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Dr KK Aggarwal

From the Desk of Editor in Chief
Padma Shri and Dr B C Roy National Awardee

Dr KK Aggarwal
President, Heart Care Foundation of India; Sr Consultant Physician, Cardiologist and Dean Medical Education Moolchand Medcity; Member Delhi Medical Council; Chairman (Delhi Chapter) International Medical Sciences Academy; 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); Editor in Chief IJCP Group of Publications & Hony. Visiting Professor (Clinical Research) DIPSAR

3oth May, 2010 Sunday,

Never events

Dear Colleague

 Implications: Why know them

  1. Mediclaim may not pay.
  2. PSU may not reimburse.
  3. CGHS may not pay.
  4. CPA may order compensation.
  5. Patient may not pay.
  6. MCI or state councils may be asked to classify them under "never events".

‘Never events’ or events that should never occur are 28 occurrences on a list of inexcusable outcomes in a health care setting. The list was compiled by the US National Quality Forum (NQF). They are defined as adverse events that are serious, largely preventable, and of concern to both the public and health care providers for the purpose of public accountability. The term 'Never Event’ was first introduce by Ken Kizer, MD, former CEO of NQF in 2001. Several US states have enacted laws requiring the disclosure of never events at hospitals and various remunerative or punitive measures for such events.

A recent Leapfrog Group Study finds that roughly half of the 1,285 hospitals that responded to their survey waive fees for never events, and that hospitals that do waive fees are much more likely to have perfect scores on the Leapfrog Safe Practices Score survey.

The 28 never events are:

  1. Artificial insemination with the wrong donor sperm or donor egg.
  2. Unintended retention of a foreign object in a patient after surgery or other procedure
  3. Patient death or serious disability associated with patient elopement (disappearance)
  4. Patient death or serious disability associated with a medication error (e.g., errors involving the wrong drug, wrong dose, wrong patient, wrong time, wrong rate, wrong preparation or wrong route of administration)
  5. Patient death or serious disability associated with a hemolytic reaction due to the administration of ABO/HLA–incompatible blood or blood products
  6. Patient death or serious disability associated with an electric shock or elective cardioversion while being cared for in a healthcare facility
  7. Patient death or serious disability associated with a fall while being cared for in a healthcare facility
  8. Surgery performed on the wrong body part
  9. Surgery performed on the wrong patient
  10. Wrong surgical procedure performed on a patient
  11. Intraoperative or immediately post–operative death in an ASA Class I patient
  12. Patient death or serious disability associated with the use of contaminated drugs, devices, or biologics provided by the healthcare facility
  13. Patient death or serious disability associated with the use or function of a device in patient care, in which the device is used or functions other than as intended
  14. Patient death or serious disability associated with intravascular air embolism that occurs while being cared for in a healthcare facility
  15. Infant discharged to the wrong person
  16. Patient suicide, or attempted suicide resulting in serious disability, while being cared for in a healthcare facility
  17. Maternal death or serious disability associated with labor or delivery in a low-risk pregnancy while being cared for in a health care facility
  18. Patient death or serious disability associated with hypoglycemia, the onset of which occurs while the patient is being cared for in a healthcare facility
  19. Death or serious disability (kernicterus) associated with failure to identify and treat hyperbilirubinemia in neonates
  20. Stage 3 or 4 pressure ulcers acquired after admission to a healthcare facility
  21. Patient death or serious disability due to spinal manipulative therapy
  22. Any incident in which a line designated for oxygen or other gas to be delivered to a patient contains the wrong gas or is contaminated by toxic substances
  23. Patient death or serious disability associated with a burn incurred from any source while being cared for in a healthcare facility
  24. Patient death or serious disability associated with the use of restraints or bedrails while being cared for in a healthcare facility
  25. Any instance of care ordered by or provided by someone impersonating a physician, nurse, pharmacist, or other licensed healthcare provider
  26. Abduction of a patient of any age
  27. Sexual assault on a patient within or on the grounds of the healthcare facility
  28. Death or significant injury of a patient or staff member resulting from a physical assault (i.e., battery) that occurs within or on the grounds of the healthcare facility

The Leapfrog Group offers four actions as industry standards following a never event:

1. Apologize to the patient,

2. Report the event,

3. Perform a root cause analysis, and

4. Waive costs directly related to the event.

Medscape adds to the list

1. Catheter–associated urinary tract infection

2. Deep–vein thrombosis/pulmonary embolism related to hip and knee replacements

3. Surgical site infections

4. Manifestations of poor glycemic control, including hypoglycemic coma

NHS list (adds)

As specified in The operating framework for the NHS in England 2010/11, from April 2010, primary care trusts will be expected to seek recovery of the cost of the procedure/treatment where one of the following seven Never Events occurs:

  • Wrong route administration of chemotherapy
  • Misplaced naso or orogastric tube not detected prior to use
  • Inpatient suicide using non–collapsible rails
  • In–hospital maternal death from post–partum haemorrhage after elective caesarean section 
  • Intravenous administration of mis–selected concentrated potassium chloride

Hospital–acquired infections such as MRSA or C.diff are not included on this list.

IVF: Artificial insemination with the wrong donor sperm or donor egg.


Dr KK Aggarwal
Padma Shri Awardee and Chief Editor


Photo Feature (From file): Health Modules

Involving Politicians to Promote Holistic Health

Mahatma Gandhi pioneered non-violent resistance to British rule in India and discouraged smoking and other addiction. The teachings of the mahatma were popularized by Heart Care Foundation of India as a health module. A student dressed as Gandhi ji was affianced in one such campaign to convey Gandhian perspective of "No smoking".

Dr k k Aggarwal
Dr. K K Aggarwal and Dr. C P Thakur, the then Union Health Minster with a Student dressed as Mahatma Gandhi with a message against smoking

International Medical Science Academy Update (IMSA): New FDA Drug Update


Dabigatran, an orally active direct thrombin inhibitor, is approved for use in Canada, Europe, and elsewhere. In a randomized trial in 2539 patients with acute venous thromboembolism (VTE), six month rates of recurrent VTE and related deaths, as well as rates of bleeding were similar in patients treated with fixed dose dabigatran or adjusted dose warfarin.
(Schulman, S, Kearon, C, Kakkar, AK, et al. Dabigatran versus warfarin in the treatment of acute venous thromboembolism. N Engl J Med 2009;361:2342.)


Mnemonic of the Day (Dr Prachi Garg)

Male erectile dysfunction (MED): biological causes – MED:

  • Medicines(propranalol, methyldopa, SSRI, etc.)
  • Ethanol 
  • Diabetes mellitus

News and Views

Emergency hysterectomy following childbirth associated with increase in complications

Researchers from Columbia University have reported on the complications of having an emergency hysterectomy following childbirth in Obstetrics & Gynecology. Data from more than 5,000 women who had a hysterectomy following childbirth were compared with data from 578,179 women who had a non–obstetric hysterectomy. The study found that even though the deaths were rare, the risk of mortality was 25 times higher among women who had a hysterectomy following childbirth. Bladder and ureteral injuries were more common in hysterectomy following childbirth (9% and 0.7%) vs compared to 1% and 0.1% in the non–obstetric hysterectomy, as was the need for a second operation. According to the authors, a cesarean delivery was the most important risk factor for childbirth–related hysterectomy.

APA proposing to add ‘olfactory reference disorder’ to appendix of DSM–V

People with the proposed diagnosis of ‘olfactory reference disorder’ (ORS)…are certain beyond doubt that they stink, when in fact they smell no worse than is average for a 21st century American.

FDA Update

FDA updates tramadol warning label to account for suicide, overdose risk in some patients

Johnson & Johnson strengthened warnings about the risk of suicide with its painkillers, Ultram and Ultracet, after reports that patients who had histories of emotional disturbance or drug abuse had died.

Neurocrine says gynecological drug met goals in mid–stage trial

Elagolix effectively reduces pain during menstruation, and non–menstrual pelvic pain related to endometriosis compared to placebo. The study compared 137 women who took either 150 milligrams of elagolix or a placebo once daily for eight weeks. Elagolix also reduced dyspareunia.

Conference calendar

International Conference on Nanotechnology, Nanotech India 2010
Date: 19th–21st November, 2010
Venue: Gokulam Park Cochin, Kerala State, India.
Website: www.nanotechindia.in

Quote of the day (Paramjeet Chadha)

When you want to know how rich you are
Never count your currency,
Just try to drop a tear and count how many hands reach out to WIPE it– that is true richness. (this is the truth I like in this. Don’t u think so…?)

Question of the Day

What are the play patterns of babyhood ? Dr Shabina Ahmed

(a) Sensorimotor play – This is the earliest form of play, kicking, moving fingers, etc.

(b) Exploratory play – Exploring their bodies by pulling hair, sucking their fingers, banging and throwing toys.

(c) Imitation play – During the 2nd year, the babies try to imitate the actions of those around them.

(d) Make believe play – Most babies endow their toys with the qualities they find they have in real life.

(e) Games – They play traditional games as peek–a-boo, pat–a–cake, hide and seek, play with parents, grand parents or older siblings.

(f) Amusements – Babies like to be sung to, talked to, read to, most fascinated

Liver Fact

SGOT can be more than SGPT in dengue fever

Women Safety Tips

If you are ever thrown into the trunk of a car, kick out the back tail lights and stick your arm out the hole and start waving like crazy"…… The driver won’t20see you, but everybody else will. This has saved lives.

World No Tobacco Day 31st May

Tobacco consumption is not acceptable in religious teaching. In Gurudwaras, entry with tobacco products is prohibited.


World No Tobacoo Day (WNTD) is being observed on 31st May 2010 at 3 PM in the Auditorium of Delhi Government Secretariat, I P Estate, New Delhi. Smt. Sheila Dikshit Hon'ble Chief Minister Delhi will be the chief guest. Dr Kiran Walia Hon'ble Health Minister Delhi will preside over. A community based integrated pilot project on tobacco cessation will be launched on the occasion. A comprehensive web site www.smokefreedelhi.org will also be launched by Dr S Bhattacharji, Director Health Services, Delhi Government on this occasion

eMedinewS Try this it Works

Stopping leaks after paracentesis

Persistent leakage of ascitic fluid is a common problem after abdominal paracentesis. Neither bandages nor drainage bags seem to help.

To prevent leakage, apply benzoin tincture around the site and place five or six Steri-Strips circumferentially around the tap site.

Make sure the tap site is near the midpoint of each strip. With half of the strip adherent to the benzoin, the other half is pulled taut and stuck down. This acts as a "drawstring" to cinch the site closed and can be removed 2 or 3 days later.

Dr Good Dr Bad

Situation: A patient with acute heart attack was not fit for reperfusion therapy.
Dr Bad: Start 60 mg prasugrel.
Dr Good: Chew 300 mg aspirin and 300 mg clopidogrel.
Lesson: For patients receiving no reperfusion therapy, start clopidogrel 300 mg as opposed to prasugrel.

Make Sure

Situation: A patient with diabetes shows deteriorating kidney function Reaction: Oh My God! His HBAIC is very high?
Lesson: Make sure that strict glycemic control is maintained in patients with type 2 diabetes in order to delay vascular complications.

IMANDB Joke of the Day


"Would you like a lock of my hair?" asked the gallant old bachelor of the spinster who had been a belle a few decades past.

"Why don’t you offer me the whole wig?" the maiden lady gibed, with a titter.

The bachelor retorted with icy disdain:

"You are very biting, madam, considering that your teeth are porcelain."

Formulae in Clinical Practice

Respiratory Index
Formula: PAO2 – PaO2/PaO2

Evidence Based Medicine (Dr varesh nagrath)

The risk of revision after primary total hip arthroplasty among statin users: a nationwide population-based nested case-control study.

Department of Orthopedics, Aarhus University Hospital, Aarhus N, Denmark. tt@dce.au.dk


BACKGROUND: Statins have been associated with beneficial effects on bone metabolism and inflammation in both experimental and clinical studies. The association between statin use and the risk of revision after primary total hip arthroplasty has not been examined.
METHODS: We identified 2349 patients from the Danish Hip Arthroplasty Registry who underwent revision of a primary total hip replacement in the period from 1996 to 2005 and matched them, using propensity score matching, with 2349 controls with a total hip replacement who had not had a revision. Using conditional logistic regression, we estimated the relative risk of revision due to all causes and due to specific causes according to postoperative statin use.
RESULTS: The ten-year cumulative implant revision rate in the underlying cohort of 57,581 total hip arthroplasties from the registry was 8.9% (95% confidence interval, 8.4% to 9.4%). Postoperative statin use was associated with an adjusted relative risk of revision of 0.34 (95% confidence interval, 0.28 to 0.41) compared with no use of statin. Statin use was associated with a reduced risk of revision due to deep infection, aseptic loosening, dislocation, and periprosthetic fracture. No difference in the risk of revision due to pain or implant failure was found between statin users and nonusers.
CONCLUSIONS: The use of statins was associated with a substantially lower revision risk following primary total hip arthroplasty. Statins, however, should not be prescribed to healthy patients undergoing total hip arthroplasty in order to improve the longevity of the replacement until further studies have confirmed our finding and the mechanisms for this association have been clarified.

Thillemann TM, Pedersen AB, Mehnert F, Johnsen SP, S balle K. The risk of revision after primary total hip arthroplasty among statin users: a nationwide population-based nested case-control study. J Bone Joint Surg Am. 2010 May;92(5):1063-72.

Milestones in Urology

1820–1904: Sir Henry Thompson, a British surgeon and polymath was awarded the Jacksonian Prize for an essay on the ‘pathology and treatment of stricture of the urethra’ (or stenosis of the urethra, a very common condition in the times of gonorrhea and other sexually transmitted diseases), and again in 1860 for another on the ‘health and morbid anatomy of the prostate gland.’ These two memoirs indicate the medical specialty to which he devoted his main attention, namely urology.

Lab Test (Dr Arpan Gandhi and Dr Navin Dang)

How was that reference range established?

The short answer is: by testing a large number of healthy people and observing what appears to be "normal" for them. The first step in determining a given reference range is to define the population to which the reference range will apply, for example, healthy females between 20 and 30 years old. A large number of individuals from this category would be tested for a specific laboratory test. The results would be averaged and a range (plus or minus 2 standard deviations of the average) of normal values would be established.

List of Approved drugs from 1.01.2009 to 31.10.2009

Drug Name


DCI Approval Date

Halobetasol Scalp 0.05% w/v

For the relief of inflammatory and pruritic manifestation of corticosteroid responsive dermatosis




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eMedinewS–Padma Con 2010

Will be organized at
Maulana Azad Medical College, New Delhi on July 4, 2010, Sunday to commemorate Doctors’ Day. The speakers, chairpersons and panelists will be doctors from NCR, who have been past and present Padma awardees.


eMedinewS–revisiting 2010

The second eMedinewS – revisiting 2010 conference will be held at Maulana Azad Medical College, New Delhi on January 2, 2011. The event will have a day–long CME, Doctor of the Year awards, cultural hungama and live webcast. Suggestions are invited .


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Public Forum (Press Release for use by the newspapers)

Smoking makes you 5 years older

Men have a greater chance of dying then women, and smoking increases any adult’s risk of death just as if five years were suddenly added to their age said Padma Shri and Dr B C Roy National Awardee Dr KK Aggarwal, President Heart Care Foundation of India.

  • For men who have never smoked, heart disease presents their greatest risk for death at any age, exceeding the odds of dying from lung, colon and prostate cancer combined.

  • Male smokers face a lung cancer risk that is greater than the odds of heart disease taking their lives after age 60, and is ten–fold higher than the chance of dying from prostate and colon cancer combined.

  • The chance of dying from heart disease and breast cancer are similar for nonsmoking women until age 60, when heart disease becomes a greater risk.

  • For female smokers, dying from lung cancer or heart disease is more likely than dying from breast cancer after age 40.

Diabetics who smoke are more likely to have severe hypoglycemia

People with diabetes who smoke are more than twice as likely to have an episode of severe hypoglycemia, or very low blood sugar, as those who have never smoked, Loss of sugar can cause mental confusion, or even coma or seizures in severe instances. Smoking, through its effect on hormone regulation and insulin clearance, has been hypothesized to result in severe hypoglycemia.

Quoting a study published in the journal Diabetes Care, Dr. Aggarwal said that after taking account of other factors, smoking conferred a 2.6–fold increased risk of having severe hypoglycemia.

Furthermore, smoking was associated with similarly increased odds of having diabetes–related nerve damage, impaired kidney function, and sight–threatening retinal defects.

Readers Responses

  1. Dear Dr. Aggarwal, Greetings from Apollo! I went through the article you have written in eMedinewS. It is very informative and thought provoking. It is a good article and I am happy to have read it. With warm personal wishes Dr. Prathap C. Reddy, Chairman, Apollo Group of Hospitals, 21, Greams Lane (Off Greams Road) Chennai 600 006, 044 2829 5777/2829 3101, fax: 044 2829 2104, chairman@apollohospitals.com

  2. Dear Dr. KK, Your suggestion that a centralized register should be maintained for doctors is a very good idea. This way we can check the fraud also. Who will do this. MCI or the health ministry? This centralized register should be kept at the MCI HQ. The data can be obtained from respective state medical associations, checked up properly and then entered into master register or on a website for information of all. The idea of allowing Nurse practitioners is also well founded as is done in some European and USA States. Certainly they will give better treatment compared to Quacks. Which authority will permit this? You being a DMC member can float this idea at the appropriate level for approval for the benefit of suffering humanity: Ashok Ahooja