giving reasons for this, 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. said that:

  1. People with symptoms of heart trouble tend to delay going to the doctor prior to the holidays as they do not want to spoil holiday fun.
  2. They are less likely to see their physicians over this period of time in order to get the acute care they may need.
  3. During the holidays, many people take a break from their diet and exercise programs.
  4. The amount of time spent eating out and eating over at friends and family becomes more than usual.
  5. It becomes easier to find excuses not to stay on an exercise regimen.
  6. Alcohol consumption can increase during the holidays, which can contribute to something called "holiday heart syndrome."
  7. Alcohol has a toxic effect on the heart muscle. It can lead to atrial fibrillation -- an abnormal heart rhythm, which is a classic finding of the holiday heart.
  8. The hectic pace of the holiday season can cause people to forget to take medications such as blood thinners and pills for high blood pressure. Such lapses can lead to acute coronary trouble.
  9. Winter is any way the peak season for heart attacks. Most heart attacks and paralysis due to brain haemorrhage peak during early morning periods of winter season due to sudden rise in BP reading.

eMedi Quiz

B-oxidation of odd-chain fatty acids produces:

1.Succinyl CoA.
2.Propionyl CoA.
3.Acetyl CoA.
4.Malonyl CoA.

Yesterday’s Mind Teaser: Injury to radial nerve in lower part of spiral groove:

1. Spares nerve supply to ex tensor carpi radialis longus.
2. Results in paralysis of anconeus muscle.
3. Leaves extension at elbow joint intact.
4. Weakens pronation movement.

Answer for yesterday’s Mind Teaser: 3. Leaves extension at elbow joint intact.

Correct answers received from: Raju Kuppusamy, Dr K V Sarma, Dr Avtar Krishan.

Answer for 18th December Mind Teaser: 1. Transitional

Correct answers received from: Dr Sunita Kalra, Dr K V Sarma, Dr Avtar Krishan, Dr Poonam Chablani.

Send your answer to email

medicolegal update
  1. Thanx for enriching us scientifically, spiritually, medico–legally… Som Datt Bherwal

eMedinewS Special

1. IJCP’s ejournals (This may take a few minues to open)

2. eMedinewS audio PPT (This may take a few minutes to download)

3. eMedinewS audio lectures (This may take a few minutes to open)

4. eMedinewS ebooks (This may take a few minutes to open)