medinews march 2011 by IJCP

Vol. 11, No. 3, March 2011

ISSN 0971-880X

Single Copy Rs. 100/-

Pages 12

Dr KK Aggarwal Gr. Editor-in-Chief, IJCP Group

Member The Indian Newspaper Society

Official Voice of Doctors of India

d i t o r i a l

Women, Work, Stress and Heart Disease: 5 ways to Protect Yourself

Dr KK Aggarwal

Padma Shri and Dr BC Roy National Awardee Sr Physician and Cardiologist, Moolchand Medcity President, Heart Care Foundation of India Group Editor-in-Chief, IJCP Group Editor-in-Chief, eMedinewS Chairman Ethical Committee, Delhi Medical Council Director, IMA AKN Sinha Institute (08-09) Hony. Finance Secretary, IMA (07-08) Chairman, IMA AMS (06-07) President, Delhi Medical Association (05-06) emedinews@gmail.com http//twitter.com/DrKKAggarwal Krishan Kumar Aggarwal (Facebook)

arvard researchers have uncovered strong links between women’s job stress and cardiovascular disease. Findings from the Women’s Health Study, involving more than 17,000 female health professionals, show that women whose work is highly stressful have a 40% increased risk of heart disease (including heart attacks and the need for coronary artery surgery) compared with their less-stressed colleagues. The results, which were presented at an American Heart Association meeting in 2010, also showed that women who worry about losing their jobs are more likely to have high blood pressure and unhealthy cholesterol levels and to be obese. ‘Job strain’ combines psychological demand and degree of control. ‘Demand’ refers to the amount, pace and difficulty of the work. ‘Control’ means the ability to make work-related decisions or be creative at work. A large 15-year study of nurses in Denmark also concluded that the greater the work pressure, the higher the risk for heart disease among women ages 51 and under. And in a study of white-collar workers in Beijing, job strain was associated in women (but not in men) with increased thickness of the carotid artery wall, an early sign of cardiovascular disease.

Stress with a ‘fight-or-flight’ response, triggers a cascade of chemicals and hormones that speed the heart rate, quicken breathing, increase blood pressure and boost the amount of energy (sugar) supplied to muscles. The body does not differentiate between grave, imminent dangers and less momentous ongoing sources of stress, such as financial difficulties, job strain and even worries about potential problems that haven’t yet arisen. When the fight-or-flight response is chronically in the ‘on’ position, the body suffers. The stress may aggravate inflammation in coronary arteries, leading to blood clots that can trigger a heart attack. Stress also makes it harder to practice heart-healthy habits, such as exercise, a good diet, not smoking and adequate sleep. It’s hard to tell what proportion of heart attack risk is due to psychological Make Sure I n s i d e stress as opposed to, say, smoking or lack of exercise. D uring Medical Practice And some women may be predisposed (genetically or from News & Views 3 A patient with diabetes shows deteriorating early life experience) to react less effectively than others to kidney function. stressors. • Foster mutually supportive relationships with friends,

family, and co-workers.

Oh my God! His HbA1c is very high!

Experts’ Views

Photo Quiz

Medifinance

Legal Column

• Get regular exercise. It’s good for the heart, reduces

anxiety and depression, and improves sleep. • Limit intrusions (such as work-related e-mails) on your ©IJCP Academy

life outside of work. • Practice relaxation techniques, such as meditation, deep

breathing, progressive relaxation or visualization. • If you’re feeling overwhelmed seek help from a mental

health professional. Source: Health Beat Harvard

Make sure that strict glycemic control is maintained in patients with type 2 diabetes in order to delay vascular complications.

KK Aggarwal

8th World Fellowship of Religions & th Perfect Health Parade 11 An Event by WFR & Heart Care Foundation of India to earmark WHO day

Programme

Sunday 3rd April 2011

One day conference on Global warming and ethnic crisis involving all pathies and all religions.

Maulana Azad Medical College Dilli Gate, New Delhi Time: 8 am to 6 pm

Flag Off Time: 10 am Perfect Health Parade Route The Parade will flagged off at 10 am from opp. Maulana Azad Medical College towards Delhi Secretariat) and towards Vikas Marg – Shahdara – Seemapuri – Guru Tegh Bhadur Hospital – Seelampur Pusta – Gandhinagar, to ISBT Kashmiri Gate – Civil Lines – Delhi University North Campus – Azadpur – Punjabi Bagh – Mayapuri – Raja Garden – Janakpuri – Tilak Nagar – Tihar Jail Road – Delhi Cantt. – R.K. Puram – Munirka – IIT Gate – Panchsheel Park – Chirag Delhi Flyover – Nehru Place – Modi Mill Flyover – Ashram – Nizamuddin – Sunder Nagar – Pragati Maidan – ITO – finally culminate at Maulana Azad Medical College at 4 pm.

Conference Time: 11 am - 5 pm A Day-long Conference The 6-8 hours conference will have two sessions firstly involving the religious scholars and secondly the medical experts from all pathies. Address for Correspondence 23, Bhai Veer Singh Marg, Gole Market, Connaught Place, New Delhi 110001, Phone 23340469 E-mail: hcfi.1986@gmail.com For Participation in Conference & Parade Contact: Dr KK Aggarwal 9718336056 Our websites

www.kkaggarwal.com, www.ijcpgroup.com, www.emedinews.in, www.heartcarefoundation.org, www.perfecthealthmela.net Forthcoming events v A day-long “Medifinance” Conference 13th March

v Dil Ka Darbar 4th September, 2011, Sunday.

v 18th Perfect Health Mela, Sunday 16th - 23rd October, 2011

v eMedinewS Revisiting 2011 January 15th, 2012, Sunday

News & Views Exercise is Actually Good for the Knees, Study Shows

or years, studies have offered conflicting opinions on whether exercise is good for knees. A new report released by the American College of Sports Medicine (ACSM) provides strong evidence that exercise is, in fact, good for the knees. The report, titled “What is the Effect of Physical Activity on the Knee Joint? A Systematic Review,” was published this month in Medicine & Science in Sports & Exercise, ACSM’s official scientific journal. A research study led by Donna Urquhart, PhD, and Flavia Cicuttini, PhD, examined the effects of physical activity on individual parts of the knee. “Several studies have already examined the impact of physical activity on the knee as a whole, but none have looked at the effect of physical activity on individual parts of the knee,” said Dr Cicuttini, head of the musculoskeletal unit in the School of Public Health and Preventive Medicine at Monash University in Australia. “As it turns out, exercise affects each part of the knee differently, which helps explain why there have been conflicting reports for so long.” According to the team’s findings, while exercise was linked to osteophytes or bony spurs, there were no detrimental changes to joint space, the place where cartilage is housed. There were beneficial effects on cartilage integrity, with evidence of greater volumes and fewer defects. “These findings are significant, as they suggest that osteophytes, in the absence of cartilage damage, may just be a functional adaptation to mechanical stimuli,” said Dr Urquhart. The report comprised data from 28 studies, representing 9,737 participants from all parts of the world. All included studies examined the relationship between physical activity and knee osteoarthritis and also included magnetic resonance imaging (MRI) evidence of osteoarthritic knees when investigating disease progression or healthy knees when investigating disease incidence. Osteoarthritis – a degenerative joint disease that attacks cartilage and underlying bone and often preys on knees, hips and hands – affects nearly 27 million Americans and is the leading cause of disability in non institutionalized adults.

Tomatoes, The New Superfood

ating more tomatoes and tomato products can make people healthier and decrease the risk of conditions such as cancer, osteoporosis and cardiovascular disease, according to a review article in the American Journal of Lifestyle Medicine. Of all the nonstarchy vegetables, Americans eat more tomatoes and tomato products than any others. Researchers Britt Burton-Freeman, PhD, MS and Kristin Reimers, PhD, RD of the National Center for Food Safety & Technology, Illinois Institute of Technology and ConAgra Foods, Inc., looked at the current research to discover the role tomato products play in health and disease risk reduction. The researchers found that tomatoes are the biggest source of dietary lycopene; a powerful antioxidant that, unlike nutrients in most fresh fruits and vegetables, has even greater bioavailability after cooking and processing. Tomatoes also contain other protective mechanisms, such as antithrombotic and anti-inflammatory functions. Research has additionally found a relationship between eating tomatoes and a lower risk of certain cancers as well as other conditions, including cardiovascular disease, osteoporosis, ultraviolet light-induced skin damage and cognitive dysfunction. Tomatoes are widely available, people of all ages and cultures like them, they are cost-effective and are available in many forms. “Leveraging emerging science about tomatoes and tomato products may be one simple and effective strategy to help individuals increase vegetable intake, leading to improved overall eating patterns and ultimately, better health.” write the authors. “Tomatoes are the most important nonstarchy vegetable in the American diet. Research underscores the relationship between consuming tomatoes and reduced risk of cancer, heart disease and other conditions,” the authors conclude. “The evidence also suggests that consumption of tomatoes should be recommended because of the nutritional benefits and because it may be a simple and effective strategy for increasing overall vegetable intake.” The article is particularly timely since the recently released Dietary Guidelines for Americans 2010 moved tomatoes to a newly established category of ‘orange/red’ fruits and vegetables to encourage higher consumption of these healthy foods.

Experts Disagree on Virtual Colonoscopy use Recommendations

he American Cancer Society, the American College of Physicians and other gastroenterology experts recommend virtual screening every five years, but the US Preventive Services Task Force concluded the evidence wasn’t strong enough to justify Medicare coverage of the service.

Sleeping on Stomach may Cause Lower Oxygen Levels in Infant Brains

abies who sleep on their stomachs - a position thought to pose a risk for SIDS - have lower levels of oxygen in their brains than those who sleep on their backs, according to a study published online in the journal Pediatrics.

$1 Million USDA Grant Aims to Reduce Obesity in Preschoolers

he preschool years are a critical period for addressing weight-related behaviors among at-risk groups, say researchers at the University of Illinois at Chicago (UIC). Among young children, obesity has tripled since 1980, and the prevalence is highest among black and Hispanic children. The UIC researchers have received a $950,000 grant from the US Department of Agriculture to integrate obesity-prevention strategies into programs delivered to low-income families through the University of Illinois Extension Cook County, and Supplemental Nutritional Assistance Program Education. Over the past decade, a team led by UIC researcher Marian Fitzgibbon developed an obesity intervention called ‘Hip-Hop to Health.’ The program has been used in Head Start and Chicago Public School preschool programs and was found to be effective in reducing body mass index in 3- to 5-year-old minority, low-income children. “By partnering with existing nutrition programs that are designed to provide information on basic nutrition, food budgeting, shopping skills and food safety to improve the health of low-income families, we will have direct access to a population of children at risk for obesity and related conditions,” says Fitzgibbon, who is principal investigator of the study and deputy director of UIC’s Institute for Health Research and Policy. Hip-Hop to Health targets preschool children and their parents and includes programming on physical activity, television viewing, food available in the home, portion sizes, obesity prevention strategies and contextual factors that can create barriers to healthy eating and physical activity. Researchers will enroll approximately 180 parent/child pairs who attend the USDA’s Expanded Food Nutrition Education Program and Supplemental Nutrition Assistance Programs in Chicago. Study participants will receive Hip-Hop to Health or general nutrition programming during six sessions over six months. “The goal of the research is to implement an appealing and effective exercise and nutrition program for wide-spread use in clinical, community and school settings that addresses the problem of pediatric obesity,” said Fitzgibbon. Angela OdomsYoung, assistant professor of kinesiology and nutrition, is co-principal investigator of the study; Carol Braunschweig, associate professor of kinesiology and nutrition, and Melinda Stolley, associate professor of medicine, are co-investigators. UIC ranks among the nation’s leading research universities and is Chicago’s largest university with 27,000 students, 12,000 faculty and staff, 15 colleges and the state’s major public medical center. A hallmark of the campus is the Great Cities Commitment, through which UIC faculty, students and staff engage with community, corporate, foundation and government partners in hundreds of programs to improve the quality-of-life in metropolitan areas around the world.

Some Stroke Survivors Skipping Prescribed Medications due to High Costs

ccording to research presented at the American Stroke Associations International Stroke Conference, some stroke survivors skip prescribed medications because the cost is too high - a situation that may be worsening, particularly among young and uninsured patients.

Vitamin D3 supplementation may Decrease PTH Levels in HIV-infected Youth Receiving Tenofovir

12-week course of high-dose vitamin D3 supplementation is safe and significantly reduces both vitamin D insufficiency and serum parathyroid hormone (PTH) levels in HIV-positive youth who are being treated with the reverse transcriptase antiretroviral tenofovir, according to findings presented at the Retroviruses and Opportunistic Infections conference.

Can a Woman with Swine Flu Breastfeed her Baby?

reastfeeding is an option if a sick mother has recovered from the virus. The risk for transmission of the virus through breast milk is unknown but is probably rare. Actively infected women who are able to express their milk for bottle-feeding should let a healthy family member take over feeding. If the mother is taking an antiviral medication, she can still breastfeed, but she needs to be on the antiviral medication for a least 48 hours before. —Dr GM Singh

Health Hazards of Ammonia • At room temperature, ammonia is a colorless, pungent-

smelling gas and is lighter than air. • At –28oF (–33oC), ammonia becomes a liquid. • In water, most of the ammonia changes to ammonium

ion, NH4+. • Ammonia is an essential element for plant, animal

and human life. It is found in water, soil and air, and is a source of much needed nitrogen for plants and animals. • Most of the ammonia in the environment comes from the

natural breakdown of manure, dead plants and animals. Man-made sources of ammonia include fertilizers, power plants, mobile sources and other manufacturing emissions. • Ammonia levels in the air as low as 5 parts per million

(ppm) can be recognized by odor. An average person detects ammonia by odor at around 17 ppm. • According to the World Health Organization, continuous

exposure to 25 ppm of ammonia in the air does not result in a significant increase in blood levels of ammonia in the body. • According to the Occupational Safety and Health

Administration, the least amount of ammonia which is found to irritate the eyes, nose and throat of the most sensitive individuals is 50 ppm.

• Because ammonia is a respiratory tract irritant, persons

who are hyperreactive to other respiratory irritants, or who are asthmatic, may be expected to be more susceptible to inhalation of high concentrations of ammonia. • When ammonia enters the body as a result of breathing,

swallowing or skin contact, it reacts with water to produce ammonium hydroxide. This chemical is very corrosive and damages cells in the body on contact. • Ammonia is corrosive. The severity of health effects

depends on the route of exposure, the dose and the duration of exposure. Exposure to high concentrations of ammonia in air causes immediate burning of the eyes, nose, throat and respiratory tract and can result in blindness, lung damage or death. Inhalation of lower concentrations can cause coughing, and nose and throat irritation. • To reduce the effects from exposure to ammonia, it is

important to wash eyes and skin as quickly as possible with large amounts of water. There is no antidote for ammonia poisoning, but ammonia’s effects can be treated, and most victims recover. People who experience serious signs and symptoms (such as severe or constant coughing, or burns in the throat) may need hospital care. • Ammonia is a strong, colorless gas. If the gas is dissolved

ammonia found in the environment causes birth defects or other developmental effects.

in water, it is called liquid ammonia. Poisoning may occur if you breathe in ammonia. Poisoning may also occur if you swallow or touch products that contain very large amounts of ammonia.

• Because ammonia is present in the human body at

• GIT: When swallowed, ammonia can cause abdominal

• There is no evidence that ammonia causes cancer. • There is no evidence that exposure to the levels of

all times, no long-term health effects from inhalation exposure to low levels of ammonia would be expected.

pain, vomiting and gastritis. • Contact with skin: Can cause irritation and burns.

Glucose Target for ICU Patients should not Exceed 180 mg/dl

ccording to the Endocrine Society, new glucose management guidelines released last week by the American College of Physicians (ACP) may not go far enough to adequately protect patients in the intensive care unit (ICU). In fact, the glucose target for ICU patients should be no more than 180 mg/dl, the group argued in response to the 200 mg/dl upper limit recommended by the ACP. In a statement, the Endocrine Society noted that exceeding the 180 mg/dl target has been linked to a great risk for infection, hospital stays that last longer and higher rates of mortality.

Chewable Integrase Inhibitor may Suppress HIV in Young Children

hewable tablets containing the integrase inhibitor raltegravir appear to help children ages 2-5 control HIV even after previous regimens have failed to keep the virus in check, according to findings presented at the Retroviruses and Opportunistic Infections conference.

Experts’ Views Obesity Update Childhood Obesity: Are we Carrying Excess Baggage? Bariatric Surgeries for Surgical Management of Obesity Weight-loss surgery can be a safe and effective option for some severely obese adolescents who have been unable to lose weight using conventional weight-loss methods. However, as with any type of surgery, there are potential risks and long-term complications. The surgical mortality rate is <0.5% at centers specializing in bariatric surgery. But, the long-term effects of weight-loss surgery on a child’s future growth and development are largely unknown.

Among the Standard Bariatric Procedures are • Roux-en-Y gastric bypass reduces stomach size and is the most common procedure performed. • Biliopancreatic diversion with duodenal switch is similar in some ways to Roux-en-Y gastric bypass, but keeps some

stomach function intact while bypassing most of the intestine. • Laparoscopic adjustable gastric banding involves placing an inflatable band around the upper portion of the stomach to

restrict the amount of food one can consume. This minimally invasive procedure is adjustable and reversible. • Jejunoileal bypass procedures • Sleeve gastrectomy involves surgically removing the left side of the stomach, leaving a much smaller stomach about

the size and shape of a banana. • Experimental: Gastric pacing devices implanted laparoscopically. Emerging data suggest that gastric pacing achieved

by using implantable electrodes may have substantial significant weight-loss effects. Ten patients in whom the pacing device was laparoscopically implanted showed a mean excess weight loss of about 25% at 3-year follow-up. Bariatric surgeries are done mostly using minimally invasive (laparoscopic) surgery, which can help decrease hospital stay time and speed up recovery. —Dr Parveen Bhatia and Dr Rama Lakshmi

Medicine Update When should Glycogen Storage Disease be Suspected Clinically?

Insulin and C-peptide

On History

C-peptide measurements can be used in conjunction with insulin and glucose levels to help diagnose the cause of documented hypoglycemia and to monitor its treatment. C-peptide levels are measured:

• Symptoms

• In newly diagnosed type 1 diabetes, as part of an

that can be attributed to sustained hypoglycemia - lethargy, sweating, seizures, failure to thrive

• Developmental delay • Cardiomyopathy - repeated episodes of CHF • Muscle weakness and cramps, which increases on

exercise • Delayed motor milestones • Neonatal jaundice which is prolonged —Dr Neelam Mohan Director Pediatric Gastroenterology Hepatology and Liver Transplantation Medanta – The Medicity

Lab Update

evaluation of ‘residual b-cell function’ • In type 2 diabetes, to monitor the status of b-cells and insulin production over time and to determine if/when insulin injections may be required.

Abnormal Findings • High C-peptide levels generally indicate high levels

of endogenous insulin production. High levels of C-peptide also are seen with insulinomas (insulinproducing tumors) and may be seen with hypokalemia, pregnancy, Cushing’s syndrome and renal failure. • Low C-peptide levels are associated with low levels of insulin production. —Dr Arpan Gandhi and Dr Navin Dang

Photo Quiz Acute Foot Rash in a Healthy Child During Travel

uring a trip to Brazil, a two-year-old girl presented with sudden foot pain while playing in the dirt near a tree. Her mother saw no glass, nails, or insects on the ground where the child was playing. The sole of the child’s left foot initially turned white in a linear pattern. Three hours later, the foot was erythematous with multiple petechiae (Figure 1). Swelling progressed from the sole to the rest of the foot, and then to the ankle with linear streaks. The child could not put weight on the foot. Four hours after the injury, she developed a fever of 103°F (39.4°C) and was difficult to console. Oral and topical antibiotics and acetaminophen were ineffective.

Question Based on the patient’s history and physical examination, which one of the following is the most likely diagnosis? A. B. C. D. E.

Acute dermatitis. Cellulitis. Contusion. Foreign body injury. Insect bites.

Figure 1. (For Answer and Discussion, see page 10...)

Rabies Update What is a Fixed virus? Fixed virus is a type of rabies virus which is an attenuated street virus least virulent, and has a fixed short incubation period of 5-9 days. It is used as seed virus for manufacturing rabies vaccines.

Can ‘Major Surgery’ be Conducted after a Dog Bite? Generally, there is no contraindication for any surgery along with antirabies treatment. A full course of antirabies vaccine including rabies immunoglobulins (RIGs) may be given, irrespective of surgery or other procedures. —Dr AK Gupta RP Bagh, Delhi, Author of ‘RABIES - the Worst Death’

New TRAI Rules • As per New TRAI rules from 1st March, 2011, SMS

• New TRAI rules come into effect from 1st March 2011.

will not be delivered on Mobiles who have registered their Mobile number in DND (Do-Not-Disturb).

• SMS will be delivered between 9.00 a.m. to 9.00 p.m.

• To receive the SMS they must remove their numbers

from DND. • To remove the number from NDNC (National Do

Not Call): Call 1909 or send SMS ‘STOP 0’ to 1909 as early as possible. • To check the DND numbers on Web: http://nccptrai.

gov.in/nccpregistry

• Sender ID will be replaced with a 5 digit number. • All types of SMS will not delivered on NDNC

number. • Pls referred the website for new rules for TRAI

regulation: http://ndncregistry.gov.in/ndncregistry/ index.jsp or http://nccptrai.gov.in/nccpregistry/

Medifinance Budget Snapshot 2011-12 - Key Features (General) Indian Economy Overview

• MFs allowed to raise money from foreign investors.

• Economy – Gross Domestic Product estimated to have

grown at 8.6% in 2010-11. • Exports grown by 29.4% and Imports grown by 17.6%. Further expected to grow at 9%.

Tax Reforms • Direct Tax Code (DTC) to be effective from 1st April,

2012.

• Goods and Service Tax been narrowed.

Investment Environment • Liberalize FDI policy in various sectors under

discussion. This area is still not addressed. A real drawback. • Direct investment in Indian Mutual Funds by any foreigner. This is a big positive.

This is a big positive. • Reforms in Housing Sector Finance Introduced.

Black Money • Five-fold strategy to be put in operation to deal with

problem of generation and circulation of black money. • Tax Information Exchange Agreements (TIEA) and Double Taxation Avoidance Agreements concluded. • (Recently TIEA was done with British Virgin Islands, Isle of Man, Bermuda, Cayman island, Gibraltar, Guernsey, Jersey, Macau, etc.) • GAAR under DTC is based on similar lines.

Improving Governance • UID Mission (under the leadership of Nandan Nilekani).

Likely generation of 10 Lac Aadhar numbers per day.

—Saurabh Aggarwal

Budget 2011 Highlights Income Tax • Basic Exemption Limits raised from 1.60 lakhs to 1.80

health check-ups, Life Insurance services providers, Legal representative.

lakhs, for Senior Citizens (now 60 years) to 2.50 lakhs and very Senior Citizens (80 years) 5 lakhs.

• Service Tax on Air travel raised (Both domestic and

• Surcharge on Domestic Companies reduced from 7.5%

• Reduction in number of exemptions in Central Excise

to 5%, and MAT raised from 18% to 18.5%. • DTC proposed to be effective from 1st April 2012. • New reduced Corporate Tax rate for Domestic

Companies will be 32.445%. • Weighted deduction on contributions made to National

Laboratories, Universities and Institute of Technology increased from 175% to 200%. • Lower Tax Rate of 15% on Dividends received by an

Indian Company from its foreign subsidiary.

Service Tax and Excise

international). rate structure. • General Excise Duty and Service Tax remains 10%.

Basic Excise rate raised from 4% to 5%. • Five percent Service Tax on all services provided by

hospitals with 25 or more beds with facility of central air conditioning. • Optional levy on branded garments or made up

proposed to be converted into a mandatory levy at unified rate of 10%. • All individual and sole proprietors having turnover

• Service Tax extended on New Services: AC Bars and

upto ` 60 lakhs exempted from the formalities of audit.

Restaurants, Hotel where rent is above ` 1,000/day,

—Tarun Kumar, CA

20% Hike in Health Budget

inance Minister Pranab Mukherjee, announced a 20% hike in the health budget for the year 2011-2012. “I propose to hike the health budget in 2011-12 by 20% to ` 26,760 crore,” Mukherjee said while presenting his third budget. He also said that the Rashtriya Swasthya Beema Yojana had emerged as an effective instrument for providing health cover to marginal workers. “It is now being extended to Mahatma Gandhi National Rural Employment Guarantee Scheme beneficiaries and others. In 2011-12, I propose to further extend this scheme to cover unorganized sector workers in hazardous mining and associated industries like lead pencil, bromide, mica and asbestos,” he added. Source: The Times of India, Feb. 28, 2011

Legal Column What are your Comments Regarding the Following Incident of Assault on Doctors?

G, a surgeon, performed laparoscopic cholecystectomy on a young male on 14th January 2011 at a private nursing home in Punjab. The patient was discharged on 16th Janaury 2011 in a satisfactory condition. He reported on 19th January 2011, with pain abdomen. On investigation, serum amylase was found to be very high. He was diagnosed as having acute pancreatitis with stone in the common bile duct. He was managed conservatively and was discharged on 21st Janaury 2011 with the advice to get further treatment at PGI Chandigarh/GMC&H Chandigarh. He was taken to GMC&H, Sector 32, where ERCP with stenting of CBD was done. He expired in the hospital on 23.2.2011. A mob brought the body to the nursing home on 24th February 2011 and ransacked the hospital and physically manhandled the operating surgeon, punching his chest and abdomen amidst slogans to kill him. The hospital staff saved him by locking him in the OT. Police was called and it registered a case against the surgeon Under Section 304 A and body was sent for postmortem examination. The surgeon has lodged a separate complaint with the police on 24.2.2011, annexing a CD of the CCTV footage. Police have not taken any action on his complaint so far but a case under section 304 A stands registered against him. Ans. My comments are as follows:

Immediate action • It should immediately constitute a high powered

committee including, amongst others, its counsel and also, preferably, a retired judge (and maybe also a police officer), to probe into this incident and submit its report along with the plan of action. • It should get published in the newspapers a balanced

and correct version of the incident so that the public understands the facts of the situation. This may be by

way of a press release or an advertisement.

• It should approach the police authorities for an immediate registration of an FIR against the accused persons under the Punjab Protection of Medicare Service Persons and Medicare Services Institutions (Prevention of Violence and Damage to Property) Act, 2008, as also under various sections of the IPC. If the police do not register an FIR, the magistrate should be approached to direct the police to do so. • It should take direct action within law against the culprits. It should circulate amongst the members the names of those involved in the incident with a request that members may, at their discretion, decline to provide services to them except in emergency unless they submit apology to the surgeon concerned and to the state IMA in writing. • This is a clear case of liability under the “The Punjab Protection of Medicare Service Persons and Medicare Services Institutions (Prevention of Violence and Damage to Property) Act, 2008”. The doctor concerned has lodged a police complaint. He should not be left alone. The state IMA should provide him all support in the interest of the profession. The support should be on the following lines:

Long-term action • The state IMA and the city/district branches should establish patient grievance redressal cells to look into complaints of medical negligence. These cells, if they function properly, would avoid or minimize the incidents of this type. • The state and district IMA branches should organize discussion meetings with the police regarding atrocities and injustice against doctors. • The state and district IMA branches should organize regular medicolegal updates for members with focus on medical negligence and grievances of doctors.

Police brings the Medical Case File of a Victim to an FMT Specialist and Requests him to Issue a Medicolegal injury Report on the Basis of Treatment Record without the Consent of the Victim/Patient. Should the FMT Specialist Issue such a Report?

n my opinion, the FMT specialist can certainly give a written medicolegal expert opinion in this situation stating clearly therein that it is an opinion based upon medical record brought for his perusal and that it does not amount to a MedicoLegal Injury Report. The question of consent does not arise in case of expert opinion based on records. —MC Gupta, Advocate

(...Cont’d from page 7)

Figure 2.

Summary Table Condition

Characteristics

Acute dermatitis

A transient but sometimes painful inflammatory reaction of the skin; reactions vary from mild, localized itching to more severe pain, swelling, and inflammation; more severe systemic reactions are rare but possible

Cellulitis

Diffuse inflammation of subcutaneous and loose connective tissue caused by bacterial infection; may lead to localized pain, erythema, swelling, and warmth

Contusion

Mechanical injury resulting in hemorrhage beneath unbroken skin; often associated with blunt trauma; injury may evolve with time

Foreign body injury

Localized trauma causing a wound; traumatic injuries can range from minor to life threatening

Insect bite

Inflammation at the site of punctured skin; usually appears within minutes to a few hours after the bite

Discussion The answer is A: Acute dermatitis from a caterpillar sting. Further investigation found lime green caterpillars feeding on the leaves of the tree near where the child was playing (Figure 2). Caterpillars usually camouflage themselves on tree leaves. The family returned to the United States nine days after the injury, and the mother took the child to their family physician. Physical examination revealed swelling, purulent pockets, and multiple black caterpillar hairs/spines on the bottom of the foot. The physician discontinued the antibiotics and cleaned the area with soapstone (localized debridement). The child was able to walk on the foot after two days, and her fever subsided. Stinging caterpillars have specialized spines that contain poison glands. If the spines penetrate the skin, toxins spread on the surface of the skin, causing dermatitis.1,2 Reactions vary from mild, localized itching to more severe pain, swelling, and inflammation. Occasionally, a systemic response with diarrhea occurs. There have been reports from around the world of reactions from caterpillar stings, including dermatologic, pulmonary, and other systemic reactions.2,3 Removal of the caterpillar spines through debridement is the most effective means to counteract the toxic process and clear the localized reaction. Stings from some species of caterpillars can cause hemorrhagic reactions and arthritis.4,5 Cellulitis is a diffuse inflammation of subcutaneous and loose connective tissue caused by bacterial infection. It can lead to localized pain, erythema, swelling, and warmth. Typical treatment involves appropriate antibiotic therapy.6

Contusions are usually caused by mechanical injury resulting in hemorrhage beneath unbroken skin. They are often associated with blunt trauma, and the injury may evolve over time. Foreign body injuries are associated with localized trauma that causes a wound. Traumatic injuries can range from minor to life threatening. A typical reaction to an insect bite is an inflammatory response at the site of the punctured skin. It usually appears within minutes to a few hours after the bite. Insects that commonly bite humans include fleas, mosquitoes, ticks, bedbugs, blackflies, and sand flies.6,7

References 1.

Stanton G. Stinging caterpillars out in late summer and fall. http:// ipmnet.umd.edu/landscape/docs/StingingCaterpillars-UMD.pdf. Accessed 2009.

Diaz JH. The evolving global epidemiology, syndromic classification, management, and prevention of caterpillar envenoming. Am J Trop Med Hyg. 2005;72(3):347-357.

Bessin R. Stinging caterpillars. http://www.ca.uky.edu/entomology/ entfacts/ef003.asp. Accessed July 5, 2009.

Secretaria de Estado da Saude do Parana. (Lonomia) acidentes II. http://www.saude.pr.gov.br/modules/conteudo/conteudo. php?conteudo=389. Accessed July 5, 2009.

Lima C. Largatas que queimam. January 31, 2008. http:// www.olharvital.ufrj.br/2006/index.php?id_edicao=114&amp; codigo=10. Accessed July 5, 2009.

Ectoparasite infestations and arthropod and stings: caterpillar stings and dermatitis. In: Kasper DL, Harrison TR, eds. Harrison’s Principles of Internal Medicine. 16th ed. New York, NY: McGrawHill; 2005:2607.

Lepidoptera: arthropods and leeches. In: Cecil RL, Goldman L, Ausiello DA, eds. Cecil Textbook of Medicine. 22nd ed. Philadelphia, Pa.: Saunders; 2004:2128-2129. Source: Adapted from Am Physician 2011;83(2):201-202.

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IJCP GROUP OF PUBLICATIONS Dr Sanjiv Chopra Prof. of Medicine & Faculty Dean Harvard Medical School Group Consultant Editor Dr Deepak Chopra Chief Editorial Advisor

Humor Dr. Good and Dr. Bad Situation: An elderly type 2 diabetic patient with cancer lung came with A1C of 7.5%.

Dr KK Aggarwal CMD, Publisher and Group Editor-in-Chief Dr Veena Aggarwal Joint MD and Group Executive Editor

EDITORIAL BOARD Dr Alka Kriplani Asian Journal of Obs & Gynae Practice Dr VP Sood Asian Journal of Ear, Nose and Throat Dr Praveen Chandra Asian Journal of Clinical Cardiology Dr Swati Y Bhave Asian Journal of Paediatric Practice Dr Vijay Viswanathan The Asian Journal of Diabetology KMK Masthan Indian Journal of Multidisciplinary Dentistry Dr M Paul Anand, Dr SK Parashar Cardiology Dr CR Anand Moses, Dr Sidhartha Das Dr A Ramachandran, Dr Samith A Shetty Diabetology Dr Ajay Kumar Gastroenterology Dr Koushik Lahiri Dermatology Dr Georgi Abraham Nephrology Dr Sidharth Kumar Das Rheumatology Dr V Nagarajan Neurology Dr Thankam Verma, Dr Kamala Selvaraj Obs and Gyne

This is high. You need insulin therapy

This result is ok

ÂŠ IJCP Academy

Anand Gopal Bhatnagar Editorial Anchor

Lesson: As per the 2007 American College of Physicians

(ACP) guidelines, A1C goal may be >7% for type 2 diabetic patients who are elderly or frail or have a limited lifespan due to comorbid condition. Dr KK Aggarwal

Illusion

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