July 13  2015, Monday
Heart Disease Myths
Dr KK AggarwalMyth No. 1– It is ok to have a high Blood Pressure in elderly.

Blood Pressure tends to rise with age, but it does not mean that this rise is normal. It happens because with age, the arterial walls become stiff and this stiffness cannot be called as a normal stiffness.

Stiff arteries make the heart to pump harder. Blood pounding against the artery walls, damages them over time.

The overworked heart muscles become less effective and pumps even harder to meet the body demand for blood. This further damages the arteries and invites fats into the artery walls. This results in lipid deposition, formation of blockage and future heart attack and paralysis.

So the fact is irrespective of age keep your diastolic blood pressure below 80 and systolic below 120. Start treatment if the blood pressure is more than 140/90.

Myth No. 2 – The risk of heart disease can be lowered with vitamins and supplements.

It’s a myth that vitamin C, E and β carotenes lower heart attack risk. The American Heart Association has stated that there is no scientific evidence that these supplements prevent or treat heart diseases.

The fact is eat a wide variety of nutritious food which includes all 6 tastes and 7 colors and get natural vitamins and supplements.

Myth No. 3 – Women do not suffer from heart disease.

The fact is whether you are a man or a woman, you are at risk, if you do not follow the lifestyle. Heart disease is the leading cause of death in women over age 65. Today more woman get heart disease than combine cancer in them.

Myth No. 4 – Heart patients should not eat fat at all.

It is true that you should eat a diet low in saturated fat and zero in transfats but other fats like unsaturated fats in vegetable oil are beneficial. Infact eating fish high in omega-3 fatty acids twice a week can lower the risk of heart disease.

5th July 2015: On occasion of Doctors’ day celebration Workshop on “Hypertension Learning Academy Module – II”
The 3rd Annual meeting of the Endocrine Society of Tamil Nadu and Puducherry will be held in Kodaikanal on 11th and 12th of July 2015. TRENDO 2015 is proposed to address latest updates, emerging concepts, clinical applications and controversies in diabetes, thyroid disorders, gonadal problems, pituitary disorders, metabolic bone disease and adrenal diseases.
Top News from ADA 2015
Hope Ahead? Varying Approaches Progress Artificial Pancreas

Conference attendees were treated to a progress report from several research teams developing "artificial-pancreas" systems. Incremental progress is steady; the remaining challenges include the prevention of hypoglycemia, which the systems have greatly reduced but not eliminated entirely, as well as postprandial glucose spikes resulting from delayed absorption of subcutaneously infused insulin. Scientists at the meeting also stressed that it will still be a few years before any of the systems in development are commercially available, likely around 2018. Nor do they represent a "cure" for type 1 diabetes but, rather, a "bridge" until such time as a cell-based cure is discovered.
Cardiology eMedinewS
  • The US Food and Drug Administration (FDA) has strengthened an existing label warning that nonaspirin nonsteroidal anti-inflammatory drugs (NSAIDs) may increase the risk for heart attack or stroke.
  • Just two drinks a day could increase a woman's blood pressure enough to put her at risk for hypertension, suggests new research published online in Hypertension.
Pediatrics eMedinewS
  • Children show emotions much younger than they understand them, suggests a new study showing that the winners of a contest - even the two-year-olds - showed some obvious swagger: heads held high, chests puffed out, hands on hips in a victorious power pose.
  • Screening newborn babies who are in the neonatal intensive care unit (NICU) using a testing process called high-frequency tympanometry can help identify middle-ear problems earlier, suggests new research published in the Canadian Journal of Speech-Language Pathology and Audiology.
Dr KK Spiritual Blog
Try to Get What You Like and Try to Like What You Get

Most people get frustrated when they do not get what they desire. The frustration can manifest as anger, jealousy or irritation, which can ultimately cause much more damage to the person. The law of nature is that you get what you deserve and not what you desire.

Each action has a karmic expression, which ultimately leads to a result, which can be desirable or undesirable. Each action, therefore, invariably ends into either a feeling of pleasure or pain. And the one which ends with pleasure creates more desire and attachment further leading to frustration.

What you are depends on your past karmic expression and what you will be in future will depend on your present karmic actions. For every action there is an opposite and equal reaction which is the natural law of karma. According to Vedanta scriptures, every karmic debt has to be paid sooner or later.

Every result should be accepted as a gift of the nature or the gift of God. One should not get excited nor tainted with results. According to Bhagavad Gita, one should be attached to the actions but detached from its results. Once you have controlled your mind and won over the
duality of pleasure and pain, you attain internal happiness and the realization of your true Self.

Every karmic expression should be accepted as a message from the God, the results of which may be evident later. Any bad experiences with your present karma need not necessarily mean that it is a result of your bad past karma or is a repayment of the past debt. It may also be taken as an experience to prevent occurrence of the same in future and also an opportunity to teach others through your own experience, so that they can prevent themselves from getting into such a bad experience. ‘The more you give, the more you get’ is another law of nature. If you want others to love you, you will also have to learn to love others.

The bad karmic actions done today can only give you a momentary pleasure, but in long run you will be a loser.

One should be content with what one gets, both in terms of one’s profession as well as day-to-day life. Contentment is the key to self-happiness. However, this does not means that one should not have any desire and one should leave everything to destiny. With continuous effort and repeated attempts, one can change one’s destiny.

Fulfillment of desires should also obey the laws of nature. Substantial fulfillment of desires is a supernatural power. People, who are committed or self-realized, attain these powers happenings and experience substantial effortless fulfillment of any desire. But even if one achieves that, one should not get attached to it. Fulfillment of desires should be seen as any ordinary karmic action and one should learn to detach oneself from the result of such an action.
Make Sure
Situation:A patient developed fainting attack after sublingual nitrate.
Reaction: Oh my God! Why was the systolic murmur missed on auscultation?
Lesson: Make sure that patient with LVOT obstruction are not given sublingual nitrates.
Dr Good Dr Bad
Situation:A patient was found to have waist-to-height ratio (WHtR) of more than 0.5.
Dr. Bad: It has no significance
Dr. Good: This is central obesity.
Lesson: Results of a cross-sectional study of Taiwanese adults concluded that a waist-to-height ratio (WHtR) greater than 0.5 is a simple, yet effective indicator of centralized obesity and associated cardiometabolic risk, even among individuals deemed 'healthy' according to body mass index (BMI), waist circumference.

(Copyright IJCP)
eMedi Quiz
A hemodynamically stable nulliparous patient with ectopic pregnancy has adnexal mass of 2.5 x 3 cms and Beta hCG titre of 1500 miu/ml. What modality of treatment is suitable for her:

1. Conservative management.
2. Medical Management.
3. Laparoscopic Surgery.
4. Laparotomy.

Yesterday’s Mind Teaser:A 55 year old lady presenting to outpatient department (OPD) with postmenopausal bleeding for 3 months has a 1x1 cm nodule on the anterior lib of cervix. The most appropriate investigation to be done subsequently is:

1. Pap smear.
2. Punch biopsy.
3. Endocervical curettage.
4. Coloposcopy.

Answer for yesterday’s Mind Teaser: 2. Punch biopsy.
Correct Answers received from:: B R Bhatnagar, Dr.Pravin H Patel, Daivadheenam Jella, Dr Avtar Krishan, Dr Prabodh K Gupta, Dr Poonam Chablani, Dr.K.Raju, Dr. G. Madhusudhan
Answer for 10th July Mind Teaser: 3. Borrelia recurrentis is the etiological agent.M
Correct Answers received: Dr G Madhusudhan, Dr R H Gobbur, Dr G Madhusudhan.
IJCP Book of Medical Records
IJCP’s ejournals
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
Press Release
Police people told that in low body temperature a person can be revived with CPR even after sometime

Cardiopulmonary Resuscitation may not be successful if the body temperature is less than 35°C, said Padma Shri Awardee Dr K K Aggarwal, President Heart Care Foundation of India and Honorary Secretary General IMA while giving training to a batch of 250 police people from PCR vans here today.

The foundation along with IMA and Delhi Red Cross Society with Delhi Police will be training 100% PCR staff by 14th August.

In hypothermic deaths, a person can be revived even after hours of cardiac arrest. Only once the body temperature is brought back to normal CPR will be effective.

As per the modern medicine, in cardiac arrest, the brain may not die for the next 10 minutes and during this period, if the heart can be revived, life can be brought back.

The revival of patient during this period can be remembered by the formula of 10: Within 10 minutes of the stoppage of heart (cardiac arrest), if effective chest compressions are given for the next ten minutes with a speed of 100 per minutes (10X10), 80% of the cardiac arrest victims can be revived.

This period can be much longer in hypothermia state. If the temperature of the body is low, the brain may remain alive till the temperature is brought back to normal.

There are instances in literature where a newborn with hypothermia was declared dead but revived in the cremation ground when the environment heat brought his temperature to normal and the pressure on the chest worked like cardiac massage.
eIMA News
Vyapam scam in Madhya Pradesh
Sri Narendra Modi ji
Prime Minister of India

Dear Sir

Indian Medical Association expresses it’s deep concerns over the issues revolving the Vyapam scam in Madhya Pradesh

It is unfortunate to learn that many Doctors and medical students fell victim to either malpractices related to admissions process or have been victimized for having shown the courage to expose the people behind the scam

Indian Medical Association takes strong exception to the fact that almost everyday key witnesses are being found dead in mysterious circumstances. This includes a dean of medical college who has shown exceptional courage in exposing the facts to the special investigation team. IMA requests to kindly speed up the CBI investigation so as to bring all the culprits to justice without delay

Thanks and regards

Prof Dr A Marthanda Pillai    Dr KK Aggarwal
National President                  Honorary Secretary General
Save Small Medical Establishments
Dr A Marthanda Pillai, Dr K K Aggarwal

Draft with input from Team IMA

1. Single doctor clinic and approachable cost effective small medical establishments with less than ten beds provide over 80% of health care delivery . Survival of these small hospitals has a very important bearing on the Indian healthcare system. They provide cheap, affordable, accessible, approachable, quality care with personal touch.

2. The new corporate health care weather single clinic based or ten bedded set up is machine centric and cost escalate. A lot of private equity is coming towards relatively low cost healthcare chains which specialize in one field. Big hospital chains are rushing to small towns. But the same ultimately will raise the cost of treatment and the smaller establishments will start vanishing from the society

3. Smaller medical establishment to cut the cost may lack in some aspects of hospitality and use of cutting edge technology. They will have core clinical care but may lack in support activities.

4. Small medical establishments, most being established in neighbourhood residential areas, save money in the land cost

5. Any corporate set up would involve buying land at high prize, huge capital expenditure, buying and replacing expensive equipments and more cost on hiring human resources

6. With over 100 acts to comply the cost of any corporate set up is very high

7. Unfortunately the insurance companies are not covering cost of patients in medical set-ups with less than 10 beds. Under Rashtriya Swasthya Bima Yojana(2007), for Rs.30 a year each family receive 30K coverage in medical care. Out of 8crore poor families, already 1.5crore families are enrolled. But, Only 4000 hospitals are empanelled.

8. Smaller establishments through the IMA will need to fight for their rights. The minimal norms need to change to 5 bedded hospitals and not ten bedded. Insurance companies need to recognize day care centers and single doctor clinics

9. Make sure the treatment cost is low & QUALITY HIGH.
1. Reduce the procedure cost and make profit through volume of work

2. Administrative costs to be contained to 3% of a patient's bill.

3. Adopt IT in health care: Use telemedicine in radiology, intensive care unit.

4. Transform from GP to FP (Family physician) with GMP.

5. Smaller establishments also need to reduce their cost further and insist in quality. They must rely on cheaper quality drugs; learn the concept of ethical earning; buy equipments through equipment protection scheme of IMA; bargain on the costly of equipments through IMA; get their institution or clinic accredited by IMA and by NABH through IMA HBI; sign up cheap maintenance of medical equipments through IMA; and through IMA extend the life of CT, MRI, Cath Labs and all these expensive machines from the current seven years to 14 years. They also should adopt IT in health care and make hospitals paperless and filmle

6. There is lot of scope. According to WHO standards, the number of beds required is 4 per 1,000 populations, so there is a tremendous scope for growth. Out of this growth small hospitals will contribute to 80% of the beds. Presently, it is almost 600,000 crore industry. 20% Of the $33 billion that Indians spend on healthcare, is spent in smaller towns

7. IMA should fight for a single Window clearance and permissions for these establishments

8. IMA should peruse for amendments to insurance stipulations - empanelment to hospitals, clinics, day care centers irrespective of bed strength and floor-space index. Empanelment criteria should be categorized as rural, semi-urban and urban hospitals.

9. All doctors should use universal disease management protocols- stipulated and structured only by medical associations but not by Govt

10. IMA should ask the government to provide soft loans (4% interest) to these set ups. Also small hospitals should be out of the ambit of CE act implications, ESI regulations and FIRE SAFETY regulations. Small hospitals are professional service centers and not commercial outfits. Duty on medical equipment and devices should be removed.

Input from Dr S Raju and others
FDA Stiffens Warning on NSAID Cardiovascular Risk: Use the lowest NSAID dose for the shortest time
MedPage Today: The US FDA is strengthening an earlier warning about the cardiovascular safety of non-aspirin nonsteroidal anti-inflammatory drugs (NSAIDs), both prescription and nonprescription.

The new labels for prescription NSAIDs should contain the following information, according to the FDA:

The risk of heart attack can occur within weeks of starting an NSAID, and that risk may increase with longer use.

The risk seems to be higher at higher doses.

It’s not clear if the risk of heart attack and stroke is the same for all NSAIDs.

The drugs can raise the risk of heart attack or stroke in both patients with a risk of heart disease and patients without.

Patients with heart disease or risk factors for it are at a greater risk of heart attack or stroke following the use of NSAIDs, because they have a higher risk at baseline.
There is also an increased risk of heart failure for patients using NSAIDs.
This latest warning follows at least a decade of concern about the safety of NSAIDs.

In 2005, the USFDA issued a warning about NSAIDs and asked Pfizer to withdraw its drug valdecoxib from the market after concerns about an increased risk of cardiovascular events and serious skin reactions. They also required the relabeling of other COX-2 selective inhibitors like celecoxib.
In 2007, the American Heart Association joined in, urging clinicians to use the lowest NSAID dose for the shortest time needed.
In 2011, the public health coalition Alliance for Rational Use of NSAIDs was formed to raise awareness of the significant health risks associated with NSAIDs.

In 2013, a Lancet meta-analysis of trials showed that high doses of common NSAIDs increased the risk of vascular events by a third.

It was believed that all NSAIDs had a similar risk, but recent evidence calls that into question. The analysis in The Lancet indicated that naproxen appeared to be the safest of the available NSAIDs. But last year, an FDA advisory committee voted that the warning label on naproxen should not be changed to say that it had a better cardiovascular risk profile than other similar drugs, since there was still insufficient evidence.

The US FDA said the warning is coming after they reviewed a meta-analysis of clinical trials on the risk of cardiovascular and upper gastrointestinal events with NSAID use and other observational studies.

Patients and health care professionals should remain alert for heart-related side effects the entire time that NSAIDs are being taken.

Patients taking NSAIDs should seek medical attention immediately if they experience symptoms such as chest pain, shortness of breath or trouble breathing, weakness in one part or side of their body, or slurred speech.
  • Middle-aged and older adults with torn cartilage or painful arthritis in their knee are not likely to benefit from arthroscopic surgery, and could be harmed by it, suggests a review of past studies, published online in the BMJ.
  • Very small (<3 mm) brain lesions, often dismissed as benign, more than triple the risk for stroke and stroke-related death in asymptomatic middle-aged and older adults with no history of clinical stroke, suggests new research published online in Annals of Internal Medicine.
  • New research led by University of Pennsylvania scientists suggests that mutations in an X chromosome gene called TEX11 are responsible for about 1% of azoospermia cases.
  • In a report published in the Journal of the Academy of Nutrition and Dietetics, investigators describe how a new scoring method for assessing beverage intake, the Healthy Beverage Index (HBI), can be used to more accurately evaluate dietary consumption of all types of fluids. Higher HBI scores were associated with more favorable lipid profiles, decreased risk of hypertension; and, among men, better C-reactive protein (CRP) levels.
  • Patients with type 2 diabetes have impaired cerebral blood flow that's tied to cognitive changes, even over the short time period of 2 years, suggests new research published online in Neurology.
Inspirational Story
Competing with Others

I was jogging one day and I noticed a person in front of me, about one–fourth of a mile. I could tell he was running a little slower than me and I thought, good, I shall try to catch him. I had about a mile to go my path before I needed to turn off. So I started running faster and faster. Every block, I was gaining on him just a little bit. After just a few minutes I was only about 100 yards behind him, so I really picked up the pace and push myself. You would have thought I was running in the last leg of London Olympic competition. I was determined to catch him. Finally, I did it! I caught and passed him by. On the inside I felt so good.

"I beat him" of course, he didn’t even know we were racing. After I passed him, I realized I had been so focused on competing against him that I had missed my turn. I had gone nearly six blocks past it. I had to turn around and go all back. Isn’t that what happens in life when we focus on competing with co–workers, neighbors, friends, family, trying to outdo them or trying to prove that we are more successful or more important? We spend our time and energy running after them and we miss out on our own paths to our God given destinies.

The problem with unhealthy competition is that it’s a never ending cycle. There will always be somebody ahead of you, someone with better job, nicer car, more money in the bank, more education, better behaved children, etc. But realize that "You can be the best that you can be, you are not competing with no one."

Some people are insecure because they pay too much attention to what others are doing, where others are going, wearing and driving.

Take what God has given you, the height, weight and personality. Dress well and wear it proudly! You’ll be blessed by it. Stay focused and live a healthy life. There’s no competition in DESTINY, run your own RACE and wish others WELL!
Quote of the Day
Chance favors those in motion. James Austin
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Reader Response
The right up is exhaustive but not practical especially in metropolitan cities because of overpopulation, traffic congestion, encroachment, lack of space, and lawlessness. Still some issues are doable and one should try for our own benefit. Thanks Dr A M Pillai And KK. Regards: Dr V K Monga
Wellness Blog
Vitamin D intake associated with reduced risk for Crohn’s disease

Increased intake of vitamin D may significantly reduce the risk for Crohn’s disease (CD) in women, according to an article published online December 12 and in the March issue of the journal Gastroenterology.
  • This study involved 72,719 women who returned the 1986 questionnaire. They had data on both vitamin D intake and physical activity and did not have a history of CD or ulcerative colitis (UC).
  • Diagnosis of CD was based on a typical history of 4 weeks or longer and was confirmed by radiologic, endoscopic, or surgical evaluation.
  • The diagnosis of UC was based on typical clinical presentation of 4 weeks or more and endoscopic, radiologic, or surgical evaluation.
  • Mean age of the participants at baseline was 53 years, mean body mass index (BMI) was 25.4 kg/m2, mean physical activity was 13.2 metabolic hours per week, 94.5% were white and 36.6% never smoked.
  • A documented 122 cases of CD and 123 cases of UC were recorded during 1,492,811 person–years of follow–up. The median predicted 25(OH)D level was 27.6 ng/mL.
  • Women in the lowest quartile of predicted 25(OH)D level compared with those in the highest quartile had a higher body mass index, were less active, tended to reside in the Northern or Midwestern regions of the United States, and had lower intake levels of dietary or supplemental vitamin D. The median age of diagnosis of CD was 64.0 years; for UC, it was 63.5 years.
  • The median interval between assessment of plasma 25(OH) D levels and disease diagnosis was 12 years for UC and 10 years for CD.
  • For every 1 ng/mL increase in predicted 25(OH)D level, the risk for CD was reduced by 6%.
  • For UC, there was also a reduction in risk, but it was non-significant at 4%.
  • Women in the highest two quartiles of 25(OH)D levels had multivariate HRs of 0.50 and 0.55, respectively, for CD.
  • Each 100 IU/day increase in total intake resulted in a 10% reduction in UC risk and a 7% reduction in CD risk.
  • For vitamin D intake from diet and supplements based on quartile distribution, there was a significant linear inverse trend for vitamin D intake and UC risk, but this trend was weaker for CD.
  • Intakes of 800 IU/day or higher resulted in greater reductions in the risks for UC and CD.
  • Vitamin D intake was inversely associated with the risks for CD and UC, vitamin D insufficiency or deficiency was an important mediator in the pathogenesis of UC and CD, and assessment of vitamin D status should be a part of the assessment of inflammatory bowel diseases.
IMA Humor
Law of Bag/Box Occupancy

All bags and boxes in a given room must contain a cat within the earliest possible nanosecond.
Rabies News (Dr A K Gupta)
A previously immunized person is bitten again. What is the re–exposure immunization schedule?

Only two doses of vaccine at Days 0 and 3 are required. RIGs are not required (WHO 2007). However, in laboratory–confirmed rabies exposures, irrespective of past rabies immunization, full course of PEP and RIGs is recommended. In rabies, it is safer to overtreat than undertreat.
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