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Dr KK Aggarwal

From the Desk of Editor in Chief
Dr B C Roy National Awardee,

Dr KK Aggarwal
President, Heart Care Foundation of India; Sr Consultant and Dean Medical Education, Moolchand Medcity; Member, Delhi Medical Council; Past President, Delhi Medical Association; Past President, IMA New Delhi Branch; Past Hony Director. IMA AKN Sinha Institute, Chairman IMA Academy of Medical Specialities & Hony Finance Secretary National IMA; Editor in Chief IJCP Group of Publications & Hony Visiting Professor (Clinical Research) DIPSAR

Dear Colleague,

25th January, Monday 2010

In every ED do a treadmill to rule out CAD

Erectile dysfunction(ED) is a strong indicator that a man might be at increased risk for heart attack, paralysis and other cardiovascular problems, a long-running study indicates. If a man presents with erectile dysfunction, he should be worked up for cardiovascular disease. The same artery-blocking conditions that reduce blood flow to the heart and brain can also reduce flow to the penis.

A report, by Andre Araujo, director of epidemiology at New England Research Institutes and published online Jan. 19 in the Journal of the American College of Cardiology has shown that men with erectile function are at 40 percent increased risk of heart disease. The study is the latest of several that have linked erectile dysfunction to cardiovascular disease. The study followed 1,057 men, aged 40 to 70, for an average of 12 years. Overall, 37 percent of the men with erectile dysfunction were in the high-risk category according to the Framingham standards, compared with 17 percent of men without erectile dysfunction.

Dr KK Aggarwal
Chief Editor

Padma awards to be declared today and we will acrry a special report on the same in tomorrow's edition.


1. Moderate physical activity performed in midlife or later appears to be associated with a reduced risk of mild cognitive impairment, whereas a six-month high-intensity aerobic exercise program may improve cognitive function in individuals who already have the condition, according to two reports in the January issue of Archives of Neurology.

2. According to a statement on the FDA's website, inhaled tiotropium bromide, which is used to treat patients with COPD, may not be linked to an increased stroke risk.

3. According to a study published Jan. 14 in the Annals of Behavioral Medicine, parents have better blood pressure readings than childless adults.

4. Prompt treatment with morphine cuts by half the chances that troops would develop symptoms of post-traumatic stress later on, and other opiates are likely to have similar effects, according to a study published Jan. 14 in the New England Journal of Medicine.

5. New research from the MIT-affiliated Whitehead Institute indicates that the Y chromosome is the fastest-changing part of the human genome and is constantly renewing itself.

6. People who are chronically sleep-deprived may think they're caught up after a 10-hour night of sleep, but new research in Science Translational Medicine shows that although they're near-normal when they awake, their ability to function deteriorates markedly as night falls. ‘Apparently, the body's daily circadian rhythm hides the effects of chronic sleep loss and gives such people a second wind between about 3 and 7 pm, when the circadian rhythm is pushing them to be awake. (Brigham and Women's Hospital and Beth Israel Deaconess Medical Center)

Letters to the editor

1. Dear Dr KK, emedinews has brought a wonderful change in the habits of millions in opening their email daily. We are addicted to it. All the messages in it are  useful for us, either it is new to us or revises our past knowledge of the subject therefore gives us confidence in using them in our patients .More and more subscribers are adding to this daily and are able to keep their professional skill updated. This is a great service of yours to medical profession which has enabled all of us to serve the humanity, thereby greatest service to humanity. Main nanhi kehta, kehte hain sare, toone sanware haath (medical practice & personnel health) hamre. Million & Millions of thanks to Great Son of India. Dr Rajendra Agrawal Shalimar Bagh, Delhi 88 

2. With reference to letter by Dr G M Singh, I want to submit that H1N1 virus (real flu) may also cause GIT symptoms besides the primary respiratory symptoms. The novel H1N1 virus causing current pandemic is found to be even more notorious for GIT symptoms
Dr Vivek Chhabra

Rheumatology Criteria for the Classification of Fibromyalgia (Dr G M Singh)
History of widespread pain has been present for at least three months
Definition: Pain is considered widespread when all of the following are present:
Pain in both sides of the body. Pain above and below the waist. In addition, axial skeletal pain (cervical spine, anterior chest, thoracic spine or low back pain) must be present. Low back pain is considered lower segment pain. Pain in 11 of 18 tender points on digital palpation
Definition: Pain, on digital palpation, must be present in at least 11 of the following 18 bilateral tender point sites:
1. Occiput: at the suboccipital muscle insertions
2. Low cervical: at the anterior aspects of the intertransverse spaces at C5-C7
3. Trapezius: at the midpoint of the upper border
4. Supraspinatus: at origins, above the scapula spine near the medial border
5. Second rib: upper lateral to the second costochondral junction
6. Lateral epicondyle: 2cm down the arm from tennis elbow
7. Gluteal: in upper outer quadrants of buttocks
8. Greater trochanter: posterior to the trochanteric prominence
9. Knee: at medial fat pad proximal to joint line.
Digital palpation should be performed with an approximate force of up to 4kg – enough to blanch your thumbnail. A tender point has to be painful at palpation, not just 'tender'.

 FDA warning for sibutramine
The FDA said the weight-loss drug sibutramine should not be taken by patients with history of cardiovascular disease following a review of additional data showing an increased risk of heart attack and stroke among that population. The agency said the manufacturer, Abbott, has agreed to add the contraindication to its labeling, which will be expanded to include patients with a history of the following:
1. Coronary artery disease (i.e., heart attack, angina)
2. Stroke or transient ischemic attack
3. Heart arrhythmia
4. Congestive heart failure
5. Peripheral arterial disease
6. Uncontrolled hypertension (>145/90 mmHg)
The initial review of sibutramine began in November 2009 when the FDA received preliminary data from the SCOUT study suggesting patients using the drug had a higher risk for cardiovascular events. 

Punjab & Sind Bank
Central Bank of India
Our HIP's

Question Of the day
What are the WHO criteria for clinical diagnosis of malaria?
The signs and symptoms of malaria are non-specific. Malaria is clinically diagnosed mostly on the basis of fever or history of fever. The following (WHO) recommendations are still considered valid for clinical diagnosis:

In settings where the risk of malaria is low, clinical diagnosis of uncomplicated malaria should be based on the degree of exposure to malaria and a history of fever in the previous 3 days with no features of other severe diseases.
In settings where the risk of malaria is high, clinical diagnosis should be based on a history of fever in the previous 24 hours and/or the presence of anemia, for which pallor of the palms appears to be the most reliable sign in young children.(Source:WHO Expert Committee on Malaria. Twentieth report. WHO Technical Report Series, No. 892).

Dr Good Dr Bad
Situation:A heart failure patient was on NSAID.
Dr Bad: Continue it.
Dr Good: Stop it now.
Lesson: Among patients with heart failure, NSAIDs have been associated with an increased risk of exacerbation, impairment of responses to ACE inhibitors and diuretics, and increased mortality.

Make Sure
Situation: A child with gastrointestinal (GI) infection undergoing gingival surgery developed infective endocarditis (IE).
Reaction: Oh my God! Why was IE prophylaxis not given
Make sure that all procedures done in patients with ongoing GI tract infection are given IE prophylaxis.

Formulae in Imaging
Pleural effusions thicker than one cm are usually large enough for sampling by thoracentesis, since at least 200 mL of liquid are already present. (Source: Radiology 1973; 109:33)

Mistakes in Clinical Practice
'IU' can be mistaken for 'IV' or the number '10'. So instead of using 'IU', use the terms 'international unit'.

ENT Facts
The onset of acute otitis media (AOM) is associated with otalgia (earpain) and decreased hearing.

Emedinews Try this It Works
Ghee, oil, butter
For an adequate intake of fat, follow the principle of no more than half a kilogram of ghee, oil and butter in a month.

Milestones in Neurology
Sir Alan Lloyd Hodgkin was a British physiologist and biophysicist, who with Andrew Fielding Huxley, won the Nobel Prize in Physiology or Medicine in 1963 for his work on the basis of nerve 'action potentials,' the electrical impulses that enable the activity of an organism to be coordinated by a central nervous system.

Laughter the Best Medicine
A Short History of medicine

"Doctor, I have an ear ache."

2000 B.C. - "Here, eat this root."
1000 B.C. - "That root is heathen, say this prayer."
1850 A.D. - "That prayer is superstition, drink this potion."
1940 A.D. - "That potion is snake oil, swallow this pill."
1985 A.D. - "That pill is ineffective, take this antibiotic."
2000 A.D. - "That antibiotic is artificial. Here, eat this root!"

SMS Anemia
Common causes pf macrocytic anemia include alcoholism, liver disease, folic acid and vitamin B12 deficiency, and myelodysplasia.

Is it mandatory to file the return of income?
Yes, every individual or Hindu undivided family (HUF) whose income is in excess of the amount not chargeable to tax is required to file the return.

What is 'Informed Consent'?
Informed consent is gaining importance as patients who allege that they did not understand the nature of the medical procedure to which they gave consent have brought many actions.

DocConnect Milestones
DocConnect: Provides relevant industry news, specialty-based news including trial findings and medical update.
Emedinews Calculator
To convert from a conventional unit to a SI Unit, multiply by the conversion factor listed. To convert from SI Units to conventional units, divide by the listed conversion factor.

Agent                           Conventional Unit            Conversion Factor               SI Unit
Alanine                                mg/dL                              112.2                        µmol/L

I believe in prayer. It's the best way we have to draw strength from heaven (Josephine Baker).

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emedinews-revisiting 2010

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Eye care snippets by Dr. Narendra Kumar (OptometryToday@gmail.com)
Trial Case Accessories
The trial case, or trial lens set, is a box containing plus and minus spherical and plus and minus cylindrical lenses. The lenses are arranged in pairs. The spherical lenses usually run from 0.25D to 20.00D, and the cylindrical lenses from 0.25D to 6.00D. The weaker lenses are usually separated by intervals of 0.25D, those of moderate strength by 0.50D, and the stronger ones by 1.00D. Smaller trial cases are available containing spherical lenses from 0.25D to 16.00D and cylindrical lenses from 0.25D to 4.00D. Minus and plus lenses are usually mounted in different colored rims, or frames. Spherical lenses are provided with a handle on the rim, while cylindrical lenses are usually without a handle for easy rotation of axis in the trial frame. The trial case is now mostly available with reduced aperture lenses with the advantages of lesser weight and thickness.

Besides the lenses, the trial case contains a set of prisms, plano lens, red and green glass, occluder or blank, pinhole disc, stenopaic slit, Maddox rod, cross cylinder, trial frame, and the PD ruler.

Spherical lenses are formed of prisms with their bases in apposition in the case of convex, or plus lenses, and with their apices in apposition in the case of concave, or minus lenses. Since light rays in passing through a prism are refracted towards its base, convex lenses cause convergence and concave lenses cause divergence of parallel rays. A cylindrical lens is not curved in the plane of its axis, and light passing in this plane is not refracted. But in the plane opposite, or perpendicular, to the axis of the cylinder the surface of the lens is curved, which in a convex cylinder makes the light rays to converge while in a concave cylinder makes the light rays to diverge. Thus, whereas a spherical lens refracts light rays equally in all planes, a cylindrical lens does not refract in the axial plane, but other rays are refracted and most markedly those which pass at right angles to its axis. It is, therefore, necessary to indicate the direction of axis of a cylinder. In the trial case, the direction of axis in a cylindrical lens is marked by a short linear scratch on the lens at its upper and lower margins.

The metric or dioptric system, of numbering lenses is universally adopted. The unit is a 1.00D lens which has its principal focus at 1 metre distance, or approximately 40 inches. In this system, the focal distance of the lens in centimetres is obtained by dividing 100 cm by the number of the lens, for example, a 2.00D lens has focal distance of 100/2 = 50cm; a 10.00D lens has a focal distance of 100/10 = 10cm.

Prism is a piece of glass bounded by two inclining plane surfaces and having an apex and a base. Rays of light passing through a prism are bent towards the base, but a prism has neither converging nor diverging power, it has no focus and cannot form an image, and parallel rays entering the prism emerge as parallel. A prism of 1? strength causes an apparent displacement of 1 cm in an object at 1 metre distance. Placed in front of an eye, the position of a prism is indicated by the direction of its base; 'base out' means that the thick part of the prism is towards the temple. The base may also be 'in' (towards the nose) or 'up' or 'down'. Prisms are used to measure the angle of deviation of visual axes, and to secure comfortable binocular vision.

The plano lens is used while doing subjective testing of vision when one of the eyes doesn't need any correction. It is also helpful in detecting cases of malingering.

The red and green glasses are used in the diplopia test to investigate a case of paralytic squint to determine which external ocular muscle is affected. The glasses are used in conjunction with a candle so that the two images can be easily distinguished by the patient. The principle is to determine (i) in which position of the gaze there is greatest separation of the two images and (ii) to which eye the 'farther away' image belongs.

The occluder (or blank) is blind disc and is used to cover one eye while recording vision of the other eye.

Pin hole disc cuts off peripheral rays of light entering the eye and helps in making a fine image. The disc is used to discover the maximum vision that can be obtained in an eye with the help of glasses.

Stenopaeic slit is used to determine the two principal meridians of astigmatism. One eye is occluded, the slit is placed before the other eye, and is rotated slowly, and the position of the slit in which the best vision is obtained is noted. The power of the convex or concave lens giving the maximum improvement is the measure of refraction in this meridian. The slit is then turned 90°, and the power of the convex or concave lens giving the maximum improvement is the measure of refraction in this second principal meridian.

Maddox rod consists of a circular red glass having parallel grooves. It converts the image of a spotlight into a streak of light. The streak of light is at right angles to the axis of the grooves. The test is used with a spotlight at a distance of 6 metres. The Maddox rod is placed horizontally before the right eye. In horizontal orthophoria, the streak passes directly through the light seen by the left eye. If the line of light is to the left or to the right of the light, there is heterophoria. Likewise, vertical heterophoria can be detected by placing the Maddox rod before one eye vertically and noting the deviation of the line of light upwards or downwards from the spotlight.

The cross cylinder consists of a convex cylinder and a concave cylinder with their axes at right angles. The usual combinations are that of + and - 0.25D Cyl and + and - 0.50D Cyl. The combined lens is mounted in a frame with a handle at 45° from the axes of each cylinder.

The cross cylinder is used to determine the axis and strength of the cylinder required. After retinoscopy, the best possible corrective glasses are placed in the trial frame. If the patient reads 6/6, he is told to look at the 6/9 line. For determining the axis, the cross cylinder is placed in front of the correcting cylinder so that its two cylinders are at 45° to the correcting cylinder. The cross cylinder is rotated so that the position of the convex and concave cylinders is reversed asking the patient to report the better position. The correcting lens is then rotated so that its axis comes nearer to that of the cylinder of the cross cylinder (convex towards convex, and concave towards concave). This process is repeated until a position comes when there is no change in visual acuity with the two rotations of the cross cylinder.

For determining the strength, the same process is followed by placing the cross cylinder so that the axis of the first cylinder and then the other coincide with the axis of the correcting cylinder. If vision is better with the convex cylinder, a +0.25D cylinder, and if vision is better with the concave cylinder, a -0.25D cylinder is placed in front of the correcting cylinder and the test repeated until vision becomes equal with the two positions of the cross cylinder. Care, however, is to be exercised as the cross cylinder may induce some accommodative effort. It is, therefore, advisable to perform the test on an eye under a cycloplegic (a drug such as homatropine which paralyze accommodation).

The trial frame is usually metallic and contains three or four cells on either side to hold spherical and cylindrical lenses for the right and left eyes while the eyes are under examination. The better types are available with adjustable IPD (inter-pupillary distance), nose bridge, and sides etc. On each side the frame has gradations to indicate the direction of the axis of the cylinder from 0° to 180°.

The PD ruler, also called the 'optician's ruler', is made of plastic and is used to record the PD or IPD. (the distance between the right and left pupils). It also gives the nose bridge size or number, and can be used to check the edge thickness of the lens blank, the size of the palpebral aperture, the diameter of cornea and pupil, and the vertex distance of the lens from the eye.  


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