Morning Medtalks with Dr KK Aggarwal 17th June 2018


Dr KK Aggarwal    17 June 2018

Minds Vision

Those who never give up, never fail.

Should we give blood transfusion during surgery

Receiving a red blood cell (RBC) blood transfusion around the time of surgery may double the odds of developing venous thromboembolism (VTE), or blood clots, up to 30 days after surgery, according to a study published in JAMA Surgery.

Hospital-associated blood clots account for 5% to 10% of all hospital deaths. Up to 70% of them may be preventable.

RBCs may have inflammation-promoting properties that may lead to clots. During storage, they may also acquire lesions that promote blood clots.

Of 750,937 individuals who underwent surgery in 2014, 6.3% (n = 47,410) received at least one perioperative RBC transfusion and 0.8% (n = 6309) experienced a postoperative VTE, including 0.6% (n = 4336) with deep venous thromboembolism (DVT), 0.3% (n = 2514) with pulmonary embolism (PE), and 0.1% (n = 541) with both DVT and PE.

Beware of free snacks

A study followed more than 5,000 employed adults across the U.S. and tracked the food and drinks they purchased at work, along with the “free-for-all” in break rooms.

Among the most commonly selected items were coffee, regular and diet soft drinks, sandwiches, salads, pizza and baked goods.

According to an epidemiologist for the CDC, in a given seven-day period, almost a quarter of the employees in the study consumed almost 1,300 calories from the food they got at work.   Sometimes in a single snack.  And about 70 percent of those calories were from the free food!

MEDtalk Views: Give blood only if Hb is < 7 gm %.

Definition of Sexual Misconduct

Sexual harassment, abuse, or misconduct: Unwanted sexual texts/emails, comments about body parts, propositions to engage in sexual activity, being asked repeatedly for a date, offer for a promotion in exchange for a sexual favor, threats of punishment for refusal of a sexual favor, deliberately infringing on body space, unwanted groping/hugging/physical contact, deliberate self-fondling, grabbing body parts, and rape.

Twelve percent of female physicians and 4% of their male counterparts in US said they have personally experienced sexual abuse, harassment, or misconduct in the past 3 years, according to Medscapes Sexual Harassment of Physicians: Report 2018.

The report presents results of a survey of more than 6200 clinicians in the United States who were asked about specific harassing behavior they have experienced or witnessed in the past 3 years, where it occurred, how they responded, and how it affected them. The survey also asked whether they had been accused of sexual harassment.

Resting or exercise screening ECG should be avoided in asymptomatic adults

A new US Preventive Services Task Force (USPSTF) statement gives nearly the same recommendations on electrocardiography (ECG) screening for asymptomatic adults as those it published 6 years ago. Resting or exercise screening ECG should be avoided in asymptomatic adults considered to be at low risk for cardiovascular (CV) events. It found "adequate evidence" that it "leads to harms that are at least small and may be moderate."

June 5 issue of the Journal of the American College of Cardiology

An elevated ratio of testosterone to estradiol in postmenopausal women is associated with an increased risk for myocardial infarction, stroke, and heart failure over a 12-year period.

The study also linked higher total testosterone levels to increased risk for cardiovascular disease and elevated estradiol levels to lower risk for coronary heart disease.

In postmenopausal women, estrogen levels plummet while the ovaries continue to produce testosterone.

Determining testosterone levels or testosterone/estradiol ratios is not routinely done, and even if we do we do not know what to do with the numbers.

Notice sent via WhatsApp valid, rules Bombay high court

The Bombay high court has held that service of notice about a litigation through WhatsApp is valid. Following the enactment of the IT Act, courts have allowed parties in a litigation to serve notice through email, in addition to traditional methods. Justice Gautam Patel observed that a credit card defaulter who was evading the bank had not only received the notice in a PDF file but also opened it and read its contents. The blue ticks on the message revealed that Jadhav had received the message and read it. (TOI)

Over the past two years, the bank had been trying to serve the notice about the litigation on Jadhav but without success as he kept shifting his rental accommodation.

Earlier this year, a Delhi metropolitan magistrate had allowed a woman to serve summons in a domestic violence case on her estranged husband in Australia via WhatsApp. The court had said that the "double tick" on WhatsApp showed that the summons have been delivered.

Aspirin desensitisation protocol

Cardiac and diabetic patients need low-dose aspirin but some form of hypersensitivity to aspirin, can present a management challenge.

However, low-dose aspirin (75 to 100 mg) can be safely introduced to most patients in this situation using a simple protocol.

The protocol takes three to five hours to complete and can be done as an outpatient or inpatient, depending on the acuity of the situation.

If the patient requires an immediate stenting procedure, other antiplatelet agents can be given instead, and low-dose aspirin can be introduced once the patient is stabilized.

The doctors should take a detailed history of the patients past reaction to aspirin and other NSAIDs to categorize the type of hypersensitivity reaction.

Identify patients with known or possible aspirin-exacerbated respiratory disease (AERD), as these individuals can have severe respiratory reactions to aspirin and should be premedicated before aspirin is introduced.

Patients may require treatment for either respiratory or cutaneous reactions during the protocol. The protocol should not be aborted if these occur. Instead, the symptoms should be treated with bronchodilators or antihistamines, and the dose that caused the reaction is repeated until the patient no longer reacts. The protocol is then continued until complete.

Patients who are successfully started on low-dose aspirin should continue the same daily dose indefinitely.

Patients with severe reactions to higher-dose aspirin or other NSAIDS should be counseled that those sensitivities have not been altered by the introduction of low-dose (≤100 mg) aspirin. For example, a patient who had anaphylaxis to ibuprofen but has been started on low-dose aspirin must still avoid ibuprofen.


  1. Ask history of AERD (aspirin-exacerbated respiratory disease)
  2. AERD is a triad of asthma, chronic rhinosinusitis, nasal polyp and adverse reaction to aspirin (wheezing, nasal discharge and nasal obstruction)
  3. If known AERD pre-medicate the patient, 10 mg Montelukast one hour before the procedure, inhaled bronchodilators, 40 mg prednisolone two hours before if asthma is still present
  4. If no AERD just give 10 mg cetirizine or 25 mg Phenargan. Add Montelukast 10 mg if symptoms develop at any stage.
  5. Give 50 mg aspirin
  6. Observe 90 minutes
  7. Give additional dose of 50 mg aspirin
  8. Observe for another period of 90 minutes
  9. If asymptomatic start aspirin 75 mg from next day
  10. If symptoms develop give another dose of aspirin 50 mg and then start aspirin the next day

Suggested Economics and Billing Heads

Head: Aspirin Challenge Test

Indications: All asthmatics, COPD, Allergic Rhinitis, Allergy patient before putting them on low dose aspirin

(Charges include: observation for 270 minutes, premedication, monitoring (PEFR, BP, SaO2), emergency kit, informed documentation of consent, nursing charges, doctor charges)

Kits available: Oxygen, SAO2 monitor, PEFR, IV canula, IV drip, pre-medications, ECG machine, Adrenaline, efcorlin.

Suggested Charges in a Nursing Home: Up to Rs 2000/-

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