March 28 2015, Saturday
Smell check, scratch and sniff, a new test for Parkinson’s disease
Dr KK Aggarwal Olfactory dysfunction presenting as odor detection, discrimination, and identification is a common finding in patients with early non vascular Parkinson’s disease.

As per a study of 2,267 men published in the Annals of Neurology, an impaired sense of smell could be an early indicator of Parkinson’s disease, occurring up to four years before motor skill problems appear.

In the study, decreased odor identification was associated with older age, smoking, more coffee consumption, less frequent bowel movements, lower cognitive function and excessive daytime sleepiness, but even after adjusting for these factors, those with the lowest odor identification scores had a five time greater risk of developing Parkinson's disease than those with the highest scores.

Nerve loss and the formation of Lewy bodies –– abnormal clumps of proteins inside nerve cells that are thought to be a marker of the disease –– are known to take place in the olfactory structures of patients with the disease.

An impaired sense of smell could also be caused by impaired sniffing, which may be another motor symptom of Parkinson’s.

Early indicators of Parkinson’s disease are olfactory abnormality, constipation and sleep disturbances.

Besides Parkinson’s disease, obesity, diabetes, hypertension, malnutrition, Alzheimer’s disease, multiple sclerosis and Korsakoff’s psychosis are all accompanied or signalled by smell disorders.
MCI President, Dr Jayshree Ben Mehta joins movement against menace of TB
  • Higher fitness levels among middle-aged men might be associated with a lower risk for later lung and colorectal cancer, but not prostate cancer, suggests a new study. The study also linked higher fitness levels in midlife to a lower risk for later death from cancer or cardiovascular disease. The findings were published online March 26 in JAMA Oncology.
  • Typhoid vaccine should not be given routinely in the United States, suggest updated recommendations from the Advisory Committee on Immunization Practices (ACIP) published in the March 26 issue of the Morbidity and Mortality Weekly Report. However, typhoid vaccination continues to be recommended for US travelers to certain countries.
  • Vacuum-assisted closure (VAC) may be superior to mesh-foil laparostomy without negative pressure for managing patients with diffuse peritonitis and open abdomen, suggests new research published online in the Journal of the Royal Army Medical Corps.
  • A new study suggests that while men tend to have their first total joint replacement at a younger age than women, they are more likely to have complications or need revision surgery. The findings were presented at the 2015 Annual Meeting of the American Academy of Orthopaedic Surgeons (AAOS).
  • Saxagliptin appears to be as safe in older patients with diabetes as it is in younger diabetics, suggests a new analysis from the SAVOR study.
Dr KK Spiritual Blog
On 8th Navratri Enjoy a Purified Mind
Maha Gauri is worshipped on the Eight Day of Navratri. SHE looks as white as moon and jasmine. White means purity of mind. She has three Eyes and four hands. SHE is dressed in a white sari.

SHE holds a drum and a trident and is often depicted riding a bull (control over the desires). Her above left hand is in fearless pose and she holds ‘Trishul’ in her lower left hand. Her above right hand holds a tambourine and the lower right hand is in a blessing Mudra.

Spiritual mantra on the 8th Navratri

By the 8th day of spiritual detoxification, one gets purity of mind.
Cardiology eMedinewS
  • The investigational oral potassium–binding agent patiromer appeared safe and effective in a 1–year, phase 2 study of patients with chronic kidney disease (CKD), type 2 diabetes, and hypertension, with or without heart failure (HF), and with mild or moderate hyperkalemia due to treatment with renin–angiotensinaldosterone system (RAAS) inhibitors. The findings were presented at the American College of Cardiology 2015 Scientific Sessions.
  • Although rarely selected, ulnar–artery catheterization is comparable, with respect to clinical outcomes, to the more common radial access during PCI, report investigators from the Ajmer Ulnar Artery Working Group Study (AJULAR). The data were presented at the American College of Cardiology (ACC) 2015 Scientific Sessions.
Pediatrics eMedinewS
  • Kids exposed to parental smoking are more likely to develop carotid atherosclerotic plaque as young adults than kids who are not exposed to secondhand smoke, suggests a new study published in Circulation.
  • Children conceived with assisted reproductive technology (ART) are twice as likely to receive a diagnosis of autism compared with their counterparts who are conceived naturally, suggests new research published online in the American Journal of Public Health.
Make Sure
Situation: A patient on 10 units of insulin developed hypoglycemia after taking a light breakfast.

Reaction: Oh my God! Why was the insulin dose not reduced?

Lesson: Make sure that insulin dose is correct. The formula is 500/total daily dose. The value will be the amount of sugar fluctuation with 10 gms of carbohydrates.
(Contributed by Dr Sudhir Gupta, Prof & Head, Forensic Medicine & Toxicology, AIIMS)

What is the medicolegal importance of age up to 15 to 21 years?
  • 15 years of age:  A girl below 15 years of age, even if a wife, can’t give valid consent for sexual intercourse.
  • 16 years of age: Any girl below 16 years of age cannot give valid consent for sexual intercourse. It will amount to rape even if sexual intercourse was done with consent.
  • Age 18–21 years
    • In accordance with Indian Majority Act 1875, a person attains majority on completion of 18 years.
    • In accordance with Child Marriage Resistance Act, a female under 18 years and male under 21 years cannot contract marriage.
    • In accordance with Section 366 B of IPC, importation of any girl from Jammu & Kashmir or a foreign country under the age of 21 years for illicit intercourse is a criminal offence.
Dr Good Dr Bad
Situation: A patient developed acute appendicitis within 7 days of taking Mediclaim policy. 
Dr. Bad: Mediclaim will cover.
Dr. Good: May not cover.
Lesson: Any diseases other than specified in clause 4.3 contracted by the insured person during the first 30 days from the commencement date of policy are not covered under Mediclaim..

(Copyright IJCP)
IJCP Book of Medical Records
IJCP’s ejournals
Quote of the Day
Children find everything in nothing; men find nothing in everything. Giacomo Leopardi
CPR 10
Total CPR since 1st November 2012 – 101090 trained
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
Sonal Namaste
It is estimated that 2 million deaths occur every year from contaminated food or drinking water.
Facts about Tuberculosis (TB)
Can TB be cured in HIV co–infected patients?
  • TB is curable in HIV co–infected patients with the same medicines used to treat HIV-negative TB patients.
  • However, HIV/TB co–infected patients require other medications like antiretroviral therapy (ART) and co-trimoxazole preventive therapy (CPT) to prevent other opportunistic infections. 
PCI in diabetes patients
Dr Shuvo Dutta, Kolkata
  • Patient selection for stent patency depends on type of atherosclerosis involving coronary arteries.
  • Which DAPT and which DES?
  • New disease not preventable even with maximized secondary prevention.
  • Large randomized trials with proper case selection for PCI can probably prove superiority of PCI over CABG.
Pharmacoinvasive treatment: Is it the way forward in STEMI management?
Dr Thomas Alexander, Coimbatore
  • In India, 3.5 - 4.6 million patients with STEMI yearly
  • Pharmacoinvasive strategy: A strategy of routine or adjunctive PCI within 3-24 hours of thrombolysis.
  • Is PI approach better than standard lysis? Is PI as good as Primary PCI?
  • Early routine PCI after fibrinolysis in STEMI patients significantly reduced reinfarction and the combined endpoint death/reinfarction and recurrent ischemia at 1 month, with no significant increase in adverse bleeding events vs standard therapy (Eur Heart J. 2010 Sep;31(17):2156-69).
  • The 1-year outcome of patients treated with PHT compares favorably with that of patients treated with other modes of reperfusion therapy; this favorable trend persists after multivariate adjustment. Patients with PHT admitted very early have a very high 1-year survival rate Circulation. 2004 Oct 5;110(14):1909-15
  • STREM: Prehospital fibrinolysis with timely coronary angiography resulted in effective reperfusion in patients with early STEMI who could not undergo primary PCI within 1 hour after the first medical contact. However, fibrinolysis was associated with a slightly increased risk of intracranial bleeding (N Engl J Med. 2013 Apr 11;368(15):1379-87).

    Pharmacoinvasive strategy is as good as primary PCI, widens the time window, logistically easier to accomplish especially during off hours, the aim is to lyse within 30 min of first medical contact followed by PCI within 3-24 hours. It is the ideal strategy in India as transportation times can be long and Cath labs are located in metros.
Tamilnadu STEMI Project: STEMI INDIA
  • Demonstrated the feasibility of developing a STEMI system of care combining the two proven strategies of primary PCI and the pharmaco-invasive strategy to manage patients with STEMI – ‘The STEMI INDIA Model’
  • Utilizing technology to diagnose STEMI has helped in starting reperfusion treatment early especially in rural and poorly served areas
  • Developing a STEMI system incorporating below poverty line insurance ensures equity by including the lower socioeconomic strata- a vulnerable and high risk population.
  • The dominant mode of re-perfusion in this country is not primary PCI and is unlikely to change in the foreseeable future
  • The implementation of the STEMI system of care has increased access to pharmacoinvasive treatment, especially in patients from rural areas who traditionally have standalone thrombolysis as the only treatment for STEMI. This has increased from 1% to 38%
  • For the first time we have demonstrated the effectiveness of the pharmacoinvasive strategy utilising streptokinase as the lytic agent.
  • Importantly, the safety of intervening within 24 hours and intervention after treatment with a cost effective non fibrin specific agent does not show increased bleeding complications
Deferred stenting
Dr Prabhu C Halkati, Karnataka
  • Coronary stenting is a Class IA indication in STEMI.
  • Stent apposition squeezes the endoluminal component of the coronary plaque and dislodges the residual superimposed thrombus distally.
  • The question remains...should we defer stenting in large thrombotic lesions once antegrade flow is observed or established after manual or mechanical thrombectomy.
  • The deferred PCI strategy involves an intention-to-stent 8 to 16 hours after initial coronary reperfusion to permit the beneficial effects of reperfusion and antithrombotic therapies.
  • Deferred completion of PCI in selected STEMI patients reduces no-reflow, distal embolization and intraprocedural thrombotic complications. It improves final coronary flow grade and myocardial blush grade. On longer term follow up, myocardial salvage as measured with cardiac MRI was significantly greater (DEFER-STEMI; J Am Coll Cardiol. 2014 May 27;63(20):2088-98).
  • Benefits of deferred stenting
    • Acute thrombotic plaques, especially in primary PCI are associated with a 30-40% rate of acute stent malapposition as shown in the IVUS.
    • Reducing thrombotic burden before stenting not only reduces embolic events but also allows for a better stent selection, which might translate into shorter lengths and larger diameters.
    • Patients with multivessel disease where surgical revasculariztion could be an option could have their stenting deferred and re-assessed by a multidisciplinary team.
    • Medical compliance could be carefully assessed and allow a better stent selection (BMS vs DES)
    • In about 10% of patients, the infarct-related coronary lesions might be treated medically without requiring a stent at all.
    • In STEMI cases, the repeated angiogram may allow treatment of the non culprit artery in patients with multivessel disease.
    • Delayed stenting allows for a proper statin loading before the stenting which has been associated with a reduction in the composite of death, MI, UA and repeat revascularization after PCI.
Inspirational Story
To Let Go

 To let go does not mean to stop caring, it means I can't do it for someone else.

To let go is not to cut myself off, it's the realization that I can't control another.

To let go is not to enable, but to allow learning from natural consequences.

To let go is to admit powerlessness, which means the outcome is not in my hands.

To let go is not to try to change or blame another, it's to make the most of myself.

 To let go is not to care for, but to care about.

To let go is not to fix, but to be supportive.

To let go is not to judge, but to allow another to be a human being.

To let go is not to be in the middle arranging all the outcomes, but to allow others to affect their own destinies.

 To let go is not to be protective, it's to permit another to face reality.

To let go is not to criticize, or regulate anyone, but to try to become what I dream I can do.

 To let go is to fear less, and to love more.
Reader Response
  1. Dear Sir, very informative news. Regards: Dr Priya
Wellness Blog
A mix of exercise protocol is better

A combination of weight training and aerobic exercise is the best prescription for overweight patients at risk for diabetes and heart disease. Only aerobic exercise is also as good as it reduces weight and takes inches off the waistlines. Just weight lifting alone has very little benefit.

According to a study published in the American Journal of Cardiology, people in the weight–training group gained about 1.5 pounds and those in the aerobic group lost an average of 3 pounds and half an inch from their waists.

Those who did both weight and aerobic training dropped about 4 pounds and 1 inch from the waistline. This group also saw a decrease in diastolic lower blood pressure and in a metabolic syndrome score.

Both the aerobic–only group and the combined-exercise group also lowered their levels of bad triglycerides.
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IMA Humor
There were these two friends, Bill and Bob, and they both loved baseball. So, they made a promise to each other, the first one to die, will come back and let the other know if there’s baseball in heaven. Well, the day comes and Bob passes. Weeks turn to months while Bill is still waiting to hear from his friend.

Then one day, Bill is walking down the street, and Bob appears. Bill all excited says: "I’ve been waiting forever! So tell me, is there or isn’t there Baseball in heaven?" Bob kinda perks up and says: "I’ve got good news and bad news." "1st, there is Baseball in heaven! The bad news is you’re pitching Friday!"
Press Release of the Day
MCI President, Dr. Jayshree Ben Mehta joins movement against menace of TB

In a function organized by IMA, Dr Jayshreeben Mehta, President MCI and Dr Ketan Desai, President-Elect World Medical Association, jointly signed and released a message - TB Haarega, Desh Jeetaga and Swacch Bharat Swasth Bharat – TB Mukt Bharat.

Addressing the gathering, Padma Shri Awardee Dr. K.K. Aggarwal, Hony. Secretary General, IMA and Dr. Jayshree Ben Mehta, President, MCI said that IMA and MCI will jointly fight the menace of TB.

They requested all the doctors registered with MCI through their State Medical Councils to notify each and every case of TB in the interest of nation.
eMedi Quiz
At the end of a balanced anaesthesia technique with non-depolarizing muscle relaxant, a patient recovered spontaneously from the effect of muscle relaxant without any reversal. Which is the most probable relaxant the patient had received?

1. Pancuronium.
2. Gallamine.
3. Atracurium.
4. Vecuronium.

Yesterday’s Mind Teaser: An increase in which of the following parameters will shift the O2 dissociation curve to the left.

1. Temperature.
2. Partial pressure of CO2
3. 2,3 DPG concentration.
4. Oxygen affinity of hemoglobin.

Answer for yesterday’s Mind Teaser: 4. Oxygen affinity of hemoglobin.
Correct Answers received from: Dr Jainendra Upadhyay, Dr Poonam Chablani, Raju Kuppusamy, Dr KV Sarma, Viswanatha Sarma, Mahendra Gandhe, Dr Prabodh K Gupta, Daivadheenam Jella, Dr Avtar Krishan
Answer for 26TH March Mind Teaser: 1.Criterion validity.
Correct Answers receives:: Dr G Madhusudhan. Dr Avtar Krishan, Daivadheenam Jella
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.