Morning Medtalks with Dr KK Aggarwal 10th June 2018


Dr KK Aggarwal    10 June 2018

Dear Colleague

In clinical medicine

I personally do not agree with the media report that five patients, admitted in the Intensive Care Unit ward of the Hallet Hospital in Kanpur, died in the last 24 hours following failure of Air- Conditioner. AC atmosphere is not a must unless the fans are also not working, and the patients ends up with heat stroke.

The Lancet HIV reports that in gay and bisexual men, an increase in HIV pre-exposure prophylaxis is associated with a reduction in condom use. In India still pre exposure prophylaxis is not yet established.

If one is interested in buying shares, buy that of CIPLA. Already shares of Cipla rose nearly 3 percent as company partnered with Eli Lilly for the marketing and distribution of Lilly’s BASAGLAR in India. Basaglar is biologically similar to Sanofis basal insulin Lantus (insulin glargine), including the same protein sequence and a similar glucose-lowering effect. Both are interchangeable but the newer one will be much cheaper. While the FDA does not call it a “biosimilar” drug for regulatory reasons, it can essentially be thought of as an alternative cheaper form of Lantus

One of my patient wanted aortic valve replacement without a sternal cut. Same day I attended a seminar by IMANDB and NHI. The question is to perform open valve surgery through a smaller incision as an alternative to median sternotomy.  

The seminar experts said that current open cardiac surgical therapies, whether performed through a median sternotomy or alternative smaller incisions, continue to rely on cardiopulmonary bypass and a still operative cardiac field (myocardial cardioplegic arrest and protection). Much of the morbidity of open cardiac surgical interventions is related to the proinflammatory and anticoagulant effects of cardiopulmonary bypass, to aortic manipulation (cannulation, clamping, and de-clamping), and to myocardial protection during cardioplegic arrest. Thus, the potential benefit of minimally invasive aortic valve surgery approaches is limited.

Also, the limitations of MIVS approaches compared with traditional median sternotomy include a more restricted operative field; requirement of more preoperative imaging, evaluation, planning, and patient selection; and requirement of greater experience and expertise of the surgical team.

Also, when performed by experienced surgeons and centers, results are largely like those of open conventional surgery. Mortality and most major morbidities are comparable for MIVS and conventional sternotomy surgery with modest improvements in transfusion rates, hospital stay, and markedly enhanced patient satisfaction with MIVS. Do not forget in most hospitals the cost may be 1.5 times higher. 

All of us travel and phase jet legs. Tasimelteon is an MT1 and MT2 melatonin receptor agonist. This circadian regulator has significant and clinically meaningful benefits in nighttime and daytime symptoms of jet lag disorder as per a phase 3 results from a randomized, placebo-controlled trial. It improved total sleep time (TST) by 85 minutes vs placebo and improved next-day alertness in this 8-hour phase advance clinical study (source Vanda Pharmaceuticals at SLEEP 2018: 32nd Annual Meeting of the Associated Professional Sleep Societies). Should we in India eagerly wait for this new molecule. Given the widespread availability and low cost of melatonin I see no compelling reason to use a melatonin agonist for jet lag, breakthrough new studies.

We all use Metformin as first-line treatment of choice for type 2 diabetes. However, its use in patients with CKD has been contraindicated until quite recently, when the FDA decided in 2016 to permit the use of metformin in patients with mild CKD (eGFR, 45 mL/min/1.73 m2 or greater). When the eGFR falls to between 30 and 45, which is moderate CKD, the FDA recommends further caution with a careful risk/benefit calculation before deciding to stop or continue the medication.

Metformin use is still contraindicated in those with advanced CKD (eGFR <30 mL/min/1.73 m2).

Now more evidence supporting the "cautious use" of metformin in selected patients with type 2 diabetes and mild to moderate chronic kidney disease is emerging. A new analysis of two large retrospective patient cohorts in the United States shows there was no significant association between metformin therapy and incident lactic acidosis in those with an estimated glomerular filtration rate (eGFR) of at least 30 mL/min/1.73 m2.

So eGFR more than 45 give metformin, < 45 and > 30 repeat eGFR and if same refer to a nephrologist and if < 30, stop metformin.

Never forget to ask the history of intake of Viagra like drugs, Marijuana and/or cocaine use in a young person < 50 years presenting with acute heart attack. While in the first it may be fatal if you give nitrate and in the later not warning the relations that such cases are associated with worse survival may be a mistake. Such cases which makes up to 10% of this population of young MI patients – are twice as likely to die of heart disease in the next ten years (May 30th JACC). It is well established that cocaine use is a strong risk factor for MI. In India in metros, cocaine users are on the rise.

In the public health field, the fear of NIPAH is over for the time being. But the virus has still not being isolated only the tests were positive. ICMR is still focusing on determining the source of the Nipah outbreak, which claimed 17 lives in Kerala. While the viral infection has been contained still over 2,000 suspected persons are being monitored to rule out any other cases. They will continue to be monitored for 42 days. Seventeen people — 14 in Kozhikode and three in Malappuram districts in Kerala including one nurse have died. Unfortunately, I again say the death of a nurse or a doctor during an epidemic while serving and saving patsints is no less than a death of a soldier on the border and should be given a national honour.


In medicolegal field, rightly the medical license of an Atlanta-area dermatologist Dr Windell Davis-Boutté who posted videos of herself rapping and dancing while performing cosmetic surgery was suspended by Georgia Composite Medical Board. She has been sued by at least seven women for negligence, among other allegations, after cosmetic procedures resulted in permanent damage. Davis-Boutté posted more than 20 videos of herself singing and dancing in the operating room as a marketing tool for her practice in Lilburn, Georgia, while patients lay immobile, often bare buttocks exposed.

About the weather Yesterday, heat wave conditions were observed at one or two pockets over West Rajasthan.

Finally, a tip, would you give a pacemaker to a patient with bradycardia and slow atrial fibrillation. Before you do that try Hyoscyamine, an anticholinergic drug it may work in some. It is available in India as Denpas | Femidol | Belladenal -In

Enjoy the day

Dr KK Aggarwal

Padma Shri Awardee

Vice President CMAAO

President HCFI

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