May 2008 Newsletter Kwmpa

For reading this Upcoming Event Respiratory CME Update: The Asthma COPD overlap; current status in Pune. Dr Nitin Abhyankar May 17th 2008, 2130 Hrs. sharp.

Newsletter Online

Address label Here

Visit

K

WMPA.co.cc

Yo u r w e b s i t e Hotel Coronet Elegance, Opp. Shivarkar Garden Fatima Nagar, Pune.

Newsletter St r a i g h t f r o m t h e h e a r t (From the Editor's desk,

KWMPA

Dr S Bhatia, [email protected])

examination where the doctor is put un-

In my last editorial, I had

der a subjective scanner; the doctor is ex-

talked about the absence of continued

pected to prove that he is able to behave

medical education affecting the quality of

appropriately with the patient, can show

our physicians. This time I take up the is-

genuine concern and can ask the right kind

sue of doctors failing to establish a good

of questions in the right kind of manner. In

doctor-patient relationship.

effect, the doctor is expected to be able to

I have had patients who have un-

establish a rapport with the patient by spend-

dergone bypass surgery; upon question-

ing adequate and quality time with him/her.

ing they fail to reveal even the basic knowl-

Unfortunately we have no such

edge about their condition. Their physicians

mechanism in our medical school and

and cardiologists have failed to give them

therefore the importance of inter-personal

enough time to explain their condition, how

relationships remain somewhat secondary

will it be treated and how are they expected

to clinical skills like correct palpation, aus-

to modify their lifestyle. In effect, the sur-

cultation etc.

geons or physicians have started limiting

Fortunately, the GPs score higher

their role to that of a technician who is per-

over specialist/super-specialists in the rap-

forming a certain procedure on a certain

port department. Most of us who are sen-

'case' and not acknowledging the whole deal

sitive enough for this issue develop their

as involving a human life which has real

own ways of establishing quick, yet effec-

fears and genuine queries.

tive rapport. I'd like to invite an open forum

Of course, the commercial aspects

to share various methods which you all have

of medicine are to be blamed to a certain

developed individually; I'd publish them next

extent, but is that all? If you have tried to

time. Please fill the 'feedback form' on

clear the MLE for USA then you'd know

website for this purpose or mail your re-

about their clinical skills assessment

sponse to [email protected]

2008 2nd Edition

President’s Page: Visit the KWMPA Calendar on “kwmpa.co.cc”

E

ven if we do not meet physically, let’s network virtually. In this issue I wish to explore the “Calendar” aspect of our website completely. So, to set the ball rolling; I propose the following leads under Academic, Leisure & Annual Family Program heads

Academics; Power to you: I am giving you an opportunity to change this. Below are a few topics I felt will be relevant to members in day-to-day practice, and have a high CME value. Please Poll which of these you think is ‘high priority’. It will be my job to look for speakers & sponsors for those topics with maximum votes. (If you have any other topic to suggest in addition, power to you!)

Suggested “Update” topics: Update 1: Giving up smoking. Update 2: Current status of chikungunya and leptospira around Pune Update 3: New vaccines in Pediatrics; (& new indications –immunosuppressed adults, travel medicine)

Suggested “Situation” topics We can also plan small focused practice oriented meetings to evolve “how to manage” guidelines in situations commonly faced by us. Situation 1: A sick patient just admitted has high BSL’s (210, 4 h later 230). Will it affect the management of the primary disease, and how to manage the BSL’s. (best practices in stress diabetics)

Update 4: Complications following falls in elderly invariably kills them (# neck femur, subdural hematoma, etc.) Recognizing a potential candidate; evaluating the medical & non medical aspects & giving appropriate advice. A value addition to our practice; no one knows they can ask us for this advice.

Situation 2: A patient has “difficult to control” hypertension – what’s going on?

Update 5: Medicolegal issues : Consumer Law, dishonoured mediclaims, et al. An interactive meeting with a lawyer practicing medicolegal cases in Pune.

Situation 4: Recurrent oral aphthous ulcers.

Update 6: Changing Indian Cooking to prevent lifestyle diseases. A leading fitness expert speaks to all those who cook; including non medical spouses.

Situation 6: Girls with irregular periods; primary management & risk of future infertility.

Update 7: Preventing COPD beyond 40’s in non smoking Indians – early OPD screening strategies. (An original study done in Pune) Update 8: Managing OA knees better. Update 9: Reducing mortality of AMI; the concept of “Door to Balloon time”. Update 10: Is osteoporosis hyped up or do we really understand “Bone Quality”. (Suggest your choices, like U2471593) How to send your choice: Simple, like, type as: U2471593, S 63521. Best option: Visit the website and go to the section “Choose your CME”. You’ll find all the above options enlisted. Just tick the ones you like and click submit. Bingo !!!

Situation 3: Is short stature in this child needing investigation, or is it Idiopathic?

Email to kwmpa.co.cc @gmail.com

Situation 5: Managing chronic daily headache.

Situation 7: A patient on Warfarin (previous DVT / prosthetic heart valve) comes with an unrelated problem ( skin infection / avulsed toenail). Does GP / nursing home level management of unrelated conditions mess up anticoagulation? Situation 8: A patient with a long standing anemia in OPD practice is now on the verge of blood transfusions. Options for investigation & best management practice.

(Poll you choices, like S 63521)

Next option: SMS me -98220 51735 (your name: U2471593, S 63521), but you may not get an acknowledgement; you will have to check the website. Traditionally, this information could have been given to any other MC member; this is still available; but equivalent to snail mail.

I

genuinely feel 50 – 60% members don’t the cerebral as well as nutritive content. Not all attend CME’s as you are not getting the 150 members can be interested in every topic. If CME’s you exyou have polled for a topic, I pected. (Other motives of takknow the minimum people Are KWMPA members ‘Thanda’? ing membership are hereby who will come. I wish to feel being ignored from the disthe academic pulse across cussion.) If you get a chance to decide the topics, the cross-section of membership & get to know I will be sure at least you will decide to come for the trend of the most popular topics.

Those who don’t even participate in this Poll are “Thanda”!

“Monsoon thoughts

break”

(August – September) Pawan Khind Resort, near Kolhapur (3 days 2 nights) Bhandardara Backwaters (3 days, 2 nights) Khanapur, Khadakvasla Lake back waters. (2 days, 1 night) Shantivan Resort, Baron Resorts, Chimbalkar Farms, etc. Bhimashankar Baramati Agritourism (Rs 400/d; including pickup & drop ([email protected])

Sinhagad treks Sunday morningto-noon ..post your opinion on the website We recognize & thank : Dr P K & Dr (Mrs) A Sinha for emailing their inability to attend, they were out of P une. Pune. Dr N G Hegde for calling to say he is unable to attend

The Proposed Annual Family Program ...an option to Year-end Family Get togethers

Dandiya Raas nite Saturday 4th or Sunday 5th October 2008 In the Navratri Festival What we can work out from now • We book a convenient Hall rightaway • Members suggestions are invited for catering • We can have Dandiya competitions for various age groups, best dress couples, etc • Members please suggest how to organize music to set the theme I invite any input from Members & Family members

We invite Members to make their suggestions on the W ebsite blog Website

..can we begin with a few small steps… We need to start an RSVP somewhere in case we are interested in common good. The first step will be not to poll topics you are unlikely to find interesting. You could change your mind & email the website later; we will count you in. This will at least give us a “core” attendance. If you said “yes” to attend but cannot when the dates are out: SMS / Email if you are sure well in advance that you will not be there. (If your friend writes/emails/sends an SMS reminder for a dinner invite you do call in to ‘regret’ if you cannot go. Kya KWMPA MC members banke hum itne burey ho gaye, that we forfeit this courtesy? Ya is se dosti kuch kam ho gayi? I am sure your response to at least six topics will be enthusiastic These will be our usual Six “Regulation Scale meetings”. I will also know how many members will turn up while talking to the sponsor. What do I do with the other topics Do we just ignore choices of the minority? In fact, a group as small as 10 may be all that are interested in a topic. A low cost meeting can be organized at any colony clubhouse / terrace / restaurant hall. If unsponsored,meals can be bought upfront a la carte ( or a pre packed mealdeal can be negotiated (Rs 100/-?). Some speakers find small but interactive meetings more rewarding than the mementoes.

How have Pharmas reacted to our “Poll-In” website Frankly, for some Pharmas, CME’s are an excuse to express hospitality. But some rate us by the group that participates in academics. And let’s get real, sponsors commit money on our (the association’s) word. Dabur (Delhi) viewed our first CME report from our website. I can tell you quite a few pharmas are waiting to check our website with an offer to sponsor popular topics. However, some Pharma divisions will readily participate with smaller budgets of Rs 10,000/-. In case they are interested in sponsoring smaller meetings, will it not be mutually beneficial?

Look Ma! No Knife Renal calculi are among the most painful conditions that can be experienced by anyone. Apart from other technologically advanced methods, where the cost is prohibitively high for many a patient even today, very often surgery is the only way out. We have

Peer Review Form This form is available online now and is open

to bear in mind the different types of stones that can form. Primary renal calculi are

to all; and not merely

formed in an apparently healthy urinary tract. These are generally composed of urates

select few. Anyone

and oxalates. The secondary renal calculi are those that are associated with or second-

can do a peer review

ary to an infection or obstruction and are usually composed of ammonium magnesium phosphate.

of any CME now. So

While treating with

just visit the website, go

homoeopathic medicines one has to be

to section 'Peer Review'

very careful in doing a thorough case taking to have the best results. I am

and click on the pro-

accompanying a picture of some of the

vided link. A form

renal calculi that have successfully been

opens up for you to fill.

removed under homoeopathic medicines

Below the form, you

by me. What is unique of these stones is that they have all come out on one

will be able to see other

single day. Something that even I have

people's comments,

never experienced in my career.

too.

(Zubbin Motafram, the Author, is a practicing Homoeopath. He can be contacted at [email protected])

Intersting news and Links Following are some of the latest news in various fields of medicine. Internet links have been provided for anyone wishing to have a dekko at them.

Feedback form: A new feedback form has been made available for all of you to tell us how to improve both

Dark Chocolate With Added Plant Sterols Reduces Cholesterol and Blood-Pres-

our website and our

sure Levels: http://www.medscape.com/cardiology

Association's activities.

Teenage Boys Have Higher CV Risk Than Girls: http://www.medscape.com/cardiol-

AND YOU CAN DO

ogy Naturally Occurring Metabolite Predicts Cardiovascular Events in Diabetics: http:/

ALL OF THIS WITH-

/www.medscape.com/diabetes-endocrinology

OUT REGISTERING

Migraine Linked to Sleep Apnea in Children and Teens:http://www.medscape.com/

ON THE SITE.

psychiatry Abacavir, Didanosine Linked to Myocardial Infarction Risk: http:// www.medscape.com/hiv Colonoscopy Easier, Less Painful With Warm Water or Oil Lubrication: http:// www.medscape.com/gastroenterology

4

Should we throw away Transcript:

Beta Blockers?

Dr. Schroeder: We know that beta-blockers do lower blood pressure by depressing cardiac output.

Authors John S. Schroeder, & Peter C. Block. Excerpts Only. Full CME at http://www.medscape.com/viewprogram/12448_pnt

We were all taught that blood pressure equals systemic vascular resistance times stroke volume or car-

Goal

diac output. Therefore, it was assumed that if beta-

The goal of this activity is to assist clinicians in iden-

blockers lowered blood pressure, they must be ben-

tifying appropriate diagnoses and treatments for their car-

eficial to the hypertensive patient. Dr. Block: So blood pressure was adequately

diac patients. Abstract: In the last few years, questions have been

lowered, but there was no improvement in outcomes.

raised about the use of beta-blockers as first-line therapy

As a matter of fact, the LIFE trial specifically raised

for hypertension...no study has shown that beta-blocker

the issue of whether or not beta-blockers actually can

monotherapy reduces morbidity or mortality in hyperten-

increase risk.[13] Isn't that true?

sive patients, even when compared with placebo (Figure 1).

Dr. Schroeder: In terms of an increased risk of

Indeed, in some early trials, such as the British Medical

stroke, that's exactly what the data suggest. The LIFE

Research Council study in the elderly, beta-blocker

trial, of course, was a comparison of the ARB losartan

monotherapy was not only ineffective, but whenever a beta-

versus atenolol. Some people have looked at the data

blocker was added to diuretics, the benefits of the antihy-

and wondered if maybe the real issue is that the ARBs,

pertensive therapy distinctly diminished.[5]

like ACE inhibitors, may simply have additional ben-

One large meta-analysis from 1998 demonstrated that although blood pressure was lowered with beta-

efits; therefore, it's not that atenolol is harmful it's just that other drugs are better.

blockers, these drugs were ineffective in preventing

However, when you look at the meta-analysis

coronary artery disease, cardiovascular events, and

of the atenolol data, there was absolutely no decrease

all-cause mortality (odds ratios 1.01, 0.98, and 1.05, re-

in cardiovascular mortality and no decrease in over-

spectively).[6] The results also showed that diuretic

all mortality. So, it's become a bit of a controversial

therapy was superior to beta-blockers with regard to

area.

all outcomes (fatal and nonfatal strokes, cardiovascular events, and all-cause mortality).

It turns out that carvedilol, since it's a non-selective beta-1, beta-2, and alpha-1 blocker, does not have an adverse effect on insulin resistance. That may be one reason why it looks like carvedilol will become the beta-blocker of choice. Most of our hypertensive patients will require two or three different classes of drugs anyway to successfully control their blood pressure. So, treatment today may require multiple drugs: a CCB, an ACE inhibitor or an ARB, and then a betablocker. Most of our patients will require multidrug therapy because the new targets for treating blood pressure have become so low during the past few years.

5

CME MARCH 2008-A report The KWMPA conducted its first CME of 2008 on 15th March 2008 at Hotel Coronet Elegance, Fatima Nagar, Pune. The Event was sponsored by Dabur. The Guest Speaker was Dr Shona Nag, Medical Oncologist, Jehangir Hospital, Pune. She spoke about Targeted therapy in Cancer. This was followed by a presentation by Dr Saurabh Bhatia about the new KWMPA website. Lastly, Dr Sanjay Salunkhe shared his plans, achievements and vision for the KWMPA with the members. The CME was followed by a Dinner. Photographs/ Slide show, videos of dr Nag, Dr Bhatia and Dr Salunke can be seen at KWMPA.co.cc under CME March 2008

Dr R. V. Lagad: "I got to know a lot of things about targeted therapy; as to where, how and why it is targeted. Dr Nag simplified the concepts and made them easy for us to understand...The usefulness

PRESIDENT

in routine practice is limited. Only a few patients can benefit from the therapy as the costs are prohibitive. However, there is

DR.SANJAY SALUNKHE VICE PRESIDENT

a silver lining, as Dr Nag is on a number of global trials and even a really bad case could be taken up for the therapy. The results of targeted therapy are very encour-

DR SWATI SANGHVI HON.SECRETARY DR VAISHALI PARAB

aging and should become affordable in the near future." Dr Vibha Bafna: We as pediatri-

HON JT. SECRETARY DR SUBROTO ROY

cians already knew about targeted therapy and its use in some of the autoimmune disorders like rheumatoid artrits, atopic der-

HON. TREASURER DR.NAVEEN RAINA

matitis' SLE , ITP, etc...It was clear that

link.

EDITOR

the lecture was prepared keeping the audi-

Peer Reviews Following the CME, the MC asked for peer reviews from eminent doctors & Members. Excerps of those are being reproduced here. For full details see 'Peer Review' form's bottom at the website. Dr. Pradeep P. Sharma: "...Molecular therapy are targeted therapy and selectively attack the target cancer cells without much affecting the normal cells thus the amount of side effects are reduced. They are as precise as missiles whereas the other therapies are like atom bombs....Till today the drugs are very costly and may be beyond the finances of the common but may be down the line when the consumption and the demand rise the prices may come down. ( This happens with most of the drugs we all know that )"

ence and their felt needs in mind ...This

DR SAURABH BHATIA

information makes us more aware of diag-

GOV. BODY MEMBERS

nosing and reffering malignancy early.It also helps us in telling our patients confidently

DR BAFNA SANJAY

about better and less toxic treatment that

DR CEMENTWALA A

advances in science has now made avail-

DR CHAVAN V.

able to us. " Dr Ravindra Chhajed: "More detail mode of administrations should have been highlighted. As a physician may we

DR DIGHE AMOL DR KAMTHE K. DR.MANDLIK V.

be able to give targetted therapy in private nursing home? How General practioners

DR. NAZIR NAZIMA

will be helpful for Oncophysicians for

DR. SIAMWALA Z.

targetted chemotherapies? These points should have been briefed in details...Many additional information came into picture,like many free trials are going on and may be

Address for Correspondence:

helpful for poor patients. New hopes for

[email protected]

advanced cases of malignancies by the way of 'TARGETED THERAPIES'."

Snailmail : 92, St. Patrick’s Town, Sholapur Road, Pune 411 013

6

Contributed by: Karmishtha Krishna,age 7 yrs,student of Std. 2 St' Mary's School ; daughter of Dr. Mrs. Kavita and Dr. Kshiteendra Krishna.The painting titled "At the Circus" won the jury prize Art Buds 2007 Young Envoys Int'l, Hyderabad.

Place Artwork Here

Registration process Video A video has been placed for everyone's convenience to help them understand the registration process at the website. This video will help you in the steps of Registration Process. We also recommend using Firefox as your

Positive “tea sign” Michael V Holmes, Royal Free Hospital, London [email protected] It was Christmas Day, and an 81 year old patient had been

internet

browser instead of Internet explorer.

brought in from a nursing home. His casualty card read: “?decreased conscious level, increased rigidity.” The carer wasn’t present. A brief

Dr Ksheetendra writes:

assessment established that his score on the Glasgow coma scale

"Dear Dr. Bhatia,

was 7 out of 15 (a prolonged sternal rub had elicited flexion of the arm at the elbow joint with flickering of the eyelids and a groaning sound). On

Thank you for having regis-

auscultation, vesical breath sounds were barely audible bilaterally.

tered me to KWMPA.co.cc.For

I summoned the registrar, making plans to transfer the patient to the resuscitation bay and possibly call the anaesthetist. The registrar’s question of “Would you like a cup of tea?” elicited symmetrical move-

your information we managed to do the same without using

ment of the face (a smile), opening of the eyes, and coherent language

Mozilla Firefox.We kept the

(“Oh, yes please”).

password such that it had

With a simple question, my registrar had provided sufficient cerebral stimulation for the Glasgow coma scale to leap to 14. The carer

atleast 2 alphabetical letters and

returned, the patient’s history was obtained, and the patient was exam-

atleast 2 numerical letters.This

ined and subsequently returned to his nursing home to rejoin the Christ-

is to help you to help the other

mas festivities. Consequently, the positive “tea sign” has become en-

members to register to

graved on my mind as an informal test of consciousness. I look forward to testing its validity in the future.

Stubborn

KWMPA.co.cc by this way. Thanks alot for the help and

The patient thought he was dead. His psychiatrist made him stand before a mirror and repeat many times, “Dead men don’t bleed.”

prompt response."

Then he stuck a pin in the patient’s finger and made it bleed a little. ”See

now?”,

the

doctor

said

triumphantly.

”Yes, I see now”, the patient replied, “dead men do bleed.”

7

8