Talwar Medical Centre

NEW DELHI: One in five women suffers from uterine fibroids – the growth of non–cancerous tumour in the womb. And a majority has to undergo surgery. But doctors say there are new techniques like MRI–guided high–intensity ultrasound beam used to burn the fibroids, which can treat the ailment without any surgery. The procedure does not require hospital stay and it does not even leave any scar. “The treatment procedure takes two to three hours only and after that the patient can go home. Normally, such patients require up to three days of hospitalization for surgery. Many women delay treatment because they do not want to undergo surgery which aggravates the problem. In many cases, the uterus has to be removed,” said Dr Prathap C Reddy, chairman, Apollo Hospitals. The hospital launched the new technology for treatment of uterine fibroids on Tuesday. According to Dr Harsh Rastogi, radiologist, the traditional treatment modalities for treatment of fibroids includes uterus removal and laparoscopic removal of the fibroids. “In both cases, 2-3 days of hospitalization is required and the patient is advised rest for a longer period. The MRI HIFU technique, on the other hand, can be done in two hours and the patient can go home,” he said. He added that the risks include burn in focus area. “But that can be controlled,”

All kids need cholesterol tests as per new AAP guidelines
As per new guidelines from the American Academy of Pediatrics (AAP) published in Pediatrics.
1. Cholesterol checks should be part of periodic well–child visits for all children
2. Screen cholesterol at least once between the ages of 9 and 11 and again at 17 to 21. Pediatricians previously had been directed to screen cholesterol only in children with risk factors like a family history of heart disease or high cholesterol. Routine screening need only be a non–HDL cholesterol measurement that doesn’t require fasting.
3. Dietary management is often effective and should be the first line of attack against elevated cholesterol. Short–term use of plant sterol or stanol esters –– such as those in some margarines –– have been shown safe at doses up to 20 g per day, but longer–term use has not been tested and should be reserved for children who do not respond to diet alone.
4. Statins should be considered for those with LDL levels at 190 mg/dL or higher for children who are at least 10 years old and have not responded after six months of lifestyle management or at an LDL of 160 to 189 mg/dL if risk factors are present.
5. One should emphasize on breastfeeding and a diet low in saturated fat after a child’s first year.
6. Advise parents on protecting children from tobacco exposure
7. Start active anti–smoking advice to children at ages 5 to 9.
8. Track weight–for–height, reviewing growth with parents and refer when above the 85th percentile without reductions for more than six months after age 4.
9. Start routine annual blood pressure checks at age 3.
10. Encourage physical activity and limiting time spent sedentary or in front of a screen to two hours or less per day.
11. Start measuring fasting glucose at age 9 to 11.
12. Detecting and intervening on these risks early should give children a healthier future.

COPD patients more likely to develop lung cancer
Lung cancer may be detected at an earlier stage by screening individuals with chronic obstructive pulmonary disease (COPD) early as per a report in Nov 20011 issue of European Respiratory Journal.

COPD is the fourth leading cause of death in the world and lung cancer is the seventh, according to the World Health Organization. These two conditions are associated.

The research has shown that individuals with COPD are more likely to develop lung cancer compared to individuals who currently or previously smoked with normal lung function.

Amongst COPD patients 1% develops lung cancer each year compared to 0.2% of people with normal lung function, a five time increase in the risk of COPD patients developing lung cancer.

Knee hygiene
* Lifestyle changes can help stave off arthritis.
* Protecting the knees when one is younger may help prevent serious problems such as arthritis and the need for knee replacement when one is older.
* Nearly half of adults develop arthritis in at least one knee by age 85, and the risk is even greater for obese people.
* Extra pounds increase the strain on knee joints.
* Eachy time one takes a step, one applies three times the body weight to the knee. While running, it’s five times; while jumping, it’s seven times.
* Seventy percent weight loss is done by diet and 30 percent by exercise.
* One cannot eat the same and exercise the pounds. It’s a myth.
* Low–impact activities such as swimming and cycling are better for the knees than high–impact workouts such as running or aerobics.
* Good core strength (abs, back and pelvis) also helps protect the knees.
* The knees can be subjected to abnormal stress if the shoes don’t give a stable base as one walks. Many patients experience dramatic reductions in knee pain after getting orthotics or shoes specifically made to fit their feet.
* If the knee pain lasts more than two weeks, one needs to see a doctor because there might be something mechanically wrong with the knee.

New ACOG guidelines for breast cancer screening
, and annual examinations at age 50.
The American College of Obstetricians and Gynecologists released revised guidelines for screening for breast cancer.

They now recommend annual screening for women beginning at age 40.

They had previously recommended mammograms every one to two years starting at age 40

New Delhi: Most of the working mothers have unhealthy children with problems like obesity, while kids whose moms work part time are better off, a lifestyle study by Assocham said. As many as 56 per cent of working women have children with problems such as overweight which may aggravate into lifestyle diseases like cardio–vascular disorder and fatty liver when they grow into adults, it said. The problem was far less with the women who take up part time assignments. Only 28 per cent of these women have kids with unhealthy physical attributes. On the other hand, homemakers’ kids are a lot healthier as they are less into junk foods like pizza, burgers, pasta and aerated drinks, the study done by Assocham Development Foundation said. The study was done on 2,000 students in 25 schools in different cities, including the metropolis Delhi, Mumbai, Pune, Kolkata, Chennai, Hyderabad and Chandigarh

Obesity in adulthood is associated with a striking reduction in life expectancy for both men and women. Among 3457 subjects in the Framingham Study, done in the United States, those who were obese (Body Mass Index or BMI ?30 kg/m2) at age 40 years lived 6 to 7 years less than those who were not (BMI ?24.9 kg/m2).

Those who were overweight (BMI 25 to 29.9 km/m2) at age 40 years lived about three years less, and those who were both obese and smoked lived 13 to 14 years less than normal–weight nonsmokers. The steady rise in life expectancy during the past two centuries may come to an end because of the increasing prevalence of obesity. Being overweight during adolescence also increase the risk of premature death as an adult. The analysis of Nurses’ Health Study has shown the risk of premature death increases with higher BMIs at age 18 years. For a BMI at age 18 of 18.5 to 21.9, 22 to 24.9, 25 to 29.9, and ?30 kg/m2, the hazard ratio for premature death were 0.98, 1.18, 1.66, and 2.79, respectively.

A prospective study from the United States, at National Cancer Institute, National Institutes of Health, Bethesda, valuated the relationship between BMI and risk of death over a maximum follow–up period of 10 years among over 500,000 men and women aged 50 to 71 years. Among the subset of individuals 50 years of age (when prevalence of chronic disease is low) who had never smoked, an increased risk of death was associated with being either overweight (20 to 50 percent increase in those between 26.5 to 29.9 kg/m2) or obese (two– to over threefold increase in those ?30 kg/m2). Overweight and obesity, (when analyzed together), is associated with increased mortality from diabetes and kidney disease.

Obesity, when analyzed alone, is associated with increased cardiac mortality and cancers considered to be obesity–related (colon, breast, esophageal, uterine, ovarian, kidney, and pancreatic cancer), but not with mortality from other cancers or non–cardiac mortality.

There are some recent studies, which showed that obese people live longer. Overweight was shown to be associated with reduced mortality from non cancer, non–cardiovascular causes, but not with cancer or cardiovascular mortality. In them being underweight was associated with increased mortality from non cancer and non–cardiac causes, but not cancer and cardiac CVD causes. Obesity and increased central fat are associated with increased morbidity in addition to mortality.

Overweight and obese individuals have a higher relative risk of hypertension, hypercholesterolemia, and diabetes mellitus compared with normal weight individuals. The risk of hypertension and diabetes increases with increasing BMI.

In the Nurses’ Health and the Health Professionals Studies, the risk of developing a chronic disease (gallstones, hypertension, heart disease, colon cancer, and stroke (in men only) increased with increasing BMI, even in those in the upper half of the healthy weight range (BMI 22.0 to 24.9 kg/m2).

Obesity is measured by using a measurement called Body Mass Index – calculated by divide a person’s weight in kilograms by the square of their height in metres. A BMI of 18.5 to 23 is considered normal (Asians). One below 18.5 is considered underweight and 25 or above is considered obese

How to classify food poisoning depending on the onset of symptoms?
What decide the severity of food poisoning are the symptoms: exposure to a particular type of food as well as the time interval between exposure to the suspect food and the onset of symptoms.

Rapid symptoms within 6–12 hours are due to organisms that make a toxin in the food before the food is consumed. Symptoms are predominantly upper intestinal like vomiting. Examples are Staphylococcus aureus, Bacillus cereus emetic toxin and botulism.

Symptoms after 24 hours are due to pathogens that make toxin once they have been ingested. They mainly cause diarrhea that may be watery (Vibrio cholerae or E. coli) or bloody (Shiga toxin–producing E. coli).

Symptoms after variable time are due to microbes that cause pathology by either damaging the epithelial cell surface or by actually invading across the intestinal epithelial cell barrier. They can produce a wide spectrum of clinical presentations from watery diarrhea (Cryptosporidium parvum, enteric viruses) to inflammatory diarrhea (Salmonella, Campylobacter, Shigella) or systemic disease (L. monocytogenes).

Food poisoning can also be classified depending on the type of symptoms vomiting or diarrhea. A sudden onset of nausea and vomiting is likely due to the ingestion of a preformed toxin, such as S. aureus enterotoxin or B. cereus emetic toxin, or a chemical irritant. There is no risk of person–to–person spread.

When the poisoning presents with diarrhea, the likely organisms are V. cholerae, Clostridium perfringens, enterotoxigenic E. coli (ETEC), B. cereus, rotavirus, astroviruses, enteric adenoviruses, and Noroviruses, and the parasitic organisms, Cryptosporidium parvum and Cyclospora cayetanensis.

There are clinical clues that should raise suspicion that a foodborne microbe is causing inflammatory diarrhea. Such symptoms and signs include: Passage of diarrhea with blood or mucus; presence of severe abdominal pain and occurrence of fever. The most likely pathogens in patients with inflammatory diarrhea are Salmonella or Campylobacter

* Daily intake of salt should be limited to 1,500 mg according to an advisory statement from the American Heart Association (AHA).
* The 2020 goal of the American Heart Association is to improve the cardiovascular health of all by 20% while continuing to reduce deaths from (cardiovascular disease) and stroke by 20%. (Dr Lawrence J. Appel, of Johns Hopkins, and colleagues wrote online in Circulation.)
* Two key components of improving cardiovascular health are population-wide lowering of blood pressure below 120/80 and reducing sodium chloride intake below 1,500 mg per day.
* The evidence includes more than 50 trials assessing the blood pressure effects of salt, as well as a meta-analysis showing that cutting salt intake by about 1,800 mg per day lowered blood pressure by 5 mm Hg systolic and 2.7 mm Hg diastolic.
* Reducing salt consumption also can help prevent the blood pressure increases that come with age, ultimately affecting 90% of adults.
* Salt also has pernicious effects aside from blood pressure increases, including left ventricular hypertrophy and renal damage, including interference with the renin-angiotensin-aldosterone system.
* Excess sodium also can result in abnormalities in mineral metabolism, fibrosis in several organs including the heart, and endothelial and arterial dysfunction.
* Benefits of lowering sodium intake by 1,200 mg per day could lead to:
a. Up to 120,000 fewer coronary heart disease events
b. As many as 66,000 fewer strokes
c. Almost 100,000 fewer heart attacks
d. Up to 92,000 fewer deaths.
* The previous recommendation was that salt intake should be below 2,300 mg per day but advised that people at risk — those with hypertension, blacks, and older individuals — lower their intake to 1,500 mg. 10. Processed foods are a main contributor, as these foods contain three-quarters of the sodium consumed
* Naproxen increase the risk of death or recurrent heat attack by 76% after a week but for treatments lasting 30 to 90 days the risk increased risk was 15%
* Ibuprofen had the lowest initial risk, just a 4% increase for treatments
lasting seven days or less.

Do not give Clopidogrel Aspirin combination for preventing strokes
The US FDA has stopped a study examining if a combination of clopidogrel and aspirin could help prevent subcortical strokes. The National Institute of Neurological Disorders and Stroke made the decision after determining that patients taking the combination were at a higher risk of bleeding events and death. For stroke the combination does not offer any protection, but does put one at increased risk for bleeding.

Dengue patients do not die of platelet deficiency but of intravascular leakage
As per international guidelines, unless the platelet count is less than 2% of base line levels AND there is spontaneous active bleeding, no platelet transfusion is required.

The cause of death in dengue is capillary leakage causing blood deficiency in vascular department, leading to multiorgan failure. At the first instance of plasma leakage from intravascular compartment to extravascular compartment, one needs to give 20 ml per kg body weight per hour of fluid replacement to the patient till the difference between upper and lower blood pressure is more than 40 mmHg or the patient passes adequate urine. Leakage normally occurs after the fever is over.

Giving unnecessary platelet transfusion to the patient can harm the individual.
I have created a Formula of 20 for the family doctors to decide about admission of a case of dengue.
* There is a rise in pulse by 20.
* There is a fall in the upper (systolic) blood pressure by 20 mmHg.
* The pulse pressure (difference between upper and lower blood pressure) is lower than 20.
* The hematocrit (thickness of blood) increases by 20%.
* Platelet count is less than 20,000.
* There are more than 20 petechiae (bleeding spots) in the tourniquet test in one square inch area.

1. Caffeine is consumed in coffee, tea, soft drinks, and small amounts in chocolate.
2. It is the most widely used pharmacologically active substance in the world.
3. Caffeine can acutely raise blood pressure by 10 mmHg in patients who are infrequently exposed.
4. There is no effect on blood pressure in habitual coffee drinkers
5. It does not increase the risk of incident hypertension.
6. There is no evidence that caffeine in doses used in routine can provoke a spontaneous arrhythmia in individuals with or without a history of cardiac arrhythmia. There is no protective effect of caffeine abstinence also. In heart patients with coronary disease, the risk may be increased in individuals who are slow metabolizers of caffeine and drink two or more cups of coffee per day.
7. Ingestion of large quantities of caffeine is associated with arrhythmic and cardiovascular events, especially in patients with underlying cardiac disease.
8. Patients with a history of cardiac arrhythmia or at increased risk for cardiovascular events should moderate their caffeine intake from all sources.
9. Consumption of caffeinated beverages is associated with some short-term benefits like increased mental alertness and improved athletic performance.
10. Consumption of caffeinated beverages is associated with short term adverse effects including headache, anxiety, tremors, and insomnia.
11. In the long term, caffeine is also associated with generalized anxiety disorder, depression, and substance abuse disorders.
12. Long term benefits of caffeinated beverages are dose-dependent. Caffeine is associated with a reduced risk of Parkinson disease, Alzheimer disease, alcoholic cirrhosis, and gout.
13. Both caffeinated and decaffeinated coffee are associated with a lower risk of type 2 diabetes.
14. Several studies have linked coffee consumption with prevalence of various cancers.
15. The majority of studies show there may be a modest inverse relationship between coffee consumption and all-cause mortality.
16. Caffeine withdrawal is a well-documented clinical syndrome with headache being the most common symptom.

1. Incidence of paralysis will reduce by 35-40%.
2. Heart attacks will go down by 20-25%.
3. Heart failure will reduce by 50%.
4. A 5 mm reduction in diastolic BP can reduce heart disease risk by 21% (Magnus and Beaglehole, 2001).
5. If we can eliminate pre hypertension (BP > 120/80 and less than 140/90 mm Hg) from the society, we can prevent about 47 % of all heart attacks.
6. The Framingham Study has shown that a pre hypertensive person is more than three times more likely to have a heart attack and 1.7 times more likely to have heart disease than a person with normal blood pressure.
7. A 3–4 mm Hg increase in systolic upper blood pressure would translate into a 20% higher paralysis death rate and a 12 % higher death rate from ischemic heart disease.

Lifestyle choices in controlling blood pressure
* Try lifestyle management for up to 6 months. It can alone control BP if initial BP is <160/100 mmHg.
* Lifestyle interventions have effects similar to single drug therapy.
* Combinations of two (or more) lifestyle modifications can achieve even better results.
* Maintain normal body weight. One can achieve a reduction of 5-20 mmHg of BP for every 10 kg weight loss.
* Consume a diet rich in fruits, vegetables, and low fat dairy products with a reduced content of saturated and total fat. It can reduce a blood pressure of 8-14 mmHg.
* Reduce dietary sodium intake to no more than 100 mmol per day (2.4 g sodium or 6 g sodium chloride). It can alone reduce BP by 2-8 mmHg.
* Engage in regular aerobic physical activity such as brisk walking (at least 30 min per day, most days of the week). This can alone reduce BP by 4-9 mmHg.
* One should limit consumption of alcohol to no more than 2 drinks (1 oz or 30 mL ethanol; e.g., 24 oz beer, 10 oz wine, or 3 oz 80-proof whiskey) per day in most men and to no more than 1 drink per day in women and lighter weight persons. This can alone reduce BP by 2-4 mmHgWhat causes heart disease in women?
After a heart attack, women’s hearts are more likely to maintain their systolic function-their ability to contract and pump blood from the chambers into the arteries, according to new research. According to C. Noel Bairey Merz, MD, Director of the Women’s Heart Center at Cedars-Sinai Heart Institute in Los Angeles, this suggests that heart disease manifests differently in women, affecting the microvasculature (small blood vessels) instead of the macrovasculature (major blood vessels) as it does in men. In their study, Dr. Bairey Merz and her colleagues found that women’s hearts were less likely than men’s to lose their ability to pump blood after a heart attack, and that female heart patients were less likely to present with obstructive coronary artery disease. Instead, the oxygen deprivation and subsequent damage to the heart is more likely to occur when small blood vessels, not major arteries, become dysfunctional. “That is the reason women are often misdiagnosed and suffer adverse events,” said Dr. Bairey Merz. “Physicians have been looking for male pattern disease, when we need to start looking at female patterns

Do not take painkillers if you are a heart patient
There is no safe duration for use of NSAID painkillers in patients with a history of heart attack according to an analysis of data from more than 83,000 patients and published in Circulation, Journal of the American Heart Association. NSAID use after heart attack increased the relative risk of death or second heart attack by as much as 45%.

NSAID treatment was associated with a statistically significantly increased risk of death at the beginning of the treatment, and the risk persisted throughout the course of treatment. We must limit NSAID use to the absolute minimum in patients with established cardiovascular disease.
* All NSAIDs increased risk of death or recurrent heart attack by 45% after a week.
* Naproxen increase the risk of death or recurrent heat attack by 76% after a week but for treatments lasting 30 to 90 days the risk increased risk was 15%
* Ibuprofen had the lowest initial risk, just a 4% increase for treatments lasting seven days or less

One should use Folfirinox rather than gemcitabine for patients with metastatic pancreatic cancer who have a good ECOG performance status and a serum total bilirubin level that is <1.5 times the upper limit of normal.

In a preliminary report presented at the 2010 ASCO meeting, Folfirinox was associated with significantly higher objective response rates (31 vs 9%), median progression–free survival, and overall survival (11.1 vs 6.8 months). These benefits were achieved at the cost of significantly more toxicity. For patients who are willing to sacrifice some survival benefit for a less toxic regimen, gemcitabine alone or gemcitabine plus capecitabine is a reasonable option. One should give gemcitabine monotherapy rather than Folfirinox for patients with an ECOG performance status other than 0 to 1.

New treatment data in lupus

• Biologics in the treatment of systemic lupus erythematosus
• Update on new therapies in SLE
• Belimumab for the treatment of SLE
• Antimalarials and mortality in lupus: should hydroxychloroquine be in the water?

2. Systemic sclerosis

• B–cell depletion with rituximab: a promising treatment for diffuse cutaneous systemic sclerosis
• Relaxin for diffuse systemic sclerosis: cause for alarm?

3. Fibromyalgia

• Fibromyalgia drugs are “as good as it gets” in chronic pain: In a recent issue of The Journal of Pain, Hauser et al performed a meta-analysis of published trials of the three drugs approved in the USA for use in fibromyalgia: duloxetine, milnacipran and pregabalin. 11 randomized controlled trials including a total of 6,388 patients met the inclusion criteria and were included in the review. Outcomes of interest were improvements in pain, fatigue, sleep disturbance, depressed mood and health–related quality of life, as well as adverse events. The authors concluded that the three drugs were superior to placebo for all outcomes noted above, with the exceptions of duloxetine for fatigue, milnacipran for sleep disturbance, and pregabalin for depressed mood. They did not note any substantial differences between the drugs in the proportion of individuals who achieved a 30% improvement in pain (the value generally considered to be the minimum clinically import did note quantitative differences in the symptoms that were most improved by each drug. Duloxetine and pregabalin were superior to milnacipran in reducing pain and sleep disturbances, duloxetine was superior to milnacipran and pregabalin in reducing depressed mood, and milnacipran and pregabalin were superior to duloxetine in reducing fatigue. Thus, there is some rationale for initially choosing the drug most likely to favorably influence an individual patient’s symptom profile.
• Fibromyalgia:

• Hysterectomy linked to cardiovascular disease
• Women who have their uterus removed for reasons other than cancer may be at a greater risk of suffering a heart attack or stroke. The risk appears to rise even higher for women who also have both ovaries removed.

  Dr. Daniel Altman of the Karolinska Institute studied more than 800,000 women with and without hysterectomies over the course of three decades. On average, women were followed for about 10 years.
  The researchers found that a woman who underwent a hysterectomy before age 50 had a nearly 20 percent higher risk of developing cardiovascular disease compared to a similar woman who still had both her uterus and her ovaries.

  In women who had hysterectomy and also had their ovaries removed, cardiovascular risk was more varied – it could equal that of a women without any surgeries or rise to more than double that of a woman with only a hysterectomy. For example, of 100 women under the age of 50 who had their ovaries removed before or at the same time as a hysterectomy, about four went on to develop heart disease, a stroke or a heart attack over the course of 10 years. On the other hand, about two of every 100 women with hysterectomy who had their ovaries removed at a later time developed cardiovascular disease. This was a similar rate to women who had neither procedure. The researchers did not find the same relationships among women aged 50 or older when they had their hysterectomies, however.

  Altman suggested that the hormonal changes that take place after the organs are removed might be to blame for the increased risks seen in the younger group. Prior research has shown that removal of the uterus can disrupt blood flow to the ovaries, which generate estrogen. Removal of the ovaries is known to trigger early menopause, which itself has been linked with an increased risk of cardiovascular disease.

  (Source: http://bit.ly/ejngs9 European Heart Journal, online December 24, 2010

Use dabigatran rather than warfarin in patients with atrial fibrillation for whom anticoagulant therapy is chosen. The randomized RE–LY trial, published in 2009, demonstrated that dabigatran 150 mg twice daily was more effective for stroke prevention than adjusted–dose warfarin in patients with atrial fibrillation.¹ For patients older than 80 years or at higher risk of bleeding, a dose of 110 mg is suggested.

Warfarin can be used in patients who are already taking it and whose INR is relatively easy to control, for those who are not likely to comply with the twice daily dosing of dabigatran, for those where cost is important, and those with a creatinine clearance less than 30 mL/min.

Propofol administered by nonanesthesiologist nurses and physicians for endoscopy appeared very safe in a study of 646,080 endoscopic procedures [13]. There were four deaths and bag-mask ventilation was required in 0.1 percent of upper endoscopies and 0.01 percent of colonoscopies [13]. In a position statement, the use of nonanesthesiologist-administered propofol for gastrointestinal endoscopy in healthy, low-risk patients was endorsed by the American Association for the Study of Liver Diseases, the American College of Gastroenterology, the American Gastroenterological Association, and the American Society for Gastrointestinal Endoscopy [14].