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For reading this

Upcoming Event
Respiratory CME Update:
The Asthma COPD overlap; Online Address label Here
current status in Pune.
Dr Nitin Abhyankar
May 17th 2008,
2130 Hrs. sharp.
Yo u r w e b s i t e
Hotel Coronet Elegance,
Opp. Shivarkar Garden
Fatima Nagar, Pune.
St r a i g h t f r o m t h e h e a r t
(From the Editor's desk,
Dr S Bhatia, examination where the doctor is put un-

In my last editorial, I had der a subjective scanner; the doctor is ex-

pected to prove that he is able to behave
talked about the absence of continued
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

2008 2nd Edition

President’s Page: Visit the KWMPA Calendar on “”

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: Suggested “Situation” topics

Update 1: Giving up smoking. We can also plan small focused practice oriented
meetings to evolve “how to manage” guidelines
Update 2: Current status of chikungunya and lep- in situations commonly faced by us.
tospira around Pune
Situation 1: A sick patient just admitted has high
Update 3: New vaccines in Pediatrics; (& new in- BSL’s (210, 4 h later 230). Will it affect the manage-
dications –immunosuppressed adults, travel ment of the primary disease, and how to manage
medicine) the BSL’s. (best practices in stress diabetics)

Update 4: Complications following falls in elderly Situation 2: A patient has “difficult to control”
invariably kills them (# neck femur, subdural he- hypertension – what’s go-
matoma, etc.) Recognizing a potential candidate; ing on?
evaluating the medical & non medical aspects & Email to
giving appropriate advice. A value addition to our Situation 3: Is short stature
practice; no one knows they can ask us for this in this child needing inves-
advice. tigation, or is it Idiopathic?

Update 5: Medicolegal issues : Consumer Law, Situation 4: Recurrent oral

dishonoured mediclaims, et al. An interactive aphthous ulcers.
meeting with a lawyer practicing medicolegal
cases in Pune. Situation 5: Managing chronic daily headache.

Update 6: Changing Indian Cooking to prevent Situation 6: Girls with irregular periods; primary
lifestyle diseases. A leading fitness expert speaks management & risk of future infertility.
to all those who cook; including non medical
spouses. Situation 7: A patient on Warfarin (previous DVT /
prosthetic heart valve) comes with an unrelated
Update 7: Preventing COPD beyond 40’s in non problem ( skin infection / avulsed toenail). Does
smoking Indians – early OPD screening strategies. GP / nursing home level management of unrelated
(An original study done in Pune) conditions mess up anticoagulation?

Update 8: Managing OA knees better. Situation 8: A patient with a long standing ane-
mia in OPD practice is now on the verge of blood
Update 9: Reducing mortality of AMI; the concept transfusions. Options for investigation & best
of “Door to Balloon time”. management practice.

Update 10: Is osteoporosis hyped up or do we re- (Poll you choices, like S 63521)
ally understand “Bone Quality”.
(Suggest your choices, like U2471593)
How to send your choice:
Next option: SMS me -98220 51735 (your name:
Simple, like, type as: U2471593, S 63521. U2471593, S 63521), but you may not get an
acknowledgement; you will have to check the
Best option: Visit the website and go to the section website.
“Choose your CME”. You’ll find all the above Traditionally, this information could have been
options enlisted. Just tick the ones you like and given to any other MC member; this is still
click submit. Bingo !!! available; but equivalent to snail mail.
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 ex- you have polled for a topic, I
pected. (Other motives of tak- Are KWMPA members ‘Thanda’? know the minimum people
ing membership are hereby who will come. I wish to feel
being ignored from the dis- the 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 break” The Proposed

thoughts Annual Family Program
(August – September) option to Year-end Family Get togethers
Pawan Khind Resort, near Kolhapur
(3 days 2 nights) Dandiya Raas nite
Bhandardara Backwaters (3 days, 2 Saturday 4th or Sunday
nights) 5th October 2008
Khanapur, Khadakvasla Lake back waters.
In the Navratri Festival
(2 days, 1 night)
Shantivan Resort, Baron Resorts, Chimbalkar
What we can work out from now
Farms, etc.
• We book a convenient Hall rightaway
• Members suggestions are invited for
Baramati Agritourism (Rs 400/d; including
pickup & drop (
• We can have Dandiya competitions for
Sinhagad treks Sunday morning- various age groups, best dress couples,
to-noon your opinion on the website etc
• Members please suggest how to
organize music to set the theme
We recognize & thank : I invite any input from Members & Family
Dr P K & Dr (Mrs) A Sinha for emailing their inability members
to attend, they were out of Pune.
Dr N G Hegde for calling to say he is unable to attend We invite Members to make their
..can we begin with a few small steps… suggestions on the Website blog
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 How have Pharmas reacted to
will be enthusiastic our “Poll-In” website
These will be our usual Six “Regulation Scale
meetings”. I will also know how many members Frankly, for some Pharmas, CME’s are an excuse
will turn up while talking to the sponsor. to express hospitality. But some rate us by the
group that participates in academics. And let’s get
What do I do with the other topics real, sponsors commit money on our (the
Do we just ignore choices of the minority? association’s) word. Dabur (Delhi) viewed our first
In fact, a group as small as 10 may be all that are CME report from our website.
interested in a topic. A low cost meeting can be
organized at any colony clubhouse / terrace / I can tell you quite a few pharmas are waiting to
restaurant hall. If unsponsored,meals can be check our website with an offer to sponsor popular
bought upfront a la carte ( or a pre packed meal- topics. However, some Pharma divisions will
deal can be negotiated (Rs 100/-?). Some speakers readily participate with smaller budgets of Rs
find small but interactive meetings more rewarding 10,000/-. In case they are interested in sponsoring
than the mementoes. smaller meetings, will it not be mutually beneficial?
Look Ma! No Knife Peer Review Form
Renal calculi are among the most painful conditions that can be experienced by This form is available
anyone. Apart from other technologically advanced methods, where the cost is prohibi-
online now and is open
tively high for many a patient even today, very often surgery is the only way out. We have
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
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
and click on the pro-
taking to have the best results. I am
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.
(Zubbin Motafram, the Author, is a practicing Homoeopath. He can be contacted
Feedback form:
A new feedback form
Intersting news and Links has been made avail-
Following are some of the latest news in various fields of medicine. Internet links able for all of you to tell
have been provided for anyone wishing to have a dekko at them.
us how to improve both
Dark Chocolate With Added Plant Sterols Reduces Cholesterol and Blood-Pres- our website and our
sure Levels: Association's activities.
Teenage Boys Have Higher CV Risk Than Girls:
Naturally Occurring Metabolite Predicts Cardiovascular Events in Diabetics: http:/
Migraine Linked to Sleep Apnea in Children and Teens: ON THE SITE.
Abacavir, Didanosine Linked to Myocardial Infarction Risk: http://
Colonoscopy Easier, Less Painful With Warm Water or Oil Lubrication: http://

Should we throw away
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. We were all taught that blood pressure equals sys-
Full CME at temic 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.
diac patients. Dr. Block: So blood pressure was adequately
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 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 efits; therefore, it's not that atenolol is harmful it's just
that although blood pressure was lowered with beta- 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 It turns out that carvedilol, since it's a non-se-
events, and all-cause mortality). lective 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 pres-
sure. So, treatment today may require multiple drugs:
a CCB, an ACE inhibitor or an ARB, and then a beta-
blocker. 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.

CME MARCH 2008-A report Dr R. V. Lagad: "I got to know a
lot of things about targeted therapy; as to
The KWMPA conducted its first CME of
where, how and why it is targeted. Dr Nag
2008 on 15th March 2008 at Hotel Coronet
Elegance, Fatima Nagar, Pune. simplified the concepts and made them
easy for us to understand...The usefulness
The Event was sponsored by Dabur. PRESIDENT
in routine practice is limited. Only a few
The Guest Speaker was Dr Shona Nag,
patients can benefit from the therapy as DR.SANJAY SALUNKHE
Medical Oncologist, Jehangir Hospital,
the costs are prohibitive. However, there is
Pune. She spoke about Targeted therapy VICE PRESIDENT
a silver lining, as Dr Nag is on a number of
in Cancer.
This was followed by a presentation by global trials and even a really bad case
could be taken up for the therapy. The re- HON.SECRETARY
Dr Saurabh Bhatia about the new KWMPA
sults of targeted therapy are very encour-
website. Lastly, Dr Sanjay Salunkhe shared DR VAISHALI PARAB
his plans, achievements and vision for the aging and should become affordable in the
near future." HON JT. SECRETARY
KWMPA with the members.
Dr Vibha Bafna: We as pediatri- DR SUBROTO ROY
The CME was followed by a Dinner.
Photographs/ Slide show, videos of dr cians already knew about targeted therapy
and its use in some of the autoimmune dis-
Nag, Dr Bhatia and Dr Salunke can be seen
orders like rheumatoid artrits, atopic der- DR.NAVEEN RAINA
at under CME March 2008
link. matitis' SLE , ITP, etc...It was clear that
the lecture was prepared keeping the audi-
ence and their felt needs in mind ...This DR SAURABH BHATIA
Peer Reviews
information makes us more aware of diag- GOV. BODY MEMBERS
Following the CME, the MC asked
nosing and reffering malignancy early.It also
for peer reviews from eminent doctors & DR BAFNA SANJAY
helps us in telling our patients confidently
Members. Excerps of those are being re- DR CEMENTWALA A
about better and less toxic treatment that
produced here. For full details see 'Peer
advances in science has now made avail- DR CHAVAN V.
Review' form's bottom at the website.
able to us. "
Dr. Pradeep P. Sharma: "...Mo- DR DIGHE AMOL
Dr Ravindra Chhajed: "More de-
lecular therapy are targeted therapy and
tail mode of administrations should have DR KAMTHE K.
selectively attack the target cancer cells
been highlighted. As a physician may we
without much affecting the normal cells DR.MANDLIK V.
be able to give targetted therapy in private
thus the amount of side effects are reduced. DR. NAZIR NAZIMA
nursing home? How General practioners
They are as precise as missiles whereas
will be helpful for Oncophysicians for DR. SIAMWALA Z.
the other therapies are like atom
targetted chemotherapies? These points
bombs....Till today the drugs are very costly
should have been briefed in details...Many
and may be beyond the finances of the
additional information came into picture,like
common but may be down the line when
many free trials are going on and may be Address for Correspondence:
the consumption and the demand rise the
helpful for poor patients. New hopes for
prices may come down. ( This happens with
advanced cases of malignancies by the way
most of the drugs we all know that )" Snailmail : 92, St. Patrick’s
Town, Sholapur Road, Pune
411 013

Contributed by: Registration process Video
Krishna,age 7 A video has been placed for
yrs,student of Std. 2
St' Mary's School ; everyone's convenience to help
Place Artwork Here daughter of Dr. Mrs.
Kavita and Dr. them understand the registra-
Krishna.The painting tion process at the website.
titled "At the Circus"
This video will help you in the
won the jury prize Art
Buds 2007 Young steps of Registration Process.
Envoys Int'l,
Hyderabad. We also recommend using

Positive “tea sign” Firefox as your internet

Michael V Holmes, Royal Free Hospital, London browser instead of Internet ex-
It was Christmas Day, and an 81 year old patient had been
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
I summoned the registrar, making plans to transfer the patient to your information we managed
the resuscitation bay and possibly call the anaesthetist. The registrar’s
to do the same without using
question of “Would you like a cup of tea?” elicited symmetrical move-
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 ce-
atleast 2 alphabetical letters and
rebral stimulation for the Glasgow coma scale to leap to 14. The carer
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 by this way.
to testing its validity in the future.

Stubborn Thanks alot for the help and

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