Dr KK AggArwAlGr. Editor-in-Chief, IJCP Group

MemberThe Indian Newspaper Society

Official Voice ofDoctors of India

Pages 12

Dr KK AggarwalPadma Shri and Dr BC Roy National Awardee

Sr Physician and Cardiologist, Moolchand MedcityPresident, Heart Care Foundation of India

Group Editor-in-Chief, IJCP GroupGroup Editor-in-Chief, eMedinewS

Chairman Ethical Committee, Delhi Medical CouncilDirector, 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/DrKKAggarwalKrishan Kumar Aggarwal (Facebook)

E d i t o r i a l

Medical Ethics: Lessons from Vaidya Sushena

A medical doctor is accorded a status next to God as he or she has a duty to heal the sick irrespective of their caste, creed, race or financial status. The classical description of the duty of a doctor was depicted

in the Hindi film ‘Achanak’ by Gulzar in 1973.

In the movie, Vinod Khanna plays the character of an army man who loves his wife intensely. He returns home after the 1971 war to find his wife, actress Lily Chakravarti, involved with his close friend. In a fit of emotion, he kills his wife and her lover. He is sentenced to death but is wounded in an attempt to escape the police. At the hospital he is looked after by a team of doctors (Om Shivpuri, Asrani) and a nurse (Farida Jalal). They work hard day in and day out to save him from the lethal injury only to hand him over to the police chief (Iftikhar) for the due capital punishment. The story ends with the message that the duty of the doctor is to save the dying man and the duty of the policeman is to award the due deserved capital punishment.

Historically, the first known example of medical ethics comes from the story of Ramayana. During the war between Lord Rama and Ravana, Meghnath shot a Brahmastra shakti baan (arrow) that hit Laxmana and he became unconscious.

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I n s I d e

Vibhishana informed Sri Rama about a physician, Sushena, who lived in Lanka. Hanumana was asked to bring him. He brought Vaidya Sushena along with his house. Vaidya Sushena, well aware that he was a physician attached to the kingdom of Ravana, and that treating Lakshmana could end up annoying Ravana, took a conscious ethical decision of treating the wounded Lakshmana. He said that only the ‘Sanjivani Booti’ (a herb found only on Sumeru Hill) could save Laxmana. But that herb grew on Himalayas at a great height and needed to be brought before the day break. Then Jambavanta reminded Hanumana that only he could bring back the ‘booti’ before sunrise. He said, “Fly across the ocean to Himalaya Mountains and bring back herbs Mritha Sanjivani, Vishalya karani, Savamakarani and Sandhanakarani.”

Single Copy rs. 100/-Vol. 11, No. 6, June 2011

MAKe Sureduring MEdical PracticE

Make sure: All painless bleeding in the urine should be investigated for cancer at the first presentation.

KK Aggarwal

© IJC

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Hanuman went to Sumeru Hill, which was far, far away from the battlefield. There he found several herbs that looked similar to the ‘Sanjivani Booti’. Confused, Hanumana immediately lifted Sumeru Hill in his right hand and flew back to the battlefield in Lanka. Thus, Laxmana was saved by Vaidya Sushena who waited by Lakshaman’s side till Hanuman returned with the remedy.

Both the above depictions relate to the true message later described in the classical Hippocratic Oath, traditionally taken by physicians pertaining to the ethical practice of medicine. But today many doctors are ruining the image of the medical profession. They indulge in indiscriminate sex determination, killing the child in the womb, making people beggars by cutting their hands, making males eunuchs by castrating their private parts, illegal organ trade or getting involved with the criminals and helping them in torturing their captive persons. The classical example is what happened in Iraq. We should take lessons from the movie ‘Achanak’ and from Vaidya Sushena who stood by his professional duty and acted according to what was right and ethical.

News & Views 3

Fitness Update 4

Expert Views 5

Clinical Algorithm 6

Photo Quiz 7

Legal Column 8

Clinical Tips 10

A patient who had blood in the urine one month back was found to have a large bladder cancer.

Oh my God! Why was he not investigated one month back?

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News & ViewsNIH Stops Clinical Trial on Combination Cholesterol Treatment

The National Heart, Lung and Blood Institute (NHLBI) of the National Institutes of Health has stopped a clinical trial studying a blood lipid treatment 18 months earlier than planned. The trial found that adding high-dose, extended-release niacin to statin treatment in people with heart and vascular disease, did not reduce the risk of cardiovascular events, including heart attacks and stroke.

Participants were selected for AIM-HIGH because they were at risk for cardiovascular events despite well-controlled low-density lipoprotein (LDL or bad cholesterol). Their increased risk was due to a history of cardiovascular disease and a combination of low high-density lipoprotein (HDL or good cholesterol) and high triglycerides, another form of fat in the blood. Low HDL and elevated triglycerides are associated with an increased risk of cardiovascular events. While lowering LDL decreases the risk of cardiovascular events, it has not been shown that raising HDL similarly reduces the risk of cardiovascular events.

During the study’s 32 months of follow-up, participants who took high-dose, extended-release niacin and statin treatment had increased HDL cholesterol and lowered triglyceride levels compared to participants who took a statin alone. However, the combination treatment did not reduce fatal or nonfatal heart attacks, strokes, hospitalizations for acute coronary syndrome or revascularization procedures to improve blood flow in the arteries of the heart and brain.

The AIM-HIGH trial, which stands for Atherothrombosis Intervention in Metabolic Syndrome with Low HDL/High Triglycerides: Impact on Global Health, enrolled 3,414 participants in the United States and Canada with a history

of cardiovascular disease who were taking a statin drug to keep their LDL cholesterol low. Study participants also had low HDL cholesterol and high triglycerides, which meant that they were at significant risk of experiencing future cardiovascular events. Niacin, also known as Vitamin B3, has long been known to raise HDL and lower triglycerides.

Eligible participants were randomly assigned to either high-dose, extended-release niacin (Niaspan) in gradually increasing doses upto 2,000 mg/day (1,718 people) or a placebo treatment (1,696 people). All participants were prescribed simvastatin (Zocor), and 515 participants were given a second LDL cholesterol-lowering drug, ezetimibe (Zetia), in order to maintain LDL cholesterol levels at the target range between 40-80 mg/dl.

Researchers began recruiting participants in early 2006. The study was scheduled to finish in 2012. The average age of the participants was 64 years. Pre-existing medical conditions included coronary artery disease (92%); metabolic syndrome, which is a cluster of risk factors for heart disease (81%); high blood pressure (71%) and diabetes (34%). More than half of participants reported having a heart attack prior to entering the study.

The rationale for the AIM-HIGH study was based in part on a large number of observational studies that consistently showed that low HDL cholesterol increases the risk of cardiovascular events in men and women, independent of high LDL cholesterol. In addition, previous small clinical studies showed that relatively high residual cardiovascular risk exists among patients with cardiovascular disease, low HDL cholesterol and high triglycerides despite intensive management of LDL cholesterol.

Ultrasound-guided Microwaves Effectively Ablate Renal TumorsOne of the numerous examples of how therapeutic ultrasound is making inroads into oncology was seen in the results of a study that showed both safety and efficacy for a method of using ultrasound-guided percutaneous microwave ablation to treat renal tumors, presented at the American Institute of Ultrasound in Medicine convention.

Delhi Mayor Prof. Rajni Abbi released a poster with a message “Think of metro as your personal limousine; public park as your personal farm house, city river your personal swimming pool and keep them clean” at a function

organized to celebrate World Environment Day. In the Photo: Padma Shri and Dr BC Roy National Awardee Dr KK Aggarwal, Prof. Rajni Abbi

Nearly One in Five Young Adults may have

High Blood PressureThe number of young adults in the United States with high blood pressure may be much higher than previously reported, according to a new study by researchers at the University of North Carolina at Chapel Hill.

Environment Day Celebrated

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Fitness Update

Exercise Decreases Pain in Fibromyalgia Sufferers

Fibromyalgia is a condition characterized by chronic dull musculoskeletal pain and often accompanied by fatigue, sleep problems and mood swings. People who suffer from the disorder often complain of amplified pain sensations and increased pain sensitivity. Exercise is typically prescribed to relieve symptoms of fibromyalgia, yet it is not always adhered to as physical activity can be very painful. In a study, 22 women in their 40’s, who suffered from acute pain caused by fibromyalgia were randomized into two groups. One group performed a 20-minute cycling session at a prescribed intensity while the other group of women selected their own pace and intensity. Researchers measured heart rate, intensity and participants’ perceived exhaustion and muscle pain every five minutes during the sessions. Additionally, a pain questionnaire was given to all participants before and at different intervals after the sessions. Results showed that exercise significantly lowered pain for three days after the sessions. The group that selected their own pace exercised at a lower intensity but reaped the same benefits as the other group. There were no significant differences between the groups, leading researchers to conclude that low-intensity exercise should be prescribed. Better yet, patients should decide on their own pace.

Decreased Physical Activity in the Workplace has Led to Weight Gain

You’ve heard it before, but new research reinforces the idea that sedentary desk jobs could be the primary cause of weight gain over the past five decades. In the early 1960’s, almost half the jobs in private industry in the US required at least moderate intensity physical activity. Now <20% of occupations require this level of activity, leading Americans’ level of daily energy expenditure to drop significantly. Researchers from the Pennington Biomedical Research Center at the University of Louisiana conducted an analysis of occupational energy expenditure in the US beginning in the year 1960 until the present, using data from the US Bureau of Labor Statistics. They also gathered body weight data from different US National Health and Nutrition Examination Surveys (NHANES).

Researchers used an energy balance model to predict people’s weights based on the average change in their occupation-related daily energy expenditure since 1960. For instance, from 1960 to 2006, the NHANES survey data and energy balance model lead researchers to estimate that the occupation-related daily energy expenditure decreased by 142 calories in men aged 50-60 years. Given a baseline weight of 76.9 kg in 1960, they calculated that the decreased activity would result in an increase in mean weight to 89.7 kg, which was close to the actual mean weight (as measured by the NHANES) of 91.8 kg in 2006. The same pattern was true in men of different ages as well as in women.

Weight Loss Leads to Improved Cognitive Capacity

New research from Kent State University in Ohio, suggests that weight loss can have a powerful impact on cognitive function, including memory, reasoning, learning and attention. They measured these skills with a series of tasks and exercises in a group of 150 obese subjects and found that 24% of the patients showed impaired learning and 23% showed signs of impaired memory and recall. After these tests, two-thirds of the obese participants underwent weight loss surgery. Those who underwent surgery lost an average 50 pounds (on average about 17% of their initial body weight) in three months whereas those who did not have surgery either gained weight or remained at the same weight. After a three-month period, a second round of cognitive tests was conducted.

The group that underwent surgery and lost weight increased all of their cognitive scores significantly, boosting scores to average or above average scores. However, those who did not lose weight had the same scores, or even lower scores than before. Researchers plan to conduct a new study to determine if the same effects occur when subjects lose weight by eating healthier and getting more active; they anticipate that the results will be the same.

Physical Activity Prevents Prostate Cancer RecurrenceAfter skin cancer, prostate cancer is the most common form of cancer in men, and it’s also the most lethal. In 2010, the disease killed approximately 32,050 men, according to the National Cancer Institute. However, recent research conducted by scientists at the University of California - San Francisco and the Harvard School of Public Health has concluded that high-intensity walking can reduce the risk of prostate cancer progression. Researchers analyzed medical records and physical activity logs of 1,455 men who had previously been diagnosed with prostate cancer. During the course of the study, the researchers differentiated between men whose prostate cancer progressed and those whose cancer did not worsen. Results showed that men who exercised or walked at a brisk pace for three hours or more per week were significantly less likely to experience a recurrence - 57% less likely, to be exact. Researchers noted that walking should be at a fast pace of 3 miles/hour or higher.

Rajat Bhatnagar, International Sports & Fitness Distribution, LLC, http://www.isfdistribution.com

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Expert Views

Infertility Update

How should matching of male partner with donor be done?There are several methods for matching the male partner with the donor. The couple should be encouraged to list the characteristics that they desire in a prospective donor, including race and/or ethnic group, height, body build, complexion, eye color and hair color and texture. Consideration should be given to blood type and Rh factor, particularly for Rh-negative recipients.

—Dr Kaberi Banerjee, Director Precious Baby Foundation

Understanding Laparoscopic Sleeve Gastrectomy

What is a 2-Stage operation?Certain patients may have a body shape that makes their surgery more technically difficult. For example, patients with a BMI over 60 - particularly those who carry their weight in their belly area - may be at increased risk for bariatric surgery.

In the staged approach, a multi-step operation like the gastric bypass or the duodenal switch is broken down into two simpler and safer operations. In the first stage, a sleeve gastrectomy is performed. This allows losing 80-100 pounds or more, which will make the second part of the operation substantially safer.

The second stage operation is usually performed 8-12 months after the first. The ‘sleeve’ stomach is converted into a formal gastric bypass or duodenal switch. This will permit additional weight loss and will provide a much more permanent result than sleeve gastrectomy alone.

Both stages of the surgery can be performed by laparoscopy, giving the advantage of shorter recovery, shorter incisions, fewer incision-related problems and less pain.

What is the preoperative preparation for LSG?After a one-on-one consultation with the surgeon, the patients make an informed decision to have laparoscopic sleeve gastrectomy (LSG) and informed consent is obtained. All patients are required to have psychological screening, routine labs, electrocardiogram, upper gastrointestinal X-rays, pulmonary function studies and a medical evaluation. All patients receive intravenous antibiotics, subcutaneous unfractionated heparin and sequential compression devices preoperatively.

—Dr Parveen Bhatia and Dr Pulkit Nandwani

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Obesity UpdatePediatric UpdateWhat are the clinical features of croup?Initially, patients have a 1- to 2-day prodrome of nasal congestion, rhinorrhea and cough. Often frightening to the caregiver, the patient will have the onset of a harsh barky cough often described as sounding similar to a seal or a bark. The patient may also have stridor, which is typically inspiratory, but it may also be biphasic. In addition to nasal flaring, suprasternal and intercostal retractions, and tachypnea and hypoxia, the presence of biphasic stridor indicates severe respiratory compromise.

How is croup diagnosed?The diagnosis of croup is a clinical one, because complete blood counts tend to be normal. Radiographs may be helpful in differentiation of other disease entities such as epiglottitis, retropharyngeal abscess, congenital abnormalities, a foreign body or hemangioma. The classic radiographic finding in a patient with croup is the steeple sign. Distension of the hypopharynx and of the laryngeal ventricle and haziness or narrowing of the subglottic space may be seen on a lateral neck radiograph; however, the absence of this finding does not rule out croup, because almost half of patients have normal radiographs.

Gastro UpdateWhat are the treatment options in cystic fibrosis liver disease?

In addition to UDCA (ursodeoxycholic acid) treatment, treatment of cystic fibrosis liver disease includes supplementation of fat-soluble vitamins.Treatment of complications of portal hypertension and associated hypersplenism include variceal banding, portosystemic shunting, transjugular intrahepatic portosystemic shunt (TIPS), splenectomy and liver transplant. However, liver transplantation is rarely required and is generally not indicated unless there are additional features of liver decompensation.

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—Dr Neelam Mohan, Director, Pediatric Gastroenterology Hepatology and Liver Transplantation, Medanta – The Medicity

Rabies UpdateCan rabies be transmitted from man-to-man? Man-to-man transmission of rabies is possible. Rabies can be transmitted following bite by a rabies patient. In 2004, three cases of human rabies were reported in US following liver and kidney transplantation from rabies patients. Transplantation of rabies infected cornea can cause rabies in recipient. Therefore a careful neurological history of donor must be taken before cornea transplantation.

—Dr AK Gupta, Author of “RABIES – The Worst Death”

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Clinical Algorithm

Figure 1. Algorithm for the initial evaluation of a patient with suspected heat-related illness.Source: Adapted from Am Fam Physician. 2011;83(11):1325-1330.

Evaluation of Heat-Related Illness

Clinical signs/symptoms of heat-related illness

Rectal temp < 104°F (40°C)

Central nervous system signs/symptoms?

Obtain rectal temperature

Rectal temp ≥ 104°F

Central nervous system signs/symptoms?

Consider alternatives:

Central nervous system disease

Febrile illness/sepsis

Hypoglycemia

Hyponatremia

Seizure

Thyroid storm

Toxicity

Mild forms of heat-related illness: cramps, edema, syncope, exhaustion

Treat for mild heat-related illness:

Observe for symptom resolution

Monitor core temperature

Symptoms resolve in < 30 minutes

Symptoms persist ≥ 30 minutes or clinical deterioration

Relative rest

Remain in cool place

Patient education

Treat for heat stroke: Address airway, breathing, and circulation

Initiate rapid cooling

Start intravenous fluids

Arrange for transport for emergency care

eMedinewS and Heart Care Foundation of India are jointly organizing the first-ever National Conference on “Insight on Medico Legal Issues” to commemorate “Doctors’ Day”.

The one-day conference will provide total insight into all the medicolegal and ethical issues concerning the practicing doctors. Both medical and legal experts will interact with the delegates on important issues. You are requested to kindly register in advance as seats are limited.

International Medical Science Academy (IMSA) Update

Association between acute care and cognitive function in older adultsA higher risk of cognitive decline and dementia has been postulated to occur in survivors of acute medical illness, particularly in older adults. In a prospective cohort study, higher rates of cognitive decline and incident dementia were observed among those who had acute care hospitalization compared to those who did not (JAMA 2010;303:763).

Yes No No Yes

National Conference on “Insight on Medico Legal Issues”There will be no registration fee. You can register by sending your request at rekhapapola@gmail.com or at 9899974439.

Date: Sunday, 10th July, 2011

Venue: Auditorium, Chinmaya Mission, 89, Lodhi Road, New Delhi-110 003

For Programme details, visit www.emedinews.in

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Photo QuizUlcer on Lower Lip of Deployed Serviceman

A 46-year-old serviceman deployed to Iraq presented with a papule on his lower lip that had developed over

four weeks. Two days after the patient nicked his lip with a razor, a small, red, tender bump appeared. Over the next few weeks, the bump became firmer and slowly enlarged.

Although the patient had received multiple insect bites in the previous weeks, he did not recall any on his lips. He had no fever or chills. He had used smokeless tobacco for 20 years and had moderate sun exposure as a child and adult. Physical examination revealed an indurated, 4-mm papule with a dry central ulcer (see accompanying figure). There was no regional lymphadenopathy, and the patient was otherwise healthy.

QuestionBased on the patient’s history and physical examination, which one of the following is the most likely diagnosis?

A. Arthropod envenomation necrosis.

B. Cutaneous leishmaniasis.(For Answer and Discussion, see page 9...)

C. Ecthyma.

D. Ecthyma gangrenosum.

E. Squamous cell carcinoma.

Imaging in Cardiovascular Interventions - ICI 2011 22 June, 2011 Frankfurt, Germany

ACI’s 6th Annual Spine Centers of Excellence Conference 22-24 June, 2011 Dallas, Texas, United States

Cardiology Review for Primary Care Medicine 30 June, 2011 to 2 July, 2011 Paradise Island, Bahamas

6th Asian Conference for Emergency Medicine 2011 4-7 July, 2011 Phratumwan, Bangkok, Thailand

Primary Care Update - A Review and Update of Common Clinical Problems 4-6 July, 2011 Orlando, FL, United States

Medico-Legal Conference 7-10 July, 2011 Bologna, Italy

National Conference on “Insight on Medico Legal Issues” 10 July, 2011 Auditorium, Chinmaya Mission, 89, Lodhi Road, New Delhi - 110 003

Worldcon 2011 - XVI World Congress of Cardiology, Echocardiography and Allied Imaging Techniques 30th to 2nd October, 2011 Leela Kempinski, Gurgaon (Delhi NCR)

Medifilmfest (1st International Health Film Festival in Delhi) October 14-23, 2011, As part of 18th MTNL Perfect Health Mela 2011 (Screening of Films October 14-17, Jury Screening at Jamia Hamdarad University Auditorium October 18-19, Award Winning Films at Talkatora Stadium October 19-23, 2011)

Conference CalendarDrug Update

List of Approved Drugs from 01.01.2010 to 31.8.2010

Drug NameLevocloperastine (as Fendizoate) Suspension e.g. to Levocloperastine HCl 20 mg/5 ml.

IndicationFor the treatment of nonproductive cough in adult patients.

DCI Approval Date29.09.10

Lab Update

Stool ExaminationDiarrhea is a common symptom of a gastrointestinal disturbance. O & P (Ova and Parasite) testing: A microscopic evaluation of stool for parasites and the ova (eggs, cysts) of parasites. A basic test but very important!!

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Legal ColumnIntegrity of a Doctor must be Whole and Complete

The word ‘integrity’ stems from the Latin adjective ‘integer’ meaning whole and complete. In the context of a medical professional, integrity is the inner sense of ‘wholeness’ of a doctor deriving from qualities such as honesty and consistency of character. As such, one may judge that others ‘have integrity’ to the extent that they act according to the values, beliefs and principles they claim to hold. Integrity is a concept of consistency of actions, values, methods, measures, principles, transparency, expectations and outcomes.

In medical ethics, integrity is regarded as the honesty and truthfulness or accuracy of one’s actions in medical care delivery in the form of diagnosis and therapeutic intervention. Integrity can be regarded as the opposite of hypocrisy in that it regards internal consistency as a virtue, and suggests that parties holding apparently conflicting values should account for the discrepancy or alter their beliefs.

One essential aspect of a consistent framework is its avoidance of any unwarranted or arbitrary exceptions for a particular doctor especially the doctor that holds the framework in medical setup. In law, this principle of universal application requires that even those in

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Medicolegal Updatepositions of official power be subject to the same laws as pertain to their fellow person.In personal ethics, this principle requires that one should not act according to any rule that one would not wish to see universally followed. For example, one should not steal unless one would want to live in a world in which everyone was a thief.Speaking about integrity can emphasize the ‘wholeness’ or ‘intactness’ of a moral stance or attitude. Wholeness may also emphasize commitment and authenticity. Integrity does not consist of loyalty to one’s subjective whims, but of loyalty to rational principles and practice of medicine in the interest of patient and public at large that strictly apply in medicolegal cases.In a formal study of the term ‘integrity’ and its meaning in modern ethics, law professor Carter sees integrity not only as a refusal to engage in behavior that evades responsibility, but also as an understanding of different modes or styles in which discourse attempts to uncover a particular truth/fact in public interest. Carter writes that integrity requires three steps: “Discerning what is right and what is wrong; acting on what you have discerned, even at personal cost and saying openly that you are acting on your understanding of right from wrong.” He regards integrity as being distinct from honesty.

—Dr Sudhir Gupta, Additional Professor, Forensic Medicine & Toxicology, AIIMS

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“Ambition should be made of sterner stuff”—William Shakespeare

“Always aim at complete harmony of thought and word and deed. Always aim at purifying your thoughts and everything will be well”

—Mahatma Gandhi

“Action may not always bring happiness, but there is no happiness without action”

—Benjamin Disraeli

“The world is a dangerous place, not because of those who do evil, but because of those who look on and do nothing”

—Albert Einstein

Famous Quotes

No Tax Return for Salary and Interest Income upto ` 5 Lakh“No income-tax returns is required for salaried persons whose annual taxable income including salary and interest is upto ̀ 5 lakh. We would shortly notify this,” a Central Board of Direct Taxes official said. However, he said this would not cover income from other sources like house property, capital gains and gains from profession and business. The scheme would be applicable from assessment year 2011-12 onwards. This means that the salaried persons eligible under the scheme would not have to file returns for the financial year 2010-11 in 2011-12 (assessment year). Under the scheme, those salaried persons who want to claim tax refund, would have to file income tax return. As per

Medifinance Updatethe Memorandum to the Finance Bill 2011, the government will be issuing a notification exempting ‘classes of persons’ from the requirement of furnishing income tax returns. Under the scheme, the salaried person wants exemption from filing IT return, has to disclose about the incomes like dividend and interest to his employer for tax deduction. In the scenario, the Form 16 issued to salaried employees will be treated as Income Tax Return. At present, it is obligatory for all salaried persons to file income tax return under the Income Tax Act, 1961. The idea behind the move is that in cases where there are no other sources of income, filing of a return is a duplication of existing information.

Source: http://articles.timesofindia.indiatimes.com/2011-06-07/india-business/29629330_1_requirement-of-furnishing-income-income-from-

other-sources-salary-and-interest-income, June 7, 2011

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DiscussionThe answer is C: Ecthyma.

Ecthyma is a cutaneous bacterial infection that extends into the dermis. It usually occurs on disrupted skin,1 beginning as a vesicle or vesicopustule, then developing a hemorrhagic crust.2 Ecthyma is classically associated with group A streptococci, but staphylococci may also be present. Because the infection extends into the dermis, scarring may result. Ecthyma is treated using systemic antibiotics with good gram-positive coverage.3

Arthropod envenomation from several types of stinging insects can quickly cause large, painful ulcers that are surrounded by erythema. Central eschar may develop. However, it is unlikely that a sting on the patient’s lip would go unnoticed. Insect bites and stings with or without envenomation can also serve as portals for infection, including ecthyma.4 Leishmaniasis is caused by intracellular parasites that gain entry during an arthropod bite. The disease can manifest as primary local lesions, delayed mucocutaneous lesions, or visceral leishmaniasis. The classic description of leishmaniasis is a nonhealing ulcer with a rolled border. Because of this patient’s travel history, leishmaniasis must be carefully considered,5 especially if there is no response to initial therapy. Ecthyma gangrenosum is a pseudomonal infection leading to a papule with hemorrhagic crust similar to ecthyma. It results from hematogenous spread of Pseudomonas, which is not suggested by the patient’s history or examination. Ecthyma gangrenosum usually occurs in persons who are immunosuppressed or gravely ill.3 When ecthyma gangrenosum is suspected, biopsy with deep tissue Gram stain and culture can be used for diagnosis. Squamous cell carcinoma often occurs on sun-exposed skin. It presents as a slowly progressive, scaly papule. The quick progression

Summary TableCondition CharacteristicsArthropod envenomation necrosis

Large, painful, rapidly developing ulcers surrounded by erythema; may develop central eschar

Cutaneous leishmaniasis

A polymorphic eruption, but classically described as a nonhealing ulcer with a rolled border at the site of an arthropod bite

Ecthyma Begins as a vesicle or vesicopustule, then develops hemorrhagic crust

Ecthyma gangrenosum Papule with hemorrhagic crust resembling ecthyma; deep tissue Gram stain and culture can confirm diagnosis, if needed

Squamous cell carcinoma

Slowly progressive, scaly papule on sun-exposed areas of skin

of the patient’s lesion and the history of trauma to his lip are more consistent with an infectious process than squamous cell carcinoma.

ReferencesWasserzug O, Valinsky L, Klement E, et al. A cluster of ecthyma outbreaks caused by a single clone of invasive and highly infective Streptococcus pyogenes. Clin Infect Dis. 2009;48(9):1213-1219.

Bolognia J, Jorizzo JL, Rapini RP, eds. Dermatology. 2nd ed. St. Louis, Mo.: Mosby; 2008.

James WD, Berger TG, Elston DM, Odom RB, eds. Andrew’s Diseases of the Skin: Clinical Dermatology.10th ed. Philadelphia, Pa.: Saunders Elsevier; 2006.

Hochedez P, Canestri A, Lecso M, Valin N, Bricaire F, Caumes E. Skin and soft tissue infections in returning travelers. Am J Trop Med Hyg. 2009;80(3):431-434.

AlSamarai AM, AlObaidi HS. Cutaneous leishmaniasis in Iraq. J Infect Dev Ctries. 2009;3(2):123-129.

Source: Adapted from Am Fam Physician. 2011;83(5):601-602.

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FDA Finds no Link between ARBs and Cancer

The use of angiotensin receptor blockers (ARBs) to lower blood pressure is not associated with an increased risk of developing cancer, the FDA announced after a formal safety review. In a meta-analysis of 31 trials that included about 1,56,000 patients, the rate of incident cancers per 100 patient-years was 1.82 in the ARB group and 1.84 in the comparison group (RR 0.99, 95% CI 0.92-1.06), according to the agency. There also were no associations between the use of ARBs and the risk of cancer-related death or specific cancers, including those of the breast, lung and prostate. “Based on our review and analysis of all currently available data regarding this potential safety signal, FDA has concluded that treatment with an ARB medication does not increase the risk of cancer,” the agency stated.

Source: Medpage Today, June 02, 2011.

Definitions Associated with Opioid Use and Abuse

Misuse Use of a medication for a medical purpose other than as directed or as indicated, whether willful or unintentional and whether harm results or not.

Abuse Any use of an illegal drug; the intentional self-administration of a medication for a nonmedical purpose such as altering one’s state of consciousness (e.g., getting high).

Tolerance A physiologic state resulting from the regular use of an opioid where increased doses are needed to maintain the same effects. In analgesic tolerance, increased opioid doses are needed to maintain pain relief.

Physical dependence

A physiologic state characterized by abstinence syndrome (withdrawal) if an opioid is stopped or decreased abruptly or if an opioid antagonist is administered. It is an expected result of opioid therapy and does not, by itself, equal addiction.

(...Cont’d from page 7)

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BackgroundAnkle sprains are a common musculoskeletal injury, causing acute pain and loss of function. They result in 302,000 visits to emergency departments in the United Kingdom annually. Of patients presenting with ankle sprains, 25 percent miss school or work for more than seven days, and long-term risks include a propensity for reinjury and residual deficits. Classic treatment of sprains includes protection, rest, ice, compression, elevation, and sometimes non–weight-bearing with crutches or immobilization with a cast. Meta-analyses have shown that functional treatment, such as early active use of the injured soft tissue, may be more effective for improving recovery from an ankle sprain. Bleakley and colleagues conducted a randomized controlled trial to compare early functional rehabilitation with current treatments for acute ankle sprains.

The StudyPatients 16 to 65 years of age who presented to an emergency department or a sports medicine clinic in Northern Ireland with a grade 1 or 2 ankle sprain that had occurred within the previous six days were eligible for the study. Patients with a grade 3 sprain (complete ligament rupture), a bony ankle injury, multiple injuries, or a contraindication to ice therapy; who did not speak English; who were under the influence of drugs or alcohol; or who had an unclear address for follow-up were excluded. Patients were randomized to an early exercise group or a standard treatment group. At the study onset, both groups were given written instructions for applying ice and compression (two 10-minute ice and compression sessions with 10 minutes of rest in between, done three times a day for the first week after injury). Also in the first week, the exercise group engaged in therapeutic exercises. This group received written and verbal instructions and a DVD that showed how to perform the exercises. Participants turned in a treatment diary at the first of four weekly follow-up visits that included treatment and

Early Exercise Helps Rehabilitate Ankle Sprainsanalgesic use, and was used to assess compliance. External ankle support (i.e., bracing, taping, and bandaging) and analgesics were not routinely provided to either group. During weeks 1 through 4 after injury, both groups had standardized ankle rehabilitation, which included muscle strengthening, proprioception training, and sports-specific exercises. This rehabilitation was supervised once per week by the research physiotherapist and done four times per week at home without supervision. Outcomes were assessed weekly for the first four weeks after injury and again at 16 weeks. The primary outcome was subjective ankle function (using the Lower Extremity Functional Scale, a self-completed questionnaire). Secondary outcomes included pain at rest and with activity, swelling, physical activity, and reinjury rates.

ResultsBetween July 2007 and August 2008, the authors randomized 50 participants to each group. From baseline to week 2 of follow-up, patients in the exercise group reported significantly better ankle function. Patients in the exercise group were more active, with increases in time spent walking, step count, and time spent in light physical activities compared with those in standard treatment. There was no difference between groups in the amount of swelling or pain at rest or with activities, and the study was not adequately powered to detect differences in the secondary outcomes. More participants dropped out of the exercise group (11 in the exercise group, four in the standard group). The reinjury rate was low (two injuries in each group). There were no statistically significant differences between groups at the end of 16 weeks for any measure.

ConclusionThe authors conclude that performing active ankle exercises in the first week after a mild to moderate ankle sprain results in improved short-term function.

Source: Adapted from Am Fam Physician. 2011;83(11):1340-1343.

Clinical Tips

Calling Who? A telephone rang. “Hello! Is your phone number 444–4444?” “Yes, it is,” came the reply. “Thank God! Could you call 100 for me? I super–glued my finger to the phone.”JO

KE

S

Funny One Liners!!!42.7% of all statistics are made up on the spot!

99% of lawyers give the rest a bad name!

A bartender is just a pharmacist with a limited inventory!

A clean desk is a sign of a cluttered desk drawer!

A clear conscience is usually the sign of a bad memory!

A closed mouth gathers no foot!

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•

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Galen (200 AD)Galen, better known as Galen of Pergamon was a prominent Roman physician.

He thought that the liver was a very important organ of the body and recognized its relationship with the gallbladder and spleen.

He was of the opinion that liver was the first organ to develop in the fetus. “The liver is the source of the veins and the principal instrument of sanguification,” he observed in On the Usefulness of the Parts of the Body.

Humor

I l l u s I o n

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Dr KK Aggarwal

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